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Hepatic abscesses: Improvement in mortality with early diagnosis and treatment
Hepatic Abscesses: Improvement in Mortality with Early Diagnosis and Treatment Bhagwan Satiani, MB, SS, Atlanta, Georgia Eugene D. Davidson, MD, Atlanta, Georgia
Early diagnosis and therapy are critical in reducing the high mortality rate in patients with hepatic abscesses 111. Despite widespread use of antibiotics, there seems to be no reduction in the incidence of pyogenic abscesses [2]. The two most frequent causes of pyogenic hepatic abscesses are antecedent biliary trace disease and cryptogenic infections. In the present study, which was conducted at Emory University, no patient with pyogenic hepatic abscess survived without operative therapy, and mortality was 13 per cent in those receiving surgical therapy. Patients with amebic abscesses of the liver were successfully treated when the diagnosis was correctly established. The methods of disease recognition and appropriate therapy are discussed herein. Material and Methods Clinical Material
During a ten year period ending December 31,1976 at Affiliated Hospitals, thirty-eight patients with hepatic abscesses were identified. There were thirty-three cases of pyogenic abscesses and five cases of amebic abscesses. All pyogenic abscesses were confirmed at operation or autopsy and amebic abscesses were diagnosed by positive hepatic scans, ultrasound examination, positive hemagglutination inhibition tests, aspiration of abscess contents, and in one case, by autopsy. Patients examined were classified according to age, sex, racial characteristics, clinical presentation, radiographic findings, bacteriology, location, therapy, and outcome. The ages ranged from thirteen to eighty-six years (mean, 49 years). There were twenty-eight males and ten females;
the Emory University
twenty-three were white and fifteen were black. The duration of symptoms prior to admission varied considerably from one day to three months (mean, 20.7 days). The difficulties in diagnosis and treatment are reflected by a mean From the Joseph Brown Whit Depamnent of Surgery, Emory University School of Medicine, Atlanta, and Veterans Administration Hospital, Decatur, Georgia. Reprint requests should be addressed to E. D. Davidson, MD. Veterans Administration Hospital, 1670 Clairmont Road, Decatur, Georgia 30033.
vehwne 135, May 1978
hospital stay of forty days in this group of patients. Symptoms elicited were similar in patients with pyogenic abscesses and those with amebic abscesses. Fever was recorded in thirty-six of these thirty-eight patients and anorexia, abdominal pain, weight loss, and nausea and vomiting were reported in approximately 50 per cent of these patients. Physical examination revealed upper abdominal tenderness in 66 per cent of the patients with 21 per cent of the patient group presenting with clinical jaundice. Five patients (13 per cent) had hepatomegaly and four patients had a pleural friction rub with an additional four patients presenting with an abdominal mass. Associated laboratory findings included leukocytosis in 86.5 per cent of the patients, anemia in 51 per cent, elevated serum bilirubin level in 36 per cent, and elevated alkaline phosphatase level in 63 per cent. Anemia was more common in patients who subsequently died (7 of 11) than in survivors (8 of 27). Alkaline phosphatase was elevated in two thirds of all patients but was not prognostically significant. An elevated serum bilirubin level was detected‘in approximately one third of the patients and in all patients who died of pyogenic or amebic abscesses. Radiologic abnormalities included abnormal chest films in 45 per cent of the patients, with either infiltrate, elevated hemidiaphragm, or pleural effusion being seen in this group. Abdominal flat fihns, upper gastrointestinal studies, and forms of cholangiography yielded positive results in occasional patients. Isotope liver-spleen scans were positive in eighteen of twenty patients with solitary abscesses and five.of seven patients with multiple abscesses. (Figure 1.) Angiography was performed on six patients and was diagnostic in each case. (Figure 2.) Ultrasonography was performed on one patient and was positive for an hepatic abscess. Solitary abscesses were present in twenty-four patients and multiple abscesses .were found in fourteen. The sole area of abscess was the right lobe in 79 per cent of patients, the left lobe in 5 per cent of patients, and bilobar abscesses were found in 16 per cent of the patients. All patients with amebic abscesses had involvement of the right lobe only. A correct preoperative assessment was made in 60 per cent of all patients. Acute cholecystitis was the most
647
Hepatic Abscess
Figure 1. Liver scan showing a large filling defect in the right hepatic lobe of a patient with a solitary pyogenic abscess.
