Gut, 1969, 10, 389-399 Gut: first published as 10.1136/gut.10.5.389 on 1 May 1969. Downloaded from Pyogenic liver abscess T. J. BUTLER AND C. F. McCARTHY From the Department of Gastroenterology, Frenchay Hospital, and the Department of Medicine, University ofBristol, Southmead Hospital, Bristol At the turn of the century, the mortality from liver TABLE I abscess was 100%. Surgical drainage reduced the SUMMARY OF PATIENTS WITH LIVER ABSCESS mortality to 50 to 75% by 1930. Antibiotics led to (TYPE 1) a further reduction but there was little change in the No. Sex Age Source Result mortality during the next 25 years until recently (yr) when the adoption of special localization techniques F 86 Gallstones-cholangitis Died promised a great improvement. In the nineteenth 2 F 68 Gallstones-cholangitis Died 3 F 46 Gallstones-cholangitis Died century a common cause of liver abscess was 4 F 61 Gallstones-cholangitis Died undiagnosed appendicitis. This has been corrected, 5 F 88 Gallstones-cholangitis Survived in 6 F 53 Gallstones-cholangitis Survived so eliminating deaths the young age groups. The 7 M 24 Postappendicular Survived condition now affects predominantly the aged and 8 M 34 Postappendicular Survived enfeebled but it remains a condition with a high 9 M 24 Postappendicular Died 10 M 61 Diverticulitis Died mortality and morbidity despite diagnostic aware- 11 M 46 Diverticulitis Died ness and therapeutic improvements. Liver abscess is 12 M 55 Postoperative, gastrectomy (DU) Survived 13 M 30 Trauma (via chest) Survived sometimes only one manifestation of severe infection 14 M 22 Trauma (via chest) Survived elsewhere. The initial features of the disease may be 15 F 76 Acute Gram-negative bacteraemia Died non-specific and the fully developed picture is late 16 F 68 Acute Gram-negative bacteraemia Died in appearing. Consequently there may be delay or 17 M 47 Postoperative, splenectomy (trauma) Survived failure in diagnosis. Inadequate drainage of multi- Six patients were excluded from the review: two loculated abscesses or failure to drain secondary patients with infected metastases from carcinoma of http://gut.bmj.com/ abscesses adds to the problem. Few see many cases the rectum and one with carcinoma of the stomach, and this stresses the need for a continual review of two with non-specific granulomata of the liver, and the condition in all its aspects. one patient with a liver abscess due to empyema of an intrahepatic gall bladder. There were two cases of MATERIAL amnoebiasis of the liver during the period under review. During the 10-year period 1957-66, 48 patients with In type 1 liver abscess, the most acute form was on September 24, 2021 by guest. Protected copyright. liver abscess were admitted to two Bristol hospitals, seen in patients nos. 15 and 16, who had multiple and have been classified as follows: liver abscesses with jaundice, anuria, convulsions, and coma due to Gram-negative bacteraemia. These TYPE 1 (17 PATIENTS) In this group presentation died within one week of onset. was acute in immediate continuity with some other In type 2 liver abscess, the preliminary diagnosis in acute abdominal pathology. The abscesses were hospital was correct in 26 of the 31 patients. In the usually multiple, but in general there was no remaining five patients, the initial diagnosis was diagnostic problem. Table I summarizes the cases in brucellosis (2), perinephric abscess (1), and reticu- this group. losis (2). TYPE 2 (31 PATIENTS) This group constituted the ANALYSIS main problem and forms the basis of the paper. The abscesses were usually solitary with a 'chronic' This is largely confined to patients with type 2 presentation. There was no such time relationship abscess as these presented the main difficulty. as in type 1 and a prolonged search, often fruitless, was needed to determine a primary source of AGE INCIDENCE This is illustrated in Fig. 1, together infection. The essential features of patients in this with an indication of mortality. The increasing group are given in Table II. This type of abscess incidence with age is shown, 50% of the patients occurred twice as frequently as the acute variety. being over the age of 60 years. 389 390 T. J. Butler and C. F. McCarthy Gut: first published as 10.1136/gut.10.5.389 on 1 May 1969. Downloaded from TABLE II SUMMARY OF PATIENTS WITH LIVER ABSCESS (TYPE 2) No. Sex Age Pain Jaundice Fever Rigors Enlarged Leucocytosis Site in (yr) Liver Liver M 56 + + + L 2 M 34 + ± + ± R 3 M 49 + + R 4 F 63 + R and L 5 F 77 _ + + R and L 6 M 55 + R 7 F 77 A- R and L 8 M 66 + R and L 9 M 65 _- + + R + R 10 F 53 + + 11 M 41 + R 12 F 73 + + R and L 13 M 60 + R and L 14 F 54 + R + R 15 M 48 + + 16 M 66 _+ R _+ R 17 M 76 + + + 18 F 44 + + + R + R 19 M 41 + + 20 F 61 + -+ R 21 M 36 + R -+ R 22 F 65 + M + R 23 37 + + + 24 38 + R and L 25 F 68 + + L 26 76 + R 27 M 73 + + R 28 F 41 R 29 M 47 -+ R 30 F 77 + R 31 M 61 + R of the abscesses occurring in this lobe alone. There http://gut.bmj.com/ were abscesses in both lobes in seven of the 31 9 patients. The largest abscess in the series was 25 cm in diameter and the smallest 6 cm in diameter. 