An overview on liver abscess in children. Causes, diagnosis and management.

1. LIVER ABSCESS
Dr Joyce Mwatonoka
3rd Year Resident
Pediatrics and Child Health
March 2021

2. Introduction
 Pyogenic liver abscesses are rare in
children
 50% are seen in children < 6yrs old
 Solitary liver abscesses (70% of
cases) in the Right lobe of the liver
(75% of cases) are more common
than multiple abscesses or solitary
Left lobe abscesses

3. Epidemiology
 Liver abscesses are the most common
type of visceral abscess
 Incidence 10/100,000. M>F
 In a report of 540 cases of
intraabdominal abscesses pyogenic
liver abscesses accounted for 48%
Intra-abdominal abscesses. Altemeier WA, Culbertson WR, Fullen WD,
Shook CD Am J Surg. 1973;125(1):70.

4. Risk factors
 DM
 Underlying hepatobiliary or pancreatic
disease
 Liver transplant
 Regular use of proton-pump inhibitors
(increase gastric Ph, impair defense
mechanisms against ingested pathogens
– Klebsiella pneumoniae)
 Immunosuppression
 Geographical location (eg; East Asia)

5. Causes and pathogenesis
 Via the portal
circulation in cases
of omphalitis, portal
vein pylephlebitis,
intraabdominal
infection, or abscess
secondary to
appendicitis or
inflammatory bowel
disease
 A primary
bacteremia (sepsis,
endocarditis)
 Ascending
cholangitis
associated with
biliary tract
obstruction caused
by gallstones or
sclerosing
cholangitis or
secondary to
choledochal cysts
 Contiguous infection
(subphrenic
abscess) or
penetrating trauma;

6. Cont…
 Very rarely, liver abscesses occur after
percutaneous liver biopsy
 In neonates; association with sepsis,
umbilical vein associated infection, or
cannulation
 In adults liver transplantation is a
significant risk factor (unknown in
pediatric)

7. Cont…
 Children with chronic granulomatous
disease, Job syndrome, or cancer are
also at increased risk for a hepatic
abscess

8. Most common pathogenic
organisms;
 Staphylococcus
aureus
 Streptococcus spp
 Escherichia coli
 Klebsiella
pneumoniae
 Salmonella, and
 Anaerobic
organisms
 Entamoeba
histolytica or
Toxocara canis–
associated liver in
developing
countries or in
highly endemic
areas

9. Cont…
 If E. histolytica is recovered from the
stool, distinguish it from Entamoeba
dispar, which looks similar but is
nonpathogenic (antiamebic antibodies)
 Multiple microabscesses are most
commonly secondary to bacteremia,
candidemia, or cat scratch disease
(Bartonella henselae infection; one of the
commonest causes of FUO in children)
 Polymicrobial involvement is seen in
approximately 50%

10. Clinical presentation
 High index of suspicion for those with
risk factors
 Dx can be challenging and is often
delayed
 Signs and sxs are nonspecific and can
include fever, abdominal pain, chills,
night sweats, malaise, fatigue,
nausea, with RUQ tenderness, and
hepatomegaly
 Jaundice is uncommon

11. Investigations
 AST, and more often ALP are
elevated
 ESR is high
 FBP; Leukocytosis is common
 Blood cultures are positive in 50% of
pts

12. Cont…
 CXR might show elevation of the Rt
hemidiaphragm or a right pleural effusion
 Ultrasound (hypo- to hyperechoic,
septations) or CT (hypoattenuation)can
confirm dx (sensitivity 85% and 95%
respectively)
 MRI
Diagnosis of pyogenic liver abscess by abdominal ultrasonography in the
emergency department. Lin AC, Yeh DY, Hsu YH, Wu CC, Chang H, Jang
TN, Huang CH Emerg Med J. 2009;26(4):273

13. Ultrasound (Lt) and CT scan
images

14. Cont…
 Enzyme-linked immunosorbent assay
testing for E. histolytica Gal/GalNAc
(galactose/N-acetyl-d-galactosamine)
lectin in serum is usually positive with
amebiasis

