How to Cite:

Gajera, D., Shah, M., Makwana, N., & Rathwa, A. (2022). Comparative study of
percutaneous catheter drainage versus percutaneous needle aspiration for liver
abscess. International Journal of Health Sciences, 6(S6), 282–288.
https://doi.org/10.53730/ijhs.v6nS6.9700

Comparative study of percutaneous catheter

drainage versus percutaneous needle aspiration
for liver abscess

Dr. Darshan Gajera

Department of Surgery, Assistant Professor, GMERS Medical College Vadodara

Dr. Mausam Shah

Department of Surgery, Assistant Professor, GMERS Medical College Vadodara

Dr. Naren Makwana

Department of Surgery, Assistant Professor, GMERS Medical College Vadodara

Dr. Ankit Rathwa*

Department of Surgery, Assistant Professor, GMERS Medical College Vadodara
*Corresponding author email: darshgajera001@gmail.com

Abstract---Background: This study aimed to assess the effectiveness

and safety of percutaneous needle aspiration (PERCUTANEOUS
NEEDLE ASPIRATION) and percutaneous catheter drainage (PER
CUTANEOUS DRAINAGE ) in the treatment of liver abscess. Methods:
A prospective randomized study was conducted in patients presenting
to Department of Surgery, GMERS Medical College, Vadodara between
July 2019 and May 2022. 50 patients with liver abscess were
randomized into two groups A and B. Complete history, presenting
symptoms, medications were noted. The effectiveness of either
treatment was measured in terms of duration of intravenous
antibiotic, clinical improvement, reduction in the size of cavity,
treatment success rate, duration of hospital stay including long-term
outcomes such as sonographic resolution of cavity and recurrence
rate at 6 months post-treatment. Results: Per Cutaneous Drainage
group had statistically significant rate of duration of antibiotics need,
days for clinical improvement and time for 50% reduction in abscess
cavity and treatment success rate with comparable long-term
outcomes. Conclusion: Per Cutaneous Drainage is more efficient than
Percutaneous Needle Aspiration and can be used primarily in the
treatment of both amoebic and pyogenic liver abscesses along with
systemic antibiotics. However, Percutaneous Needle Aspiration can
serve as a safe alternative when Per Cutaneous Drainage is not
available.

International Journal of Health Sciences ISSN 2550-6978 E-ISSN 2550-696X © 2022.

Manuscript submitted: 18 Feb 2022, Manuscript revised: 27 April 2022, Accepted for publication: 9 June 2022
282
 283

Keywords---percutaneous needle aspiration, per cutaneous drainage,

pyogenic, liver abscesses.

Introduction

One of the differential for cystic lesions of the liver. Abscess occur when normal
hepatic clearance mechanism is overwhelmed or when the system fails. Liver
abscess are commonly due to amoebic followed by pyogenic, mixed and
uncommonly fungal infections. The organism can reach the liver via three distinct
routes namely via blood stream, biliary tree or by direct extension in case of
pyogenic liver abscess. However, amoebic liver abscess occurs by faeco-oral
transmission of one of the two species namely Entamoeba histolytica and
Entamoeba dispar. Liver abscess mainly affects the right lobe (~65%) much more
commonly than the left lobe (~10–15%) and can also be bilobar (~20–25%).2

When multiple abscesses are present, pyogenic or mixed infection needs to be

suspected. Diagnosis of liver abscess is usually delayed due to non-specific and
subacute symptoms. Classic triad of fever, jaundice and right upper quadrant
pain is seen in less than 10% of cases. Diagnosis is made by combination of
clinical symptoms, laboratory investigations and imaging. The treatment of
pyogenic liver abscess has evolved over the past two decades with primary
modality of treatment being antibiotics and surgery being reserved in
resistant/complicated cases, multiple abscess, and inaccessible location or when
a known abdominal source control is required. Percutaneous drainage under
imaging guidance has significantly reduced the need for surgery and also
improved the outcome with lower morbidity and mortality with a reported success
rate of 70–100%.3–5 The primary mode of treatment of amoebic liver abscess is
medical; however, as many as 15% of amoebic abscesses may be refractory to
medical therapy.6 Also, secondary bacterial infection may complicate 20% of
amoebic liver abscesses.7 Both percutaneous needle aspiration and percutaneous
catheter drainage have been shown to be effective and safe. The lack of definitive
evidence to guide us on the use of one percutaneous drainage method over the
other prompted us to carry out this large prospective randomized study.