8 METASTATIC ABSCESSES IN OTHER ORGANS Abscesses other than in the liver were found in 14 patients, ie, in nearly half of the cases. In 10 the second patients, on September 24, 2021 by guest. Protected copyright. ,,, 6 abscess was in the lungs, in two in the brain, and c) two patients had abscesses in both lung and brain. (0 0. D CLINICAL PRESENTATION Table III shows the wide - 4 0 variety of presentation and clinical problem on D D the admission to 0) patient's hospital. D -o The majority of patients were referred to medical D D units in the first but it is to Z 2 instance, important D D D D D refer patients with metastatic abscesses at once to and units. In the 30 to D thoracic neurosurgical past, D D D D 40 years ago, brain abscesses were usually of the A 5* 'neighbourhood' variety secondary to middle ear or 0 1 2 3 4 5 6 7 8 frontal sinus disease and carried a reasonable Age in decades prognosis. Now an increasing frequency ofmetastatic FIG. 1. Age incidence of liver abscess. brain abscess is evident; the liver, as well as the lung, must be borne in mind in searching for the source. SEX RATIO There were 18 men and 13 women in the Ofthe three patients with unsuspected liver abscesses, group. two were admitted from the waiting list with herniae, SITE OF ABSCESS A marked prediliction for the right whilst the third was a diabetic with a large liver lobe of the liver was observed, more than two-thirds abscess. Pyogenic liver abscess 391 Gut: first published as 10.1136/gut.10.5.389 on 1 May 1969. Downloaded from TABLE II-continued SUMMARY OF PATIENTS WITH LIVER ABSCESS (TYPE 2) Presentation Metastatic Absctess Surgical Treatment Primarry Source Result Pyrexia of unknown origin PUO Drainage Lung Survived PUO Lung abscess Drainage (liver and lung) Cryptogenic Survived PUO Bilateral lung abscess Drainage (liver and lung) Cryptogenic Survived 'Cardiac failure' Cryptogenic Died Unsuspected Lung abscess Cholangitis Died Abdominal mass Drainage Actinomycosis Died Lung sepsis Lung Died Coma Lung abscess Postoperative Died 'Cardiac failure' Diverticulitis Died Collapse Drainage Cholangitis Died PUO Brain abscess Drainage (brain) Cryptogenic Died Coma Brain and lung abscess Pancreas Died Collapse Cryptogenic Died Abdominal pain Cholangitis Died Lung sepsis Lung abscess Drainage (liver and lung) Cryptogenic Survived Abdominal pain Drainage Cryptogenic Survived Unsuspected Cryptogenic Died Coma Brain abscess Drainage (liver and brain) Cryptogenic Died PUO Brain and lung abscess Drainage (liver and brain) Cryptogenic Died PUO Lung abscess Drainage (liver and lung) Cryptogenic Survived Abdominal mass Lung abscess Actinomycosis Died Unsuspected Drainage Cholangitis Survived PUO Drainage Cholangitis Survived Abdominal mass Lung abscess Drainage Crohn's disease Died PUO Resection L lobe of liver Diverticulitis Survived Coma Lung abscess Drainage Cryptogenic Died PUO Drainage Cryptogenic Survived Abdominal pain Drainage Cholangitis Survived PUO Lung abscess Drainage (liver and lung) Postoperative Suivived Diarrhoea Drainage Diverticulitis Survived PUO Drainage Diverticulitis Survived TABLE III of and thtir short. The significance symptoms http://gut.bmj.com/ CLINICAL PRESENTATION IN 31 PATIENTS WITH duration may not be appreciated by the elderly and LIVER ABSCESS (TYPE 2) are attributed simply to their age. Case Presentation No. of Abscesses No. TABLE IV Pyrexia of unknown 11 FREQUENCY OF CLINICAL FEATURES IN 30 PATIENTS origin WITH LIVER ABSCESS (TYPE 2) 2 Coma 4 (1 hepatic, 1 diabetic, 2 brain sepsis) Weight loss (31) 100 °'. 3 Abdominal pain 3 on September 24, 2021 by guest. Protected copyright. 4 Abdominal mass 3 Anaemia (31) 100% 5 Lung abscess 2 Hepatomegaly (23) 73-3 6 'Cardiac failure' 2 Fever (21) 66-6% 7 Collapse 2 Leucocytosis (21) 66-6% 8 Unsuspected 3 Pain (18) 5666% 9 Diarrhoea 1 Rigors (12) 40% Total 3 1 Jaundice (8) 23-3 % The onset was usually painless with little else but malaise. When pain appeared it was either centrally CLINICAL FEATURES The frequency of important disposed in the abdomen or in the right hypo- clinical features appearing during the course of the chondrium. Liver tenderness was common, but disease is shown in Table IV.