common incorrect preoperative diagnosis with subphrenic abscess, ascending cholangitis, appendicitis, abdominal malignancy, and fever of unknown origin being other preoperative diagnoses. Six patients in the pyogenic group did not undergo operation, and the diagnosis was made at autopsy in each of these patients. In four of the five patients with amebic abscesses the diagnosis was made serologically, and aspiration was performed in two of the four patients. At autopsy, one patient was found to have disseminated amebiasis and amebic hepatic abscess. Twenty-four patients in the pyogenic group had blood cultures drawn, fourteen (58 per cent) of which were positive. Twenty different bacterial species were isolated from these fourteen patients, including seventeen aerobic and three anaerobic organisms. Three patients grew two separate organisms, and one patient grew four organisms from blood culture. Of the four patients with multiple organisms in their blood, three died. Twenty-five of twenty-eight patients undergoing operation and drainage of pyogenic abscesses had positive bacterial growth from the abscess cavity. Aerobic organisms predominated in this group with thirty-two species being isolated in addition to four anaerobic species. Escherichia coli and streptococci were most commonly found followed by pseudomonas and enterobacter species.
Intraperitoneal exploration and drainage was undertaken in the majority of patients, with an average delay of 8.2 days between admission and surgical drainage. Appropriate antibiotic coverage was instituted in most cases preoperatively and was altered as cultures and antibiotic sensitivitks indicated. Until sinograms showed resolution of,the abscess cavity, drainage catheters were retained. Amebic abscesses were treated successfully by three different treatment regimens: two patients received emetine hydrochloride, chloroquin, and tetracycline; metronidazole (FlagyF), 750 mg three times a day, was admin-
646
Figure 2. Selective hepatic angiogram demonstrating an. avascuiar mass in the right lobe of a patient with a solitary pyogenic abscess.
istered to one patient; and chloroquin was used in addition to metronidazole in the fourth patient. The average length of treatment was fourteen days. Each drug regimen resulted in rapid control of symptoms and cure of the disease with no recurrence. Fifteen major complications were recorded in thirteen treated patients (42 per cent). There was rupture of the abscess into the right hemithorax and resultant bronchial fistula in two patients with pyogenic abscesses (with 1 death) and in one patient with an amebic abscess. Acute renal failure was observed in three treated patients with two deaths. There were two pelvic abscesses, including one amebic pelvic abscess, one brain abscess with meningitis, and one wound infectron. One patient developed purulent pericarditis and expired. There were two recurrent pyogenic abscesses in the follow-up period with one mortality. Overall, eleven of these thirty-eight patients identified with liver abscesses died, a mortality of 29 per cent. Of the thirty-one patients who were treated only four (13 per cent) died. Seven of the deaths represented patients in whom the diagnosis was not made antemortem. The overall mortality rate was 42 per cent in the first five years of the study, and 16 per cent in the last five year period ending December 31, 1976. Mortality rates in this series showed an expected increase in patients more than sixty years old. There was a 38 per cent mortality rate in patients in this age group. Table I shows the mortality rate broken down by sex, race, etiology, type of organism, location, and whether the abscess was multiple or solitary. Fischer’s exact test revealed
The Amerlcen Journal of Surgery
Satiani and Davidson
that the presence of multiple abscesses was significantly more lethal (p < 0.035). It is also interesting that the mortality rate of Caucasian patients was significantly
TABLE I
greater than black patients in this series (p < 0.015); however, the reasons for this racial difference are not apparent.