15. Differential diagnoses
 Hepatitis of any cause (eg, viral, drug
induced)
 Primary or secondary liver tumors
 Right lower lobe pneumonia
 Acute cholangitis
 Acute cholecystitis
 Tuberculous liver abscesses
 Hepatic hydatid cysts (Echinococcus)
 Hepatosplenic candidiasis, with
microabscesses

16. Treatment
 Treatment requires percutaneous
ultrasound- or CT-guided needle
aspiration/catheter drainage and less
often open surgical drainage,
particularly if multiple or large
abscesses are present
 Some place a drain and leave it in
until the abscess wall collapses,
others just do single or repeated
aspirations

17. Drainage
Both therapeutic and diagnostic
 CT-guided or ultrasound-guided
percutaneous drainage (with needle
aspiration only or with catheter
placement)
 Open surgical drainage
 Laparoscopic drainage
 Drainage by endoscopic retrograde
cholangiopancreatography (ERCP)

18. Cont…
 Single, unilocular abscesses with a
diameter ≤5 cm; Percutaneous
drainage with either catheter
placement or needle aspiration
 Single, unilocular abscesses with
diameter >5 cm; catheter preferred

19. Cont…
 Multiple or multiloculated
abscesses; decision made on an
individual basis by a multidisciplinary
team taking into account the number,
size, and accessibility of the
abscess(es), the experience of the
surgeons and radiologists
Percutaneous needle aspiration versus catheter drainage in the management of
liver abscess: a systematic review and meta-analysis. Cai YL, et al. HPB
(Oxford). 2015;17(3):195. Epub 2014 Sep 10

20. Antibiotic therapy
 Treatment recommendations are
based upon the probable source of
infection and should be guided by
local bacterial resistance patterns, if
known
 The empiric regimen should cover
streptococci, enteric gram-negative
bacilli, and anaerobes. In addition E.
histolytica (unless involvement
unlikely)

21. Cont…
 A third or later generation
cephalosporin (eg, ceftriaxone)
plus metronidazole
 A beta-lactam-beta-lactamase inhibitor
combination (eg, piperacillin-
tazobactam) with or
without metronidazole (the
metronidazole for E.
histolytica coverage)
 Ampicillin plus gentamicin plus metron

22. Cont…
Alternative regimens include:
 A fluoroquinolone with metronidazole
 A carbapenem with or
without metronidazole (the
metronidazole would be to provide E.
histolytica coverage)
 If the pt is in septic shock or if S.
aureus is a concern (eg, indwelling
catheter or injection drug use),
add vancomycin

23. Cont…
 Regardless of whether a causative
organism has been identified,
antibiotic therapy is recommended for
4-6wks
 If no culture results, empiric oral
antibiotic choices include amoxicillin-
clavulanate alone, or a
fluoroquinolone plus metronidazole
A pilot study of oral fleroxacin once daily compared with conventional
therapy in patients with pyogenic liver abscess.AUChen YW, Chen YS,
Lee SS, Yen MY, Wann SR, Lin HH, Huang WK, Liu YC SOJ Microbiol
Immunol Infect. 2002;35(3):179

24. Follow-up
 Should only be done in the setting of
persistent clinical symptoms or if
drainage is not proceeding as
expected
 Radiological abnormalities resolve
much more slowly (16 – 22 weeks)
than clinical and biochemical markers
Long-term follow-up of pyogenic liver abscess by ultrasound. K C S,
Sharma D Eur J Radiol. 2010 Apr;74(1):195-8. Epub 2009 Feb 12.

25. Prognosis
 Mortality has decreased significantly
with early dx and initiation of
appropriate therapy
 The mortality rate in developed
countries ranges from 2 to 12%
 Independent risk factors for mortality
include need for open surgical
drainage, the presence of malignancy,
and the presence of anaerobic
infection

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ATTENTION!