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There are three major forms of liver abscess, classified by cause:
- Pyogenic liver abscess, which is most often polymicrobial, accounts for 80% of hepatic abscess cases in the United States.
- Amoebic liver abscess due to "Entamoeba histolytica" accounts for 10% of cases.
- Fungal abscess, most often due to "Candida" species, accounts for less than 10% of cases.
Major bacterial causes of liver abscess include the following:
- "Streptococcus" species (including "Enterococcus")
- "Escherichia" species
- "Staphylococcus" species
- "Klebsiella" species (Higher rates in the Far East)
- Anaerobes (including "Bacteroides" species)
- "Pseudomonas" species
- "Proteus" species
However, as noted above, many cases are polymicrobial.
Antibiotics are commonly used as a curing method for pancreatic abscesses although their role remains controversial. Prophylactic antibiotics are normally chosen based on the type of flora and the degree of antibiotic penetration into the abscess. Pancreatic abscesses are more likely to host enteric organisms and pathogens such as "E. coli", "Klebsiella pneumonia", "Enterococcus faecalis", "Staphylococcus aureus", "Pseudomonas aeruginosa", "Proteus mirabilis", and "Streptococcus" species. Medical therapy is usually given to people whose general health status does not allow surgery. On the other hand, antibiotics are not recommended in patients with pancreatitis, unless the presence of an infected abscess has been proved.
Although there have been reported cases of patients who were given medical treatment and survived, primary drainage of the abscess is the main treatment used to cure this condition. Drainage usually involves a surgical procedure. It has been shown that CT-guided drainage brought inferior results than open drainage. Hence, open surgical procedure is preferred to successfully remove the abscess. However, CT-guided drainage is the option treatment for patients who may not tolerate an open procedure. Endoscopic treatment is at the same time a treatment option that increased in popularity over the last years.
The outlook is generally based on the severity of the infection. It is however a severe complication which may result in the death of the patient if the appropriate treatment is not administered. Patients are at risk of sepsis and multiple organ failure and in cases in which the infected abscess is not removed through surgery, the mortality rate can reach 100%.
Even without treatment they rarely result in death as they will naturally break through the skin.
More recently, several North American hospitals have opted for less-invasive loop drainage over standard drainage and wound packing. In one study of 143 pediatric outcomes, a failure rate of 1.4% was reported in the loop group versus 10.5% in the packing group (P<.030), while a separate study reported a 5.5% failure rate among loop patients.
Treatment must also include a lumenal amoebicide to prevent reinvasion of tissues by amoebae still in the intestines (see Amoebiasis). After completion of treatment with tissue amebicides, administer luminal amebicides for eradication of the asymptomatic colonization state. Failure to use luminal agents can lead to relapse of infection in approximately 10% of patients.
The treatment of invasive amoebiasis should be directed to all sites where "E. histolytica" may be present. Hence the ideal amoebicide should be able to act within the intestinal lumen, in the intestinal wall, and systemically, particularly in the liver.
Systemic amoebicidal drugs include emetine, dehydroemetine, chloroquine diphosphate, metronidazole, and tinidazole.
A pyogenic liver abscess is a type of liver abscess caused by bacteria.
E.g.: stones, cholangiocarcinoma
E.g.: diverticulitis, appendicitis, Crohn's disease
E.g.: penetrating injury, iatrogenic (radiofrequency ablation)
When properly diagnosed, the mortality of Lemierre's syndrome is about 4.6%. Since this disease is not well known and often remains undiagnosed, mortality might be much higher.
Lemierre's syndrome is primarily treated with antibiotics given intravenously. "Fusobacterium necrophorum" is generally highly susceptible to beta-lactam antibiotics, metronidazole, clindamycin and third generation cephalosporins while the other fusobacteria have varying degrees of resistance to beta-lactams and clindamycin. Additionally, there may exist a co-infection by another bacterium. For these reasons is often advised not to use monotherapy in treating Lemierre's syndrome. Penicillin and penicillin-derived antibiotics can thus be combined with a beta-lactamase inhibitor such as clavulanic acid or with metronidazole. Clindamycin can be given as monotherapy.
If antibiotic therapy does not improve the clinical picture, it may prove useful to drain any abscesses and/or perform ligation of the internal jugular vein where the antibiotic can not penetrate.
There is no evidence to opt for or against the use of anticoagulation therapy. The low incidence of Lemierre's syndrome has not made it possible to set up clinical trials to study the disease.
The disease can often be untreatable, especially if other negative factors occur, i.e. various diseases occurring at the same time, such as meningitis, pneumonia.
Subphrenic abscess is a disease characterized by an accumulation of infected fluid between the diaphragm, liver, and spleen. This abscess develops after surgical operations like splenectomy.
Presents with cough, increased respiratory rate with shallow respiration, diminished or absent breath sounds, hiccups, dullness in percussion, tenderness over the 8th–11th ribs, fever, chills, anorexia and shoulder tip pain on the affected side. Lack of treatment or misdiagnosis could quickly lead to sepsis, septic shock, and death. It is also associated with peritonitis.
Recurrent pyogenic cholangitis is characterised by recurrent bouts of bacterial cholangitis with primary hepatolithiasis. It is prevalent in Hong Kong and East Asian including China, Taiwan, Korea, Japan, Indonesia and the Philippines. Apart from affecting humans it is also a common disease in cats.
Genitourinary amoebiasis or renal amoebiasis is a rare complication to amoebic liver abscess, which in turn is a complication of amoebiasis. It is believed to result from liver abscesses breaking open, whereupon the amoebas spread through the blood to the new locale. Genital involvement is thought to result from fistula formation from the liver or through rectocolitis. The involvement causes lesions which exude a high degree of pus.