White Black Male Female
23 15 28 10
Comments
Right lobe Left lobe Both lobes
30 (79%) 2 (5%) 6 (16%)
Pyogenic Amebic
33 5
10 (30.0%) 1 (20.0%)
Solitary Multiple
24 14
4 (16.6%) 7 (50.0%)
Pure aerobic organism Anaerobic present
20 4
4 (20.0%) 2 (50.0%)
A discussion of liver abscesses was published as early as 1879 by Paschal [3] who observed that 10 to 30 per cent of untreated abscesses ruptured into the lung and another 30 per cent into the peritoneal cavity. He recommended extraperitoneal drainage, if possible. Although the incidence of pyogenic liver abscesses has not changed dramatically over the past few decades, the underlying etiology and age distribution have [4]. Appendicitis is now an uncommon cause of pyogenic hepatic abscess. Suppurative pylephlebitis is consequently rare and was observed at autopsy in only one patient in our series. Cryptogenic abscesses were most common in our series with abscesses secondary to biliary tract disease seen next most frequently. Hepatic abscesses were previously described as occurring more frequently in the third decade of life [5]. They are now encountered more frequently in older individuals, consistent with a decrease in abscesses associated with appendicitis. Furey [6] has pointed out that liver abscesses associated with ascending cholangitis are rare in neo. plastic obstruction, unless accompanied by calculi or following a biliary operation. He also correctly emphasized that fever, jaundice, and cardiovascular collapse in this setting are indicative of acute cholangitis. Predictably, normal liver function tests are usually found in the majority of patients with a solitary lesion, except for an elevated alkaline phosphatase level, which is often the only clue to the correct diagnosis. Hirschowitz [7] stated that this pattern was strongly suggestive of the presence of an hepatic abscess or malignancy. Although overpenetrated thoracoabdominal films, cholangiograms, and barium studies are sometimes useful, isotope liver scanning has proved to be of tremendous value in early diagnosis. The high degree of diagnostic accuracy observed in the present study with liver scans and angiography in patients with multiple abscesses has been confirmed by others [2,8]. Ultrasound and computerized axial tomography might be useful, but experience with these new noninvasive diagnostic modalities needs to be accumulated. Portal venography via contrast injection through the obliterated umbilical vein has been proposed for diagnosis but has had limited trial [9].
vowm 196, May 1979
Mortality of Liver Abscess Patients
Mortalities 10 (43.5%) 1 (6.7%) 7 (25.0%) 4 (40.0%) 5 (17.0%) 1 (50.0%) 5 (83.0%)
The most common organism responsible for hepatic abscess remains Escherichia coli [4,10]. In contrast to earlier reports [4,11], anaerobic abscesses in this series were not common and, when present, were more often associated with biliary tract disease. Anaerobic abscess may be suspected on the basis of spiking fevers, irrational behavior, operative findings of gas and foul smelling pus in the abscess cavity, a unique morphology on gram stain, and lack of aerobic growth. Although successful treatment of solitary pyogenic abscesses with percutaneous needle aspiration and antibiotic administration has been described [IL?], this has not been widely accepted. In our opinion, surgical drainage is imperative, and therapeutic aspiration is indicated in selected amebic abscesses only. An anterior approach is generally indicated for treatment of associated intraabdominal pathology, although the posterior (Ochsner) approach has been preferred by some when a solitary abscess has been localized preoperatively in the superior or posterior aspect of the right lobe. Palpation of the liver followed by needle aspiration of suspicious areas and subsequent dependent drainage with a large sump catheter is usually sufficient. Choledochotomy is obviously mandatory in underlying acute obstructive suppurative cholangitis. Ineffective biliary decompression has been suggested as the cause of multiple abscesses, and despite the introduction of newer antibiotics, the prognosis for patients with multiple hepatic abscesses remains poor [4,13]. Aggressive antibiotic therapy directed by cultures obtained from the blood and abscess cavity plus removal of the underlying condition offers the best chance of survival when surgically undrainable multiple abscesses are encountered. Penicillin or erythromycin and chloraphenicol have been recommended while awaiting bacteriologic data ]4]. Reported mortality rates of hepatic abscesses vary
