History

Fact Explanation
Asymptomatic Asymptomatic liver abscess is very rarely seen. [4]
Fever Liver abscess causes fever as a result of release of pyrogens. Fever can come as spikes or may be continuous presenting as pyrexia of unknown origin. Fever is associated with chills, nausea, vomiting, anorexia and malaise. [1,2]
Right upper quadrant pain Patients complain of right upper quadrant pain due to inflammation and swelling of the liver. [1,2]
Cough Patient develop cough and sometimes hiccup due to diaphragmatic irritation. This can cause referred pain over the right shoulder as well. Right sided empyema and collapse can also cause cough. [1,5]
Loss of appetite and loss of weight Patients can complain of long term loss of appetite and weight. [1]
Yellowish discoloration of the skin and eyes Jaundice can be the only presenting complain in some patients. Jaundice is commonly associated with multiple liver abscesses. [1]
Presence of risk factors Biliary diseases are common risk factors for the development of hepatic abscesses. Presence of inflammatory bowel disease, diverticulitis, appendicitis, history of bowel surgery, diabetes, alcoholism and immuno-compromised states can lead to spread of the infective organisms in to the liver and development of liver abscess. However some patients may not have a detectable foci of origin of the infection, these abscesses are called cryptogenic abscesses. [1,2,3]
References
  1. MCKAIGNEY C. Hepatic Abscess: Case Report And Review West J Emerg Med [online] 2013 Mar, 14(2):154-157 [viewed 17 July 2014] Available from: doi:10.5811/westjem.2012.10.13268
  2. YU CHIN-WEI, LEE CHING-HSING. Pyogenic Liver Abscess. N Engl J Med [online] 2011 March, 364(12):1154-1154 [viewed 18 July 2014] Available from: doi:10.1056/NEJMicm1003533
  3. NAZIR N. T., PENFIELD J. D., HAJJAR V.. Pyogenic liver abscess. Cleveland Clinic Journal of Medicine [online] December, 77(7):426-427 [viewed 18 July 2014] Available from: doi:10.3949/ccjm.77a.09151
  4. ZHANG KAN K., MAYODY MAJID, SHAH RAJESH P., VAKIANI EFSEVIA, GETRAJDMAN GEORGE I., BRODY LYNN A., SOLOMON STEPHEN B.. Asymptomatic Liver Abscesses Mimicking Metastases in Patients after Whipple Surgery: Infectious Complications following Percutaneous Biopsy—A Report of Two Cases. Case Reports in Hepatology [online] 2012 December, 2012:1-5 [viewed 18 July 2014] Available from: doi:10.1155/2012/817314
  5. GHOSH SOUMIK, SHARMA SOURABH, GADPAYLE A. K., GUPTA H. K., MAHAJAN R. K., SAHOO R., KUMAR NAVEEN. Clinical, Laboratory, and Management Profile in Patients of Liver Abscess from Northern India. Journal of Tropical Medicine [online] 2014 December, 2014:1-8 [viewed 18 July 2014] Available from: doi:10.1155/2014/142382

Examination

Fact Explanation
Febrile [1] Patients can be febrile to touch.
Jaundice [1,2] Liver abscess can give rise to jaundice.
Abdominal examination Tender hepatomegaly can be detected. If the abscess is situated in the left liver abscess, epigastric pain can be found and hepatomegaly may not be detected. Hepatic rub can be found in some patients. [1,2]
Examination of the respiratory system Liver abscess can lead to development of right pleural effusion. This can be detected by the presence of reduced chest movements, stony dull percussion note, and absent breath sounds over the right lower lobe of the lung. [3,4]
References
  1. MCKAIGNEY C. Hepatic Abscess: Case Report And Review West J Emerg Med [online] 2013 Mar, 14(2):154-157 [viewed 17 July 2014] Available from: doi:10.5811/westjem.2012.10.13268
  2. BRANUM GD, TYSON GS, BRANUM MA, MEYERS WC. Hepatic abscess. Changes in etiology, diagnosis, and management. Ann Surg [online] 1990 Dec, 212(6):655-62 [viewed 17 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/2256756
  3. GHOSH SOUMIK, SHARMA SOURABH, GADPAYLE A. K., GUPTA H. K., MAHAJAN R. K., SAHOO R., KUMAR NAVEEN. Clinical, Laboratory, and Management Profile in Patients of Liver Abscess from Northern India. Journal of Tropical Medicine [online] 2014 December, 2014:1-8 [viewed 18 July 2014] Available from: doi:10.1155/2014/142382
  4. AGGARWAL R, AGGARWAL M, DWIVEDI S. Giant liver abscess with bilateral pleural effusion: An unfamiliar association Trop Parasitol [online] 2012, 2(2):129-130 [viewed 18 July 2014] Available from: doi:10.4103/2229-5070.105180