Methods

This was a prospective randomized comparative study conducted at the

Department of Surgery, Department of Surgery, GMERS Medical College,
Vadodara between July 2019 and May 2022. We included patients with liver
abscess who were older than 16 years and were having largest cavity of more than
5 cm in size or more than 60 mL in volume. Patients with ruptured abscess,
cavity smaller than 5 cm, un-correctable coagulopathy or concomitant
malignancy were excluded from the study. The patients presenting with signs and
symptoms of liver abscess were admitted and carefully worked up with detailed
history and examinations. Laboratory investigations were sent which included –
complete blood counts, renal function test, liver function test, prothrombin time
and INR, viral markers, blood culture and amoebic serology. Chest X-ray was
done to look for concomitant pulmonary pathology. Ultrasound of the abdomen
was done to confirm abscess and in doubtful cases computed tomography of the
284

abdomen was also done. After confirming the diagnosis, all patients received
empirical intravenous (IV) antibiotic in the form of ceftriaxone 1 g 12 hourly and
metronidazole 500 mg 6 hourly, till the availability of pus culture sensitivity
report. Group A included 25 patients of liver abscess in which Percutaneous
Needle Aspiration was done. Group B had 25 patients of liver abscess treated with
Per Cutaneous Drainage. The procedures were done after explaining it and taking
informed consent from the patients.

Percutaneous needle aspiration

The procedure was done with full aseptic precaution. Local anaesthetic solution
(lignocaine 2%) was infiltrated at the intended site of puncture and 16/18-gauge
long needle was guided towards the cavity under real-time ultrasonography (USG)
guidance. The pus was aspirated with the attached syringe. Colour and nature of
the pus were noted and a sample was sent for culture and sensitivity. The cavity
was aspirated to its maximum. The procedure was repeated for other cavities, if
needed. A repeat USG was done on the third day to look for reduction in size of
the cavity. If the cavity size remained 5 cm or more, then repeat aspiration was
done. Inability to attain 50% reduction in the size of cavity and/or a clinical
improvement after three aspirations was taken as treatment failure. These
patients were then treated with Per Cutaneous Drainage or laparotomy.

Percutaneous catheter drainage

Here also, the procedure was done with full aseptic precaution. Local anaesthetic
solution (lignocaine 2%) was infiltrated at the intended site of entry. A small stab
was made in the skin at the site of entry. A 14-F pigtail catheter with sharp trocar
was then inserted through the skin into the cavity under USG guidance. The
entry was confirmed by aspirating the pus. Pus was sent for culture and
sensitivity testing. A collection bag was attached and the catheter was fixed to the
skin. Daily output of the catheter was measured and it was flushed regularly with
normal saline to prevent blockage. Repeat USG was done on the third day to
assess the size and residual content. Catheter was removed when it stopped to
drain with clinical and sonographic improvement. Requirement of laparotomy was
considered as treatment failure. Post-procedure assessment and follow-up
Patients’ clinical parameters were recorded daily. Patients were switched to oral
antibiotics on improvement of clinical symptoms, that is, normalization of fever
and leucocyte counts. Time to attain clinical improvement, 50% reduction in the
size of cavity, number of days of IV antibiotics used, any complication of
treatment, success rate of treatment and hospital stay were recorded. Patients
were discharged after they improved clinically. A repeat USG was done at 2 weeks
and then every month for 6 months.
 285

Results

Gender Distribution

18

32

MALE FEMALE

In a total of 50 patients, male predominance was found

Age Distribution

22

10
9
7

1 1

<20 21-30 31-40 41-50 51-60 >61

Series 1

The mean age of the study population was 39.5 years which ranged from 18 to 61
years.
286

Clinical Features

Fever 99%
Anorexia 93%
Right Upper quadrant pain 82%
Jaundice 12%
Diarrhoea 8%

Number of cavities

SINGLE CAVITY MULTIPLE CAVITY

62% 38%

Lobe involvement

RIGHT LOBE LEFT LOBE

88% 12%

Duration of Antibiotics

PERCUTANEOUS PER CUTANEOUS

NEEDLE ASPIRATION DRAINAGE
MEAN DURATION 8.2 ±3.1 5.6 ±2.1

Hospital Stay

PERCUTANEOUS PER CUTANEOUS

NEEDLE ASPIRATION DRAINAGE
Mean Hospital Stay 3.2 5.6

Recurrence

PERCUTANEOUS PER CUTANEOUS

NEEDLE ASPIRATION DRAINAGE
Recurrence 13 (6.5%) 2(1%)

Discussion

Liver abscesses, both amoebic and pyogenic, continue to be an important cause of

morbidity and mortality in the tropical countries like India. Percutaneous
drainage (either needle aspiration or catheter drainage) with systemic antibiotics
has become the preferred treatment for the management of liver abscesses. 5,8–15
Liver abscess commonly affects adult males which was consistent with our study
results where males were affected eight times more often than females with a
mean age of 39 years. In our study, the most common symptom was fever, seen in
99% of cases, followed by anorexia and right upper quadrant pain. Recently,
image-guided percutaneous treatment (needle aspiration or catheter drainage) has
replaced surgical intervention as the primary treatment for pyogenic as well as
amoebic liver abscesses.16–18 Although, many studies found Percutaneous Needle
 287