649
Satiani and Davidson
considerably depending upon the etiology, incidence of multiple abscesses, and frequency of anaerobic participation. The average mortality rate in six recent reports [1,2,4,10,14,15] was 60 per cent (30 to 80 per cent). Our overall mortality of 29 per cent compares favorably with these reports. Our figures include all multiple abscesses and those discovered at autopsy. Amebic abscesses may be seen in patients in all parts of the country. Hemagglutination inhibition tests should be obtained in all suspected amebic abscesses. DeBakey and Ochsner [16] reviewed 263 cases of amebic abscesses in 1951 with 5.5 per cent mortality for sterile and 42.9 per cent for infected amebic abscesses, with the overall mortality being 22 per cent. The mortality rate should be lowered with early recognition and appropriate therapy; the only death from an amebic abscess in our series resulted from failure in diagnosis. Summary
This study demonstrates that hepatic abscesses are highly lethal when untreated. There was an overall mortality of 29 per cent; however, if autopsy cases are excluded the mortality was only 13 per cent. Positive blood cultures (especially if multiple or anaerobic organisms), significant anemia, elevated bilirubin levels, multiple abscesses, and being Caucasian were identified as factors associated with increased mortality. Early diagnosis coupled with aggressive surgical and antibiotic therapy is needed.
650
References 1. Altemeier WA, Schwengerdt CG, Whiteley OH: Abscesses of the liver: surgical considerations. Arch Surg 101: 258, 1970. 2. Ranson JHC, Madayag MH, Localio SA, Spencer FA: New diagnostic and therapeutic techniques in management of pyogenic liver abscesses. Ann Surg 181: 508, 1975. 3. Paschal F: Treatment of abscesses of the liver by drainage. Gaillards t&d J 28: 113, 1879. 4. Pitt HA, Zuidema GD: Factors influencing mortality in the treatment of pyogenic hepatic abscesses. Surg Gynecol Obstet 140: 228. 1975. 5. Ochsner A, DeBakey M, Murray S: Pyogenic abscess of the liver. II. An analysis of forty-seven cases with review of the literature. Am J Surg 40: $92, 1938. 8. Furev AT: Ascendina cholanaitis. NY./ Med 86: 1299, 1906. 7. Hirschowitz 61: Pyog&ic liver &scess. Review wifh case report of solitary abscess caused by salmonella enteritis. Gastfoenterology21: 291, 1952. 8. Shingleton WW, Taylor LA, Pincher FJ: Radioisotope photoscan of liver in differential diagnosis of upper abdominal disease: review of 232 cases. Ann Surg 163: 885, 1966. 9. Piccone VA: In Discussion of Joseph WL, Kahn AM, Longmire WP Jr: Pyogenic liver abscess: changing patterns in approach. Am J Surg 115: 83, 1968. 10. Warren KW, Hardy KJ: Pyogenic hepatic abscess. Arch Surg 97: 40, 1988. 11. Sabbaj J, Sutter VL, Finegold SM: Anaerobic pyogenic liver abscess. Ann Intern Med 77: 829, 1972. 12. McFadzean AJS, Chang KPS, Wong C: Solitary pyogenic abscess of the liver treated by closed aspiration and antibiotics. Br J Surg 41: 141, 1953. 13. Dow RW, Lindenauer SM: Acute obstructive suppurative cholangitis. Ann Surg 189: 272, 1969. 14. Joseph WL, Kahn AM, Longmire WP Jr: Pyogenic liver abscess: changing patterns in approach. Am J Surg 115: 63, 1968. 15. Gaisford WD, Mark JBD: Surgical management of hepatic abscess. Am JSurg 118: 317, 1969. 16. DeBakey ME, Ochsner A: Hepatic amebiasis: a twenty year experience and analysis of 263 cases. Surg Gynecol Obstet 92: 209, 1951.