Differential Diagnoses

Fact Explanation
Cholecystitis Cholecystitis, inflammation of the gall bladder, presents with right upper quadrant pain, jaundice, fever, nausea and vomiting. [1]
Empyema Empyema is the collection of pus within the pleural space. [2]
Peptic ulcer disease Burning epigastric pain is characteristic of peptic ulcer disease. Some patients can remain asymptomatic during the early stages of the disease. [3]
Hepatocellular carcinoma (HCC) Radiological features of the liver abscess can be similar to the HCC. Patients with HCC can also have right upper quadrant abdominal pain, fever, malaise and jaundice. [4]
Hydatid cysts Hydatid cysts are caused by the larval stage of the Echinococcus tapeworm. Imaging studies and serology can aid in making the definitive diagnosis. [5]
References
  1. PARMET SHARON, LYNM CASSIO, GLASS RICHARD M.. Acute Cholecystitis. JAMA [online] 2003 January [viewed 18 July 2014] Available from: doi:10.1001/jama.289.1.124
  2. BRIMS F. J. H., LANSLEY S. M., WATERER G. W., LEE Y. C. G.. Empyema thoracis: new insights into an old disease. European Respiratory Review [online] December, 19(117):220-228 [viewed 18 July 2014] Available from: doi:10.1183/09059180.00005610
  3. ARO P.. Peptic Ulcer Disease in a General Adult Population: The Kalixanda Study: A Random Population-based Study. American Journal of Epidemiology [online] 2006 April, 163(11):1025-1034 [viewed 18 July 2014] Available from: doi:10.1093/aje/kwj129
  4. SUN VC, SARNA L. Symptom Management in Hepatocellular Carcinoma Clin J Oncol Nurs [online] 2008 Oct, 12(5):759-766 [viewed 18 July 2014] Available from: doi:10.1188/08.CJON.759-766
  5. ETTORRE GIUSEPPE, VENNARECCI GIOVANNI, SANTORO ROBERTO, LAURENZI ANDREA, CERIBELLI CECILIA, DI CINTIO ANTONIO, RIZZI ELISA, ANTONINI MARIO. Giant hydatid cyst of the liver with a retroperitoneal growth: a case report. Array [online] 2012 December [viewed 18 July 2014] Available from: doi:10.1186/1752-1947-6-298