Aspiration to be less invasive and cheaper alternative to catheter drainage with

comparable outcomes, we found catheter drainage to be better than needle
aspirations. Patients in the Per Cutaneous Drainage group had earlier clinical
recovery and reduction in cavity size with lesser duration of need for systemic
antibiotics all of which were statistically significant comparable to the results of
Rajak et al. 19 and Kulhari and Mandia.20 We also found that patients in the
Percutaneous Needle Aspiration group had higher recurrence rate (16.5%) as
compared to the Per Cutaneous Drainage group (1%) requiring further treatment
in the form of surgery or catheter drainage. The possible explanations for better
outcomes in the Per Cutaneous Drainage group is that because of wider calibre
catheter, it provides for a continuous drainage, drains thick pus and also
prevents re-accumulation.

Conclusion

Per Cutaneous Drainage is more efficient than Percutaneous Needle Aspiration

and can be used primarily in the treatment of both amoebic and pyogenic liver
abscesses along with systemic antibiotics.

References

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management, and outcome. Medicine 1996; 75: 99–113.
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AJR Am. J. Roentgenol. 1993; 160: 799–802.
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 British Medical Bulletin, 2019, 132:45–52
doi: 10.1093/bmb/ldz032
Advance Access Publication Date: 13 December 2019

Invited Review

Liver abscess: diagnostic and management issues

found in the low resource setting
Gaetan Khim1,*, Sokhom Em2 , Satdin Mo2 , and Nicola Townell1
1 Diagnostic Microbiology Development Program, 12152 Phnom-Penh, Cambodia, and 2 Siem Reap Referral

Hospital, 17252 Siem Reap, Cambodia

*Correspondence address. E-mail: gaetan.khim@dmdp.org.

Editorial Decision 16 September 2019; Accepted 16 September 2019

Abstract
Introduction: Liver abscesses are mainly caused by parasitic or bacterial
infection and are an important cause of hospitalization in low-middle income
countries (LMIC). The pathophysiology of abscesses is different depending
on the etiology and requires different strategies for diagnosis and manage-
ment. This paper discusses pathophysiology and epidemiology, the current
diagnostic approach and its limitations and management of liver abscess in
low resource settings.
Sources of data: We searched PubMed for relevant reviews by typing the
following keywords: ‘amoebic liver abscess’ and ‘pyogenic liver abscess’.
Areas of agreement: Amoebic liver abscess can be treated medically while
pyogenic liver abscess usually needs to be percutaneously drained and
treated with effective antibiotics.
Areas of controversy: In an LMIC setting, where misuse of antibiotics is a
recognized issue, liver abscesses are a therapeutic conundrum, leaving little
choices for treatment for physicians in low capacity settings.
Growing points: As antimicrobial resistance awareness and antibiotic stew-
ardship programs are put into place, liver abscess management will likely
improve in LMICs provided that systematic adapted guidelines are estab-
lished and practiced.
Areas timely for developing research: The lack of a quick and reliable

© The Author(s) 2019. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.comThis is an
Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-
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46 K. Gaetan et al., 2019, Vol. 132

diagnostic strategy in the majority of LMIC makes selection of appropriate

treatment challenging.

Key words: liver abscess, amoebic, pyogenic, resource limited settings, low-middle income countries

Pathophysiology to poor living conditions and contamination of

Liver abscesses can be broadly divided into two drinking water. A good example of this was shown
categories: amoebic and pyogenic (see Table 1).The by high amoebiasis rates (63/1000 children) in Thai-
pathogenesis of amoebic liver abscess (ALA) is Cambodian border refugees between 1987 and
different from pyogenic liver abscess (PLA).1 In 1989.7
the former, Entamoeba histolytica induces hep- The most common extra-intestinal manifestation
atic apoptosis and the latter is a suppurative is liver abscess, with parasite being carried to
infection of the liver parenchyma. Confirma- the liver via the portal vein. The incidence of
tory diagnosis is important, albeit difficult in the disease is highest in Asia, where rates can
resource limited settings, as it leads to appropriate be as high as 21 per 100 000 inhabitants per
management. year.8 ALA predominantly affects middle age (30–
60 years old) men. Risk factors include alcohol
consumption and malnutrition (low body mass and
hypoalbuminemia).9
Epidemiology
PLAs have a global distribution, although incidence
varies significantly between different countries from
more than 900 cases in a 10-year period in Asian Pathogenesis of liver abscess
countries such as Taiwan, Singapore and South A pyogenic abscess is defined as a collection of pus
Korea to 23 cases in the same timeframe in non- consisting of numerous inflammatory cells, notably
Asian regions.2 In the US,3 the incidence of PLA neutrophils and tissue debris.10 Infection is associ-
is 2.3 per 100 000, predominantly in older men ated with necrosis from inflammation of surround-
and diabetes and cancer are considered risk factors ing tissue.
to the development of PLA. The most common The word abscess may represent a misnomer
pathogen isolated in this setting was Streptococcus when it is used to define the pathologic process
milleri followed by Klebsiella pneumoniae. This caused by E. histolytica in the liver. In the case
differs from South Korea and Taiwan, where K. of ALA, there is hepatocyte cell death either by
pneumoniae is the most common pathogen found apoptosis or necrosis.11,12 It is generally agreed that
in PLA.1, 4 there is an absence of inflammatory cells due to
Entamoeba histolytica is a protozoan that causes lysis of neutrophils by the protozoan forming the
amebiasis (gastrointestinal infection) and the most typically described non-purulent ‘anchovy paste’
common cause of intestinal parasite infection in abscess.1 Cell death will continue to occur with
returned travelers.5 Entamoeba histolytica is globally expansion of the abscess until patient receives
distributed with higher rates of infection in low- appropriate treatment. Of note, a hamster study
middle income countries (LMIC) settings compared revealed that soon after seeding E. histolytica
to high income countries (HIC). Furthermore, into liver parenchyma, inflammatory cells mainly
significant proportion of cases in HIC is usually consisting of polymorphonuclear surrounded the
imported, while non-imported cases usually affect parasite and were subsequently lysed along with
immunosuppressed patients.6 Infection is associated hepatocytes.13
Diagnostic and management issues found in the low resource setting, 2019, Vol. 132 47