The American Journal ol Surf
Early diagnosis and therapy are critical in reducing the high mortality rate in patients with hepatic abscesses 111. Despite widespread use of antibiotics, there seems to be no reduction in the incidence of pyogenic abscesses [2]. The two most frequent causes of pyogenic hepatic abscesses are antecedent biliary trace disease and cryptogenic infections. In the present study, which was conducted at Emory University, no patient with pyogenic hepatic abscess survived without operative therapy, and mortality was 13 per cent in those receiving surgical therapy. Patients with amebic abscesses of the liver were successfully treated when the diagnosis was correctly established. The methods of disease recognition and appropriate therapy are discussed herein. Material and Methods Clinical Material
During a ten year period ending December 31,1976 at Affiliated Hospitals, thirty-eight patients with hepatic abscesses were identified. There were thirty-three cases of pyogenic abscesses and five cases of amebic abscesses. All pyogenic abscesses were confirmed at operation or autopsy and amebic abscesses were diagnosed by positive hepatic scans, ultrasound examination, positive hemagglutination inhibition tests, aspiration of abscess contents, and in one case, by autopsy. Patients examined were classified according to age, sex, racial characteristics, clinical presentation, radiographic findings, bacteriology, location, therapy, and outcome. The ages ranged from thirteen to eighty-six years (mean, 49 years). There were twenty-eight males and ten females;
the Emory University
twenty-three were white and fifteen were black. The duration of symptoms prior to admission varied considerably from one day to three months (mean, 20.7 days). The difficulties in diagnosis and treatment are reflected by a mean From the Joseph Brown Whit Depamnent of Surgery, Emory University School of Medicine, Atlanta, and Veterans Administration Hospital, Decatur, Georgia. Reprint requests should be addressed to E. D. Davidson, MD. Veterans Administration Hospital, 1670 Clairmont Road, Decatur, Georgia 30033.
vehwne 135, May 1978
hospital stay of forty days in this group of patients. Symptoms elicited were similar in patients with pyogenic abscesses and those with amebic abscesses. Fever was recorded in thirty-six of these thirty-eight patients and anorexia, abdominal pain, weight loss, and nausea and vomiting were reported in approximately 50 per cent of these patients. Physical examination revealed upper abdominal tenderness in 66 per cent of the patients with 21 per cent of the patient group presenting with clinical jaundice. Five patients (13 per cent) had hepatomegaly and four patients had a pleural friction rub with an additional four patients presenting with an abdominal mass. Associated laboratory findings included leukocytosis in 86.5 per cent of the patients, anemia in 51 per cent, elevated serum bilirubin level in 36 per cent, and elevated alkaline phosphatase level in 63 per cent. Anemia was more common in patients who subsequently died (7 of 11) than in survivors (8 of 27). Alkaline phosphatase was elevated in two thirds of all patients but was not prognostically significant. An elevated serum bilirubin level was detected‘in approximately one third of the patients and in all patients who died of pyogenic or amebic abscesses. Radiologic abnormalities included abnormal chest films in 45 per cent of the patients, with either infiltrate, elevated hemidiaphragm, or pleural effusion being seen in this group. Abdominal flat fihns, upper gastrointestinal studies, and forms of cholangiography yielded positive results in occasional patients. Isotope liver-spleen scans were positive in eighteen of twenty patients with solitary abscesses and five.of seven patients with multiple abscesses. (Figure 1.) Angiography was performed on six patients and was diagnostic in each case. (Figure 2.) Ultrasonography was performed on one patient and was positive for an hepatic abscess. Solitary abscesses were present in twenty-four patients and multiple abscesses .were found in fourteen. The sole area of abscess was the right lobe in 79 per cent of patients, the left lobe in 5 per cent of patients, and bilobar abscesses were found in 16 per cent of the patients. All patients with amebic abscesses had involvement of the right lobe only. A correct preoperative assessment was made in 60 per cent of all patients. Acute cholecystitis was the most
647
Hepatic Abscess
Figure 1. Liver scan showing a large filling defect in the right hepatic lobe of a patient with a solitary pyogenic abscess.
