Diagnosis
Liver abscess
A collection of pus in the liver.
Etiology
Cause [moc]
Bacteria: Escherichia coli, Klebsiella, Streptococcus, Staphylococcus, Proteus
Amoeba: Entamoeba histolytica
Parasite: Echinococcus multilocularis
Fungus
Pathophysiology [moc]
Sepsis (hematologic dissemination through the portal vein)
Endocarditis
Biliary tract disease: biliary stone, cholecystitis, perforated gallbladder, cholangitis, stricture, malignancy, congenital anomalies)
Diverticulitis/appendicitis
Liver cancer or liver metastases
Penetrating trauma
Risk factors [moc]
Diabetes
Cirrhosis
Male gender
Elderly
Immunocompromised states
Proton pump inhibitor
Intraabdominal infection
Chemoembolization
Endoscopic retrograde cholangiography
Complications [moc]
Rupture --> peritonitis and shock
Liver or kidney failure
Recurring liver abscesses
Subphrenic abscess
Fistula to organs nearby (such as pleuropulmonary and hypobranchial fistula)
Acute pancreatitis
Abdominal or hepatic venous thrombosis
Liver pseudoaneurysm
Infectious metastatic complications include endophthalmitis or central nervous system septic emboli
Epidemiology
Incidence per 100.000 [moc][kpn][cbb][gmk][wmq][qg9][bbn][hte][fv6]
Symptoms & findings
Symptoms
Anorexia, Chills, Cough, Dark urine, Dyspnea, Fever, Hepatomegaly, Hypotension, Icterus, Malaise, Nausea, Night sweats, Tachycardia, Tachypnea, Vomiting, Weight loss
Clinical findings
Cholestasis, Elevated ALAT, Elevated ALP, Elevated ASAT, Elevated CRP, Elevated GGT, Jaundice, Leukocytosis
Anamneses
None listed.
Localized findings
Approach
Blood test: CRP, WBC, SR, ASAT, ALAT, Bilirubin, PT-INR, GGT, ALP
Serology for Entamoeba histolytica and Echinococcus
Blood culture
Ultrasound abdomen
CT abdomen
Direct aspirate
Treatment
Drainage: Ubi pus, ibi evacua (Where there is pus, evacuate it) [moc]
Needle aspiration (sometimes repeated) might be sufficient for abscesses <5 cm
US or CT-guided if possible
Laparoscopic
Open surgery: peritonitis, thick wall abscesses, ruptured abscess, multiple large abscesses, and previously failed drainage procedures
Antibiotic treatment: intravenous and then oral for total duration of two to six weeks
Cephalosporins + Metronidazole
Penicillins + Aminoglycosides + Metronidazole
Carbapenems in case of allergy
Culture results help narrow down the organism, so empiric treatment is no longer needed, as it can lead to antibiotic resistance
Echinococcus --> benzimidazole (albendazole) for several years
Differential diagnoses
Anaphylaxis, Appendicitis, Autoimmune hepatitis, Budd-Chiari syndrome, Cholangitis, Cholecystitis, Choledocholithiasis, Cholelithiasis, Drug-induced liver injury, Endocarditis, Gastritis, Hepatocellular carcinoma, Pneumonia, Sepsis, Shock, Viral hepatitis
References
[1] Akhondi H, Sabih DE. Liver Abscess. [Updated 2023 Jul 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK538230/
[2] Zimmermann L, Wendt S, Lübbert C, Karlas T. Epidemiology of pyogenic liver abscesses in Germany: Analysis of incidence, risk factors and mortality rate based on routine data from statutory health insurance. United European Gastroenterol J. 2021 Nov;9(9):1039-1047.
[3] Tsai FC, Huang YT, Chang LY, Wang JT. Pyogenic liver abscess as endemic disease, Taiwan. Emerg Infect Dis. 2008 Oct;14(10):1592-600.
[4] Chen YC, Lin CH, Chang SN, Shi ZY. Epidemiology and clinical outcome of pyogenic liver abscess: an analysis from the National Health Insurance Research Database of Taiwan, 2000-2011. J Microbiol Immunol Infect. 2016 Oct;49(5):646-653.
[5] Yeh PJ, Chen CC, Lai MW, Yeh HY, Chao HC. Pediatric Liver Abscess: Trends in the Incidence, Etiology, and Outcomes Based on 20-Years of Experience at a Tertiary Center. Front Pediatr. 2020 Mar 24;8:111.
[6] Kaplan GG, Gregson DB, Laupland KB. Population-based study of the epidemiology of and the risk factors for pyogenic liver abscess. Clin Gastroenterol Hepatol. 2004 Nov;2(11):1032-8.
[7] Sharma A, Mukewar S, Mara KC, Dierkhising RA, Kamath PS, Cummins N. Epidemiologic Factors, Clinical Presentation, Causes, and Outcomes of Liver Abscess: A 35-Year Olmsted County Study. Mayo Clin Proc Innov Qual Outcomes. 2018 Feb 22;2(1):16-25.
[8] Svensson, E., Jönsson, A., Bläckberg, A., Sunnerhagen, T., Kiasat, A., & Ljungquist, O. (2023). Increasing incidence of pyogenic liver abscess in Southern Sweden: a population-based study from 2011 to 2020. Infectious Diseases, 55(6), 375–383.
[9] Losie, J.A., Lam, J.C., Gregson, D.B. et al. Epidemiology and risk factors for pyogenic liver abscess in the Calgary Health Zone revisited: a population-based study. BMC Infect Dis 21, 939 (2021).