Table 1 Differences between amoebic and pyogenic abscess

Amoebic abscess Pyogenic abscess

Pathogen Entamoeba histolytica Klebsiella pneumoniae, Streptococcus milleri,

Escheria coli, Burkholderia pseudomallei,
Staphylococcus aureus, Polymicrobial including
anaerobes
Distribution Globally, higher rates in LMICs, Globally, older patients
typically males 30–50 years
Acquisition Poor sanitation, contaminated drinking Biliary source, e.g. impacted gall stone
water Systemic infection
Pathogenesis Inflammation—abundant neutrophils Necrosis—absence of neutrophils
Imaging Usually single (can be multiple) Either single or multiple
Typically in right lobe (can be in left Any lobe can be involved
lobe) Hot appearance on sulfur colloid scan
Cold appearance on sulfur colloid scan
Fine needle Macroscopic—thick, chocolate brown, Macroscopic—purulent, may be foul smelling
aspirate odourless, ‘anchovy paste’ Culture—limited availability in LMICs
Microscopy for
trophozoites—insensitive (25%)
Antigen testing—sensitive and specific,
generally not available in LMICs
PCR—sensitive and specific, generally
not available in LMICs
Other Serology—useful in returned travelers, Blood cultures—sensitivity 50%, limited
diagnostic limited role in residents of high availability in LMICs, in LMICs patients often
modalities endemicity pre-treated with antimicrobials prior to specimen
Antigen testing of serum—sensitive and collection.
specific, generally not available in LMICs
Treatment Medical therapy with metronidazole Percutaneous drainage along with antibiotics is
usually sufficient. (May require drainage mainstay of therapy. Antibiotic treatment in
in co-infection or impending rupture.) small responsive abscesses.

Causative organisms of pyogenic liver

abscess There are challenges in defining the different
PLA may be caused by a variety of organism, includ- microbiological pathogens, which cause PLA. One
ing K. pneumoniae, Escherichia coli and Burkholde- reason for this problem is that it is common that pus
ria pseudomallei.14 The microbiology differs accord- from a liver abscess is collected after administration
ing to the presumed route of hepatic invasion. Infec- of antibiotics.1 This may lead to an under-estimation
tions may arise from the biliary tree (usually from an of bacteria causing liver abscess and may also
impacted gallstone), circulation (portal vein, hepatic contribute to a gap in physician knowledge to
artery), a contiguous focus of infection and penetrat- determine which antibiotic is most appropriate for
ing trauma. In the South–East Asian region, patients treatment. This raises another issue of selection
working with soil and water with comorbidities such bias, where the positive culture results may have
as diabetes, liver and renal failure and hazardous a more resistant profile if patients had received
consumption of alcohol are also at risk of infection antimicrobial therapy prior to culture. It may also
with B. pseudomallei.15 under-estimate the number of susceptible pathogens
48 K. Gaetan et al., 2019, Vol. 132