common incorrect preoperative diagnosis with subphrenic abscess, ascending cholangitis, appendicitis, abdominal malignancy, and fever of unknown origin being other preoperative diagnoses. Six patients in the pyogenic group did not undergo operation, and the diagnosis was made at autopsy in each of these patients. In four of the five patients with amebic abscesses the diagnosis was made serologically, and aspiration was performed in two of the four patients. At autopsy, one patient was found to have disseminated amebiasis and amebic hepatic abscess. Twenty-four patients in the pyogenic group had blood cultures drawn, fourteen (58 per cent) of which were positive. Twenty different bacterial species were isolated from these fourteen patients, including seventeen aerobic and three anaerobic organisms. Three patients grew two separate organisms, and one patient grew four organisms from blood culture. Of the four patients with multiple organisms in their blood, three died. Twenty-five of twenty-eight patients undergoing operation and drainage of pyogenic abscesses had positive bacterial growth from the abscess cavity. Aerobic organisms predominated in this group with thirty-two species being isolated in addition to four anaerobic species. Escherichia coli and streptococci were most commonly found followed by pseudomonas and enterobacter species.
Intraperitoneal exploration and drainage was undertaken in the majority of patients, with an average delay of 8.2 days between admission and surgical drainage. Appropriate antibiotic coverage was instituted in most cases preoperatively and was altered as cultures and antibiotic sensitivitks indicated. Until sinograms showed resolution of,the abscess cavity, drainage catheters were retained. Amebic abscesses were treated successfully by three different treatment regimens: two patients received emetine hydrochloride, chloroquin, and tetracycline; metronidazole (FlagyF), 750 mg three times a day, was admin-
646
Figure 2. Selective hepatic angiogram demonstrating an. avascuiar mass in the right lobe of a patient with a solitary pyogenic abscess.
istered to one patient; and chloroquin was used in addition to metronidazole in the fourth patient. The average length of treatment was fourteen days. Each drug regimen resulted in rapid control of symptoms and cure of the disease with no recurrence. Fifteen major complications were recorded in thirteen treated patients (42 per cent). There was rupture of the abscess into the right hemithorax and resultant bronchial fistula in two patients with pyogenic abscesses (with 1 death) and in one patient with an amebic abscess. Acute renal failure was observed in three treated patients with two deaths. There were two pelvic abscesses, including one amebic pelvic abscess, one brain abscess with meningitis, and one wound infectron. One patient developed purulent pericarditis and expired. There were two recurrent pyogenic abscesses in the follow-up period with one mortality. Overall, eleven of these thirty-eight patients identified with liver abscesses died, a mortality of 29 per cent. Of the thirty-one patients who were treated only four (13 per cent) died. Seven of the deaths represented patients in whom the diagnosis was not made antemortem. The overall mortality rate was 42 per cent in the first five years of the study, and 16 per cent in the last five year period ending December 31, 1976. Mortality rates in this series showed an expected increase in patients more than sixty years old. There was a 38 per cent mortality rate in patients in this age group. Table I shows the mortality rate broken down by sex, race, etiology, type of organism, location, and whether the abscess was multiple or solitary. Fischer’s exact test revealed
The Amerlcen Journal of Surgery
Satiani and Davidson
that the presence of multiple abscesses was significantly more lethal (p < 0.035). It is also interesting that the mortality rate of Caucasian patients was significantly
TABLE I
greater than black patients in this series (p < 0.015); however, the reasons for this racial difference are not apparent.