Investigations - for Diagnosis

Fact Explanation
Full blood count Anemia can be detected. Neutrophilic leukocytosis can be found secondary to infection. [1,3,4]
Serum protein levels Hypoalbuminemia is the most common association of liver abscess. [1,3,4]
Alkaline phosphatase Elevation of alkaline phosphatase enzyme can be found is many patients. [3,4]
Serum bilirubin Serum bilirubin can be elevated. [3,4]
Hapatic transaminases Elevated hepatic transaminases can be found in some patients. [1,3]
Blood culture [1,2] Blood culture can be positive in some patients. But bacteremia cannot be detected in some.
Culture of abscess fluid aspirate [1] Gram stain and culture of the aspirate of the abscess lead to the isolation of the organism. Both aerobic and anaerobic cultures are indicated in most of the patients. Antibiotic sensitivity test can lead the necessary treatment. [3]
Chest X-ray Chest X-Ray is often normal in many patients. Elevated hemidiaphragm can be seen due to the liver abscess. Right sided pleural effusion, lung atelectasis or right lobar consolidation can be detected in some patients. [1]
Ultrasound scan of the abdomen [1] This is a noninvasive investigation option to diagnose liver abscess. Ultrasound scan shows a irregular cystic mass. However if gas forming organisms are present (Klebsiella pneumoniae, ) in the abscess the ultrasound visualization is a little difficulty.
CT abdomen [1] Contrast enhanced CT scan has higher sensitivity in diagnosing liver abscess than the ultrasound scan. Fluid and gas filled intrahepatic mass or masses can be detected in CT. [2]
Endoscopic retrograde cholangiopancreatography If biliary etiology is suspected ERCP is helpful in diagnosis. Magnetic resonance cholangiopancreatography is more advanced alternative for ERCP. [1]
References
  1. MCKAIGNEY C. Hepatic Abscess: Case Report And Review West J Emerg Med [online] 2013 Mar, 14(2):154-157 [viewed 17 July 2014] Available from: doi:10.5811/westjem.2012.10.13268
  2. YU CHIN-WEI, LEE CHING-HSING. Pyogenic Liver Abscess. N Engl J Med [online] 2011 March, 364(12):1154-1154 [viewed 18 July 2014] Available from: doi:10.1056/NEJMicm1003533
  3. NAZIR N. T., PENFIELD J. D., HAJJAR V.. Pyogenic liver abscess. Cleveland Clinic Journal of Medicine [online] December, 77(7):426-427 [viewed 18 July 2014] Available from: doi:10.3949/ccjm.77a.09151
  4. RAHIMIAN JOSEPH, WILSON TINA, ORAM VALERIE, HOLZMAN ROBERT S.. Pyogenic Liver Abscess: Recent Trends in Etiology and Mortality. CLIN INFECT DIS [online] 2004 December, 39(11):1654-1659 [viewed 18 July 2014] Available from: doi:10.1086/425616

Investigations - Followup

Fact Explanation
Ultrasound scan of the abdomen Ultrasound scan is a non-invasive investigation option to monitor the size of the abscess and to detect recurrence of lever abscess. [1]
References
  1. NAZIR N. T., PENFIELD J. D., HAJJAR V.. Pyogenic liver abscess. Cleveland Clinic Journal of Medicine [online] December, 77(7):426-427 [viewed 18 July 2014] Available from: doi:10.3949/ccjm.77a.09151

Management - Specific Treatments

Fact Explanation
Drainage of the abscess Since the action of antibiotics is limited in an abscess, drainage of the abscess will hasten the recovery. Percutaneous drainage can be done if the abscess can be approached percutaneously, if not or if the abscess is larger than 5cm in diameter surgical drainage is necessary. Drainage can be guided by ultrasound or CT for accurate localization and drainage. Minimal invasive procedures like laparoscopic drainage are practiced recently. [1,2,3]
Antibiotic treatment Antibiotic therapy should be guided by the isolated organism’s antibiotic susceptibility. If sepsis is suspected, early administration of broad spectrum antibiotics will be helpful. An extended spectrum B-lactam, third generation cephalosporin and metronidazole are commonly used combination. Fluoroquinolone is an alternative to B-lactams. [1,2,3]
References
  1. MCKAIGNEY C. Hepatic Abscess: Case Report And Review West J Emerg Med [online] 2013 Mar, 14(2):154-157 [viewed 17 July 2014] Available from: doi:10.5811/westjem.2012.10.13268
  2. BRANUM GD, TYSON GS, BRANUM MA, MEYERS WC. Hepatic abscess. Changes in etiology, diagnosis, and management. Ann Surg [online] 1990 Dec, 212(6):655-662 [viewed 18 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1358249
  3. NAZIR N. T., PENFIELD J. D., HAJJAR V.. Pyogenic liver abscess. Cleveland Clinic Journal of Medicine [online] December, 77(7):426-427 [viewed 18 July 2014] Available from: doi:10.3949/ccjm.77a.09151