that have been rendered culture negative by prior sion of the pathogen is either via ingestion, inhala-
treatment. Laboratory capacity in culture and tion or inoculation and can cause various types
identification may be limited in LMICs. Examples of infections such a sepsis, pneumonia and deep-
include inability to test due to lack of culture seated abscesses. In a northeast Thailand study, 33%
capabilities and lack of anaerobic culture facilities (n = 77/230) cases had deep-seated abscesses, liver
such that a negative culture may not equate an abscess only 26% (n = 20/77) liver and spleen abscess
absence of growth. Studies have identified that 31% (n = 24/77). It was observed that the majority
gram-negative rods such as E. coli, K. pneumoniae, (70% n = 31/44) of liver abscesses had multiple
anaerobes, S. milleri and Staphylococcus aureus lesions. Over one-third (n = 16) cases underwent
are important causative pathogen.16 The source of percutaneous incision and drainage and splenectomy
infection usually arises from the biliary, intestinal was performed in two cases.15 This infection has
tract or portal system with subsequent seeding of also been recognized in Cambodia, an LMIC in SE
the liver. Asia.14 Although the disease is still under-recognized,
In Taiwan,17 K. pneumoniae is an important increased utilization of the microbiology services
pathogen that is frequently isolated. Although shows that the disease is endemic throughout Cam-
multi-resistant strains of K. pneumoniae have been bodia.
increasingly observed in these settings, the K.
pneumoniae isolates responsible for liver abscess
have generally remained susceptible. The study Diagnosis of liver abscess
described 182 cases of liver abscesses between The clinical presentation of both amoebic and PLA is
1990 and 1996, 88% (n = 160) were caused by K. indistinguishable. Patients usually present with fever
pneumoniae, diabetes was a frequent risk factor. It and right upper quadrant tenderness. Although lab-
has been observed that gas-forming K. pneumoniae oratory tests, such as leukocytosis (predominantly
liver abscess is thought to be associated with worse neutrophils), raised inflammatory markers (e.g. C-
prognosis.18 Patients with diabetes mellitus are at reactive protein), increased alkaline phosphatase and
increased risk of developing gas-forming primary abnormal liver function tests are often present they
liver abscess and infectious metastatic disease. The have no real value in differentiating amoebic versus
study hypothesizes that the gas formation process PLA.1
may be caused by high level of glucose in tissues, Imaging techniques, such as ultrasonography and
which allows for vigorous metabolism and growth of computed tomography (CT) scanning, are useful
K. pneumoniae. Toxic by-products of inflammation tools to demonstrate a space occupying lesion and
accumulate with delayed clearance by circulation confirm presence or absence of a liver abscess, it may
due to microangiopathy, which delays the transport not reliably differentiate between PLA and ALA.19
of end products out of the lesion. This would Traditionally, ALA most commonly occurs as a sin-
suggest that good glycemic control is also important gle lesion in the right lobe but can be present in
for controlling the infection and improved clinical the left lobe and be multiple.1 CT scanning has a
outcome.18 higher sensitivity (97% sensitive) compared to ultra-
Melioidosis is an important cause of liver abscess sound (85% sensitive) for detection of liver abscess,20
in Southeast Asia.15 The infection is caused by B. although this modality may not always be accessible
pseudomallei, a saprophytic gram-negative bacillus in an LMIC setting.
found in the environment. Patients working in close Fine needle aspiration for culture is the gold
contact with soil and water such as rice farmers standard for diagnosis of PLA. This is not the
and people with weakened immune systems, such as case for ALA as parasite culture is insensitive
diabetics, renal or liver impairment or thalassemia and not routinely available in clinical laboratories.
are at most risk of contracting infection. Transmis- Microscopy also lacks sensitivity as trophozoites
Diagnostic and management issues found in the low resource setting, 2019, Vol. 132 49