White Black Male Female
23 15 28 10
Comments
Right lobe Left lobe Both lobes
30 (79%) 2 (5%) 6 (16%)
Pyogenic Amebic
33 5
10 (30.0%) 1 (20.0%)
Solitary Multiple
24 14
4 (16.6%) 7 (50.0%)
Pure aerobic organism Anaerobic present
20 4
4 (20.0%) 2 (50.0%)
A discussion of liver abscesses was published as early as 1879 by Paschal [3] who observed that 10 to 30 per cent of untreated abscesses ruptured into the lung and another 30 per cent into the peritoneal cavity. He recommended extraperitoneal drainage, if possible. Although the incidence of pyogenic liver abscesses has not changed dramatically over the past few decades, the underlying etiology and age distribution have [4]. Appendicitis is now an uncommon cause of pyogenic hepatic abscess. Suppurative pylephlebitis is consequently rare and was observed at autopsy in only one patient in our series. Cryptogenic abscesses were most common in our series with abscesses secondary to biliary tract disease seen next most frequently. Hepatic abscesses were previously described as occurring more frequently in the third decade of life [5]. They are now encountered more frequently in older individuals, consistent with a decrease in abscesses associated with appendicitis. Furey [6] has pointed out that liver abscesses associated with ascending cholangitis are rare in neo. plastic obstruction, unless accompanied by calculi or following a biliary operation. He also correctly emphasized that fever, jaundice, and cardiovascular collapse in this setting are indicative of acute cholangitis. Predictably, normal liver function tests are usually found in the majority of patients with a solitary lesion, except for an elevated alkaline phosphatase level, which is often the only clue to the correct diagnosis. Hirschowitz [7] stated that this pattern was strongly suggestive of the presence of an hepatic abscess or malignancy. Although overpenetrated thoracoabdominal films, cholangiograms, and barium studies are sometimes useful, isotope liver scanning has proved to be of tremendous value in early diagnosis. The high degree of diagnostic accuracy observed in the present study with liver scans and angiography in patients with multiple abscesses has been confirmed by others [2,8]. Ultrasound and computerized axial tomography might be useful, but experience with these new noninvasive diagnostic modalities needs to be accumulated. Portal venography via contrast injection through the obliterated umbilical vein has been proposed for diagnosis but has had limited trial [9].
vowm 196, May 1979
Mortality of Liver Abscess Patients
Mortalities 10 (43.5%) 1 (6.7%) 7 (25.0%) 4 (40.0%) 5 (17.0%) 1 (50.0%) 5 (83.0%)
The most common organism responsible for hepatic abscess remains Escherichia coli [4,10]. In contrast to earlier reports [4,11], anaerobic abscesses in this series were not common and, when present, were more often associated with biliary tract disease. Anaerobic abscess may be suspected on the basis of spiking fevers, irrational behavior, operative findings of gas and foul smelling pus in the abscess cavity, a unique morphology on gram stain, and lack of aerobic growth. Although successful treatment of solitary pyogenic abscesses with percutaneous needle aspiration and antibiotic administration has been described [IL?], this has not been widely accepted. In our opinion, surgical drainage is imperative, and therapeutic aspiration is indicated in selected amebic abscesses only. An anterior approach is generally indicated for treatment of associated intraabdominal pathology, although the posterior (Ochsner) approach has been preferred by some when a solitary abscess has been localized preoperatively in the superior or posterior aspect of the right lobe. Palpation of the liver followed by needle aspiration of suspicious areas and subsequent dependent drainage with a large sump catheter is usually sufficient. Choledochotomy is obviously mandatory in underlying acute obstructive suppurative cholangitis. Ineffective biliary decompression has been suggested as the cause of multiple abscesses, and despite the introduction of newer antibiotics, the prognosis for patients with multiple hepatic abscesses remains poor [4,13]. Aggressive antibiotic therapy directed by cultures obtained from the blood and abscess cavity plus removal of the underlying condition offers the best chance of survival when surgically undrainable multiple abscesses are encountered. Penicillin or erythromycin and chloraphenicol have been recommended while awaiting bacteriologic data ]4]. Reported mortality rates of hepatic abscesses vary