The treatment includes lowering the increased intracranial pressure and starting intravenous antibiotics (and meanwhile identifying the causative organism mainly by blood culture studies).
Hyperbaric oxygen therapy (HBO2 or HBOT) is indicated as a primary and adjunct treatment which provides four primary functions.
Firstly, HBOT reduces intracranial pressure. Secondly, high partial pressures of oxygen act as a bactericide and thus inhibits the anaerobic and functionally anaerobic flora common in brain abscess. Third, HBOT optimizes the immune function thus enhancing the host defense mechanisms and fourth, HBOT has been found to be of benefit when brain abscess is concomitant with cranial osteomyleitis.
Secondary functions of HBOT include increased stem cell production and up-regulation of VEGF which aid in the healing and recovery process.
Surgical drainage of the abscess remains part of the standard management of bacterial brain abscesses. The location and treatment of the primary lesion also crucial, as is the removal of any foreign material (bone, dirt, bullets, and so forth).
There are few exceptions to this rule: "Haemophilus influenzae" meningitis is often associated with subdural effusions that are mistaken for subdural empyemas. These effusions resolve with antibiotics and require no surgical treatment. Tuberculosis can produce brain abscesses that look identical to conventional bacterial abscesses on CT imaging. Surgical drainage or aspiration is often necessary to identify "Mycobacterium tuberculosis", but once the diagnosis is made no further surgical intervention is necessary.
CT guided stereotactic aspiration is also indicated in the treatment of brain abscess.
Supportive measures may be instituted prior to surgery. These measures include fluid resuscitation. Intravenous opioids can be used for pain control.
Antibiotics are often not needed. If used they should target enteric organisms (e.g. Enterobacteriaceae), such as "E. coli" and "Bacteroides". This may consist of a broad spectrum antibiotic; such as piperacillin-tazobactam, ampicillin-sulbactam, ticarcillin-clavulanate (Timentin), a third generation cephalosporin (e.g.ceftriaxone) or a quinolone antibiotic (such as ciprofloxacin) and anaerobic bacteria coverage, such as metronidazole. For penicillin allergic people, aztreonam or a quinolone with metronidazole may be used.
In cases of severe inflammation, shock, or if the person has higher risk for general anesthesia (required for cholecystectomy), an interventional radiologist may insert a percutaneous drainage catheter into the gallbladder ('percutaneous cholecystostomy tube') and treat the person with antibiotics until the acute inflammation resolves. A cholecystectomy may then be warranted if the person's condition improves.
Homeopathic approaches to treating cholecystitis have not been validated by evidence and should not be used in place of surgery.
In RPC the gallstones found within the biliary system are calcium bilirubinate stones or pigmented calcium stones. Calcium bilirubinate stones are prevalent in Asia and very rare in Europe and the United States. In addition to the presence of these friable concretions of various shapes and sizes within the biliary tree, the bile is often muddy in consistency and contains numerous fine particles of calcium bilirubinate. This differs greatly from cholesterol stones, which are common in Europe and the United States. Pure cholesterol stones contain >96% cholesterol whereas mixed cholesterol stones contain 71.3% cholesterol. The formation of calcium bilirubinate stones in RPC has been attributed to the high incidence of infection with "Escherichia coli" in the bile. In humans, the majority of bilirubin is excreted in the bile as bilirubin glucuronide.
Hepatolithiasis is associated with Clonorchis sinensis and Ascaris lumbricoides infestation of the liver. This theory is based on high incidence of dead parasites or ova within stone in autopsy findings.
The infection is frequently penicillin resistant. There are a number of antibiotics options including amoxicillin/clavulanate, clindamycin, or metronidazole in combination with benzylpenicillin (penicillin G) or penicillin V. Piperacillin/tazobactam may also be used.
In those who have previously had cellulitis, the use of antibiotics may help prevent future episodes. This is recommended by CREST for those who have had more than two episodes.
Treatment is by removing the pus, antibiotics, sufficient fluids, and pain medication. Steroids may also be useful. Admission to hospital is generally not needed.
Death occurs in about 10% of cases and people do well about 70% of the time. This is a large improvement from the 1960s due to improved ability to image the head, better neurosurgery and better antibiotics.
For most people with acute cholecystitis, the treatment of choice is surgical removal of the gallbladder, laparoscopic cholecystectomy. Laparoscopic cholecystectomy is performed using several small incisions located at various points across the abdomen. Several studies have demonstrated the superiority of laparoscopic cholecystectomy when compared to open cholecystectomy (using a large incision in the right upper abdomen under the rib cage). People undergoing laparoscopic surgery report less incisional pain postoperatively as well as having fewer long term complications and less disability following the surgery. Additionally, laparoscopic surgery is associated with a lower rate of surgical site infection.
During the days prior to laparoscopic surgery, studies showed that outcomes were better following early removal of the gallbladder, preferably within the first week. Early laparoscopic cholecystectomy (within 7 days of visiting a doctor with symptoms) as compared to delayed treatment (more than 6 weeks) may result in shorter hospital stays and a decreased risk of requiring an emergency procedure. There is no difference in terms of negative outcomes including bile duct injury or conversion to open cholecystectomy. For early cholecystectomy, the most common reason for conversion to open surgery is inflammation that hides Calot's triangle. For delayed surgery, the most common reason was fibrotic adhesions.
A subcutaneous abscess is an abscess located in the subcutaneous tissue (also hypodermis). The abscess is formed due to a hypodermal infection by a bacterium, a fungus or a parasite. Typically, this kind of abscess needs drainage, usually for a minimum of 24 hours, by means of gauze packing or a Penrose drain.
Antibiotics choices depend on regional availability, but a penicillinase-resistant semisynthetic penicillin or a first-generation cephalosporin is currently recommended for cellulitis without abscess. A course of antibiotics is not effective in between 6 and 37% of cases.