are seen in <25% of cases.1 The macroscopic Stool testing therefore has no real value in diagnosis
aspect of the aspirate may provide some preliminary of liver abscess.
information on the cause of the liver abscess. Molecular testing of liver abscess contents is reli-
Traditionally, ALA is odourless, chocolate brown able for the diagnosis of ALA.23 Although this test
and thick, and commonly referred to as anchovy offers the possibility to accurately diagnose Enta-
paste9 while PLA is usually purulent and foul moeba infection, the availability of molecular test
smelling, particularly as a result of infection with in LMIC settings is limited as it requires dedicated
anaerobes. Although this may be helpful, its role in equipment and costly consumables.
differentiation for the purpose of diagnosis remains In HIC, cause of liver abscess is usually deter-
uncertain. mined using multiple diagnostic strategies, including
Blood cultures are an important adjunct to the blood cultures, Entamoeba serology, liver abscess
diagnosis of pyogenic abscess and although their aspirate for culture and molecular and antigen test-
yield is usually lower than pus aspirate of liver ing. Each of these individual options is challenged in
abscess, they may provide helpful information in the LMIC setting. In the LMIC setting, a patient will
patients before they receive antimicrobials or aspira- usually present, following failure to respond to initial
tion of their abscess. It is recommended to perform antibiotic therapy, imaging reveals an abscess and
a blood culture for any patient suspected of liver the cause remains undifferentiated, due to limited
abscess on entry.1 testing capacity. LMICs often lack essential micro-
Serology can be useful in returned travelers who biology services and where available utilization of
have visited areas of high endemicity and reside in services is often poor.24 Specimen collection should
low endemicity settings. Due to long-term positiv- be performed prior to antibiotics, if clinical pre-
ity following exposure, it is of less value in high sentation allows, however in LMICs collection of
endemicity settings where patients may have been specimens often occurs late and is generally reserved
previously exposed.19 The test can also be falsely neg- for patients who have failed to respond to antimi-
ative in case of acute presentations, patient’s immune crobial treatment. In LMICs, where it is common
response, the type of serologic test or the pathogen for patients to receive medication prior to hospi-
strain.21 talization, from either pharmacies or private clinics
Antigen testing may be useful in LMICs. The (≥50% of all transactions in Asia),25,26 extends to
TechLab E. histolytica II Antigen Detection test a wide variety of medication including antimicro-
detects the presence of Gal/GalNAc antigen in serum bials.27 The reasons for patients to favor receiv-
and is both sensitive (≥95%) and specific (100%, ing medications from the pharmacy are multiple,
n = 70 controls including nine PLA).19 Sensitivity including easy accessibility, possibility to purchase
decreases significantly in patients who have been medication in small quantities and familiarity with
pre-treated with metronidazole prior to testing. The the dispenser.26 Insufficient training in staff work-
accessibility of the antigen detection testing may also ing in pharmacies result in restrictions in terms of
be a potential barrier to its access in an LMIC. their knowledge and availability of products.28 It
Another new potential marker such as pyruvate is also recognized28 that dispensing of medication
phosphate dikinase in the form of a lateral flow has insufficient regulation resulting in uncontrolled
assay shows potential in the diagnosis of ALA.22 dispensing.
There remains a need for tests that are non-invasive,
accurate, readily available and affordable in the field
of diagnostics for ALA. Treatment
As most patients with ALA have no bowel symp- In LMICs, antimicrobial guidelines generally recom-
tom, examination of stool for ova and parasite and mend empiric therapy targeting both amoebic and
antigen testing is insensitive and not recommended. pyogenic causes of liver abscess. As treatment is
50 K. Gaetan et al., 2019, Vol. 132

often administered prior to collection of appropriate are needed to confirm the optimal approach of liver
specimens, the causative pathogen and prevalence of abscess management in LMIC setting.
either disease remain unclear. Development of empir- The selection of an appropriate antibiotic will
ical antibiotic guidelines, with selection of the most differ according to the isolated pathogen, suscep-
appropriate antimicrobials for the treatment of liver tibility pattern and local epidemiology. For exam-
abscess, is hindered by a lack of local microbiology ple, the recommended treatment for melioidosis is
data. As a result, recommendations are often not ceftazidime,15 while meropenem might be recom-
tailored to the local setting and taken from other mended for infection with ESBL producing K. pneu-
settings. moniae.
ALA is managed medically, while combined
infections and PLA require both drainage either
by repeated needle aspiration or percutaneous
Prognosis of patients affected by liver
catheter drainage9,29 and appropriate antimicrobial
abscess
treatment. Surgical drainage is usually reserved for
complicated cases and has now been replaced by less The prognosis of PLA is dependent on the time
invasive methods as the standard of care.9 to diagnosis.2 Patient’s with delayed diagnosis are
The mainstay of treatment for ALA is either more likely to need medical treatment with drainage
metronidazole or tinidazole orally for a period of procedure. Patients who present with shock acute
10 days or 5 days, respectively. This is followed renal failure and acute respiratory failure were likely
by treatment with a luminal agent such as paro- to have poor outcomes.
momycin for a period of 5–10 days to eradicate any Worldwide, E. histolytica is an important cause
remaining cysts in the intestinal tract. Most cases of of mortality, only second to malaria as a cause of
ALA respond to medical treatment, while patients death from parasitic disease.1 ALA is a progressive
not responding to medical treatment should undergo and uniformly fatal disease if left untreated. Patients
drainage.1,19 Drainage is required for complications with ALA have a favorable outcome when treat-
of infection, which include patients who have sec- ment is commenced in a timely manner.11 Complex
ondary bacterial infection (either de novo or sec- and ruptured abscesses are associated with increased
ondary to drainage) and patients who are considered mortality.
high risk of ALA rupture.
The treatment for PLA has evolved over the
years, from open surgical drainage to percutaneous Conclusions
drainage aided by imagery. There is uncertainty In the LMIC setting, both amoebic and pyogenic
regarding which type of liver abscess should receive abscesses are prevalent and have similar clinical pre-
antimicrobials only versus drainage.30 Current sentations. Current diagnostic testing strategies have
recommendations are that liver abscesses less than limitations in relation to implementation in LMIC
3 cm can be treated medically.31 Aspirations of liver settings, and as a result, it can be challenging to
abscesses are effective and lead to resolution in a high accurately identify the causal pathogen. This leads
percentage of patients. Repeated aspiration incre- to issues regarding the optimal management of liver
mentally increases the likelihood of management abscesses in LMICs.
success following each aspiration.32 The use of needle Despite limitations with sensitivity and availabil-
aspiration is an attractive option for low-middle ity, blood cultures should be collected in all patients
income settings where availability of materials is presenting with a liver abscess. Large pyogenic
limited. In LMICs, it is preferable to avoid insertion abscesses require drainage; aspirations (repeated if
of a drain, as they can be difficult to manage and necessary) are an appropriate treatment modality
be a source of secondary infections. More studies for LMICs. Culture of aspirated liver contents
Diagnostic and management issues found in the low resource setting, 2019, Vol. 132 51