649
Satiani and Davidson
considerably depending upon the etiology, incidence of multiple abscesses, and frequency of anaerobic participation. The average mortality rate in six recent reports [1,2,4,10,14,15] was 60 per cent (30 to 80 per cent). Our overall mortality of 29 per cent compares favorably with these reports. Our figures include all multiple abscesses and those discovered at autopsy. Amebic abscesses may be seen in patients in all parts of the country. Hemagglutination inhibition tests should be obtained in all suspected amebic abscesses. DeBakey and Ochsner [16] reviewed 263 cases of amebic abscesses in 1951 with 5.5 per cent mortality for sterile and 42.9 per cent for infected amebic abscesses, with the overall mortality being 22 per cent. The mortality rate should be lowered with early recognition and appropriate therapy; the only death from an amebic abscess in our series resulted from failure in diagnosis. Summary
This study demonstrates that hepatic abscesses are highly lethal when untreated. There was an overall mortality of 29 per cent; however, if autopsy cases are excluded the mortality was only 13 per cent. Positive blood cultures (especially if multiple or anaerobic organisms), significant anemia, elevated bilirubin levels, multiple abscesses, and being Caucasian were identified as factors associated with increased mortality. Early diagnosis coupled with aggressive surgical and antibiotic therapy is needed.
650
References 1. Altemeier WA, Schwengerdt CG, Whiteley OH: Abscesses of the liver: surgical considerations. Arch Surg 101: 258, 1970. 2. Ranson JHC, Madayag MH, Localio SA, Spencer FA: New diagnostic and therapeutic techniques in management of pyogenic liver abscesses. Ann Surg 181: 508, 1975. 3. Paschal F: Treatment of abscesses of the liver by drainage. Gaillards t&d J 28: 113, 1879. 4. Pitt HA, Zuidema GD: Factors influencing mortality in the treatment of pyogenic hepatic abscesses. Surg Gynecol Obstet 140: 228. 1975. 5. Ochsner A, DeBakey M, Murray S: Pyogenic abscess of the liver. II. An analysis of forty-seven cases with review of the literature. Am J Surg 40: $92, 1938. 8. Furev AT: Ascendina cholanaitis. NY./ Med 86: 1299, 1906. 7. Hirschowitz 61: Pyog&ic liver &scess. Review wifh case report of solitary abscess caused by salmonella enteritis. Gastfoenterology21: 291, 1952. 8. Shingleton WW, Taylor LA, Pincher FJ: Radioisotope photoscan of liver in differential diagnosis of upper abdominal disease: review of 232 cases. Ann Surg 163: 885, 1966. 9. Piccone VA: In Discussion of Joseph WL, Kahn AM, Longmire WP Jr: Pyogenic liver abscess: changing patterns in approach. Am J Surg 115: 83, 1968. 10. Warren KW, Hardy KJ: Pyogenic hepatic abscess. Arch Surg 97: 40, 1988. 11. Sabbaj J, Sutter VL, Finegold SM: Anaerobic pyogenic liver abscess. Ann Intern Med 77: 829, 1972. 12. McFadzean AJS, Chang KPS, Wong C: Solitary pyogenic abscess of the liver treated by closed aspiration and antibiotics. Br J Surg 41: 141, 1953. 13. Dow RW, Lindenauer SM: Acute obstructive suppurative cholangitis. Ann Surg 189: 272, 1969. 14. Joseph WL, Kahn AM, Longmire WP Jr: Pyogenic liver abscess: changing patterns in approach. Am J Surg 115: 63, 1968. 15. Gaisford WD, Mark JBD: Surgical management of hepatic abscess. Am JSurg 118: 317, 1969. 16. DeBakey ME, Ochsner A: Hepatic amebiasis: a twenty year experience and analysis of 263 cases. Surg Gynecol Obstet 92: 209, 1951.
The American Journal ol Surf