should always be performed to ensure targeted 2. Ko WC, Paterson DL, Sagnimeni AJ, et al. Community-
antimicrobial therapy. acquired Klebsiella pneumoniae bacteremia: global dif-
There are currently few tests available for rapid ferences in clinical patterns. Emerg Inf Dis 2002;8:
160–6.
and affordable diagnosis of ALA in countries where
3. Kaplan GG, Gregson DB, Laupland KB. Population-
infection is common. Introduction of a reliable bed-
based study of the epidemiology of and the risk factors
side diagnostic test, e.g. serum antigen testing, for for pyogenic liver abscess. Clin Gastroenterol Hepatol
ALA in LMICs would increase detection rates of 2004;2:1032–8.
ALA. Treatment of ALA is in the most part medical 4. Chung D, Lee S, Lee H, et al. Emerging invasive liver
and so improved diagnostics would avoid unnec- abscess caused by K1 serotype Klebsiella pneumoniae in
essary drainage procedures and subsequent compli- Korea. J Inf 2007;54:578–83.
cations. This would also allow a reduction in the 5. Herbinger K, Fleischmann E, Weber C, et al. Epi-
demiological, clinical and diagnostic data on intestinal
empiric use of antimicrobials, for the treatment of
infections with Entamoeba histolytica and Entamoeba
PLA, and reduce selection pressure for the develop-
dispar among returning travelers. Infection 2011;39:
ment of antimicrobial resistance. 527–35.
An area of consideration for research could be to 6. Seeto RK, Rockey DC. Amoebic liver abscess: epi-
rely on systematic blood cultures and aspiration of demiology, clinical features, and outcome. West J Med
abscesses that are amenable to drainage. Although 1999;170:104–9.
this would not be feasible for small abscesses, 7. Candler W, Phuphaisan S, Echeverria P, et al. Amebiasis
macroscopic observation and testing of content at an evacuation site on the Thai-Cambodian border.
Southeast Asian J Trop Med Public Health 1990;21:
aspirate for E. histolytica, by antigen or molecular
574–9.
testing and microbiology, could be helpful in 8. Blessmann J, Van LP, Nu PAT, et al. Epidemiology of
stratifying patients and deciding which treatment amebiasis in a region of high incidence of amoebic
protocol would be most appropriate. This invasive liver abscess in Central Vietnam. Am J Trop Med Hyg
approach would mean that patients with E. histolyt- 2002;66:578–83.
ica infection would have an aspirate to eliminate 9. Priyadarshi RN, Prakash V, Anand U, et al. Ultrasound-
guided percutaneous catheter drainage of various types
co-infection.
of ruptured amoebic liver abscess: a report of 117 cases
from a highly endemic zone of India. Abdom Radiol
2018;44:877–85.
Acknowledgements 10. De Souza Andrade-Filho J. Revista do Instituto
We gratefully acknowledge support from the Defense Threat de Medicina Tropical de São Paulo. 2012. Avail-
Reduction Agency. I would like to show my gratitude to able from: http://www.scielo.br/scielo.php?script=sci_a
Dr Nikki Townell for providing comments to this paper as rttext&pid=S0036-46652012000400011
well as Dr Mo Satdin and Dr Em Sokhom for agreeing to 11. Prakash V, Oliver TI. Amoebic Liver Abscess. In: Abai
participate in this review of the literature. B, Abu-Ghosh A, Acharya AB, et al. Florida: Stat-
Pearls Publishing, 2019. Available from: https://www.
ncbi.nlm.nih.gov/books/NBK430832/
Conflict of interest statement 12. Wuerz T, Kane JB, Boggild AK. A review of amoebic
liver abscess for clinicians in a nonendemic setting. Can
The authors have no potential conflicts of interest.
J Gastroenterol 2012;26:729–33.
13. Tsutsumi V, Mena-Lopez R, Anaya-Velazquez F, et al.
Cellular bases of experimental amoebic liver abscess.
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1. Sifri CD, Madoff LC. Infections of the liver and biliary 14. Bory S, Daily F, Khim G, et al. A report from the
system (liver abscess, cholangitis, cholecystitis). In: Ben- Cambodia training event for awareness of Melioidosis
nett JE, Dolin R, Blaser MJ (eds.). Principles and Practice (C-TEAM). Trop Med Inf Dis 2018;3:1–6.
of Infectious Diseases, 8th edn. Philadelphia: Elsevier 15. Maude RR, Vatcharapreechasakul T, Ariyaprasert P,
Saunders, 2015,1270–9 et al. Prospective observational study of the frequency
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and features of intra-abdominal abscesses inpatients E. dispar DNA in stool sample. Br Med Clin Microbiol
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Trop Med Hyg 2012;106:629–31. 24. Om C, Daily F, Vlieghe E, et al. ‘If it’s a broad spectrum,
16. Moore-Gillon J, Eykyn SJ, Phillips I. Microbiology of it can shoot better’: inappropriate antibiotic prescribing
pyogenic liver abscess. Br Med J 1981;283:819–20. in Cambodia. Antimicrob Resist Inf Cont 2016;5:1–8.
17. Wang JH, Liu YC, Lee SSJ, et al. Primary liver abscess 25. Smith F. Private local pharmacies in low and middle-
due to Klebsiella pneumoniae in Taiwan. Clin Infect Dis income countries: a review of interventions to enhance
1998;26:1434–8. their role in public health. Trop Med Int Health
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and mechanism of gas formation of pyogenic liver 26. Rosalind M, Catherine G. Performance of retail phar-
abscess due to Klebsiella pneumoniae. J Clin Microbiol macies in low- and middle-income Asian settings: a
2004;42:2783–5. systematic review. Health Pol Plan 2016;31:940–53.
19. Haque R, Mollah NU, Ali IM, et al. Diagnosis of 27. Minh P, Huong D, Byrkit R, et al. Strengthening phar-
amoebic liver abscess and intestinal infection with the macy practice in Vietnam: findings of a training inter-
TechLab Entamoeba histolytica II antigen detection and vention study. Trop Med Int Health 2013;18:426–34.
antibody test. J Clin Microbiol 2000;38:3235–9. 28. Stenson B, Syhakhang L, Lundborg C, et al. Real world
20. Bächler P, Baladron MJ, Menias C, et al. Multimodality pharmacy: assessing the quality of private pharmacy
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potential pitfalls. Gastrointest Imag 2016;36:1001–23. J Technol Assess Health Care 2001;17:579–89.
21. Otto MP, Gérôme P, Rapp C, et al. False-negative 29. Chaturbhuj R, Sanjay G, Sanjay J, et al. Percutaneous
serologies in amoebic liver abscess: report of two cases. treatment of liver abscesses: needle aspiration versus
J Travel Med 2013;20:131–3. catheter drainage. Am J Radiol 1998;170:1035–9.
22. Syazwan S, Muhammad HY, Dyana ZN, et al. Pro- 30. Kareem O, Sanket S, Koea J. Liver abscess: contempo-
duction of recombinant Entamoeba histolytica pyruvate rary presentation and management in a Western popu-
phosphate dikinase and its application in a lateral flow lation. New Zeal Med Assoc 2018;131:65–70.
dipstick test for amoebic liver abscess. Br Med J Inf Dis 31. Su YJ, Lai YC, Lin YC, et al. Treatment and prognosis of
2014;14:1–9. pyogenic liver abscess. Int J Emerg Med 2010;3:381–4.
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 Review

Liver Abscess: Complications and

Treatment
Sanchit Sharma, M.D., D.M., and Vineet Ahuja, M.D., D.M.

Liver abscess is an inflammatory space-­occupying lesion and/or multiple abscesses and compression of biliary tree
of the liver caused by infectious agents. Amoebic liver ab- by an abscess near porta hepatis or caused by concomi-
scess (ALA) and pyogenic liver abscess (PLA) are its two tant alcoholic hepatitis.1 Although classically described as
predominant causes. Rarely, liver abscess can be caused a solitary abscess in the right lobe of the liver, 35% of
by fungi, mycobacteria, and other atypical organisms. ALA patients may have a left lobe liver abscess with or without
is the predominant cause of liver abscess in India, seen in a right lobe abscess, and 15% of patients can have mul-
more than 60% of cases.1 It is caused by Entamoeba histo- tiple liver abscesses.3 Recognizing the unusual variants of
lytica with feco-­oral route, the predominant mode of trans- ALA is important because these are generally associated
mission. In this review, we describe the overview of ALA with complications (Table 1).2 The clinical course of ALA is
and PLA, along with its complications and management. usually benign in the absence of poor prognostic markers
(Table 2).1,4

AMOEBIC LIVER ABSCESS

Diagnosis
Overview Clinically and radiologically, ALA may be difficult to distin-
Amoebiasis is endemic in India and primarily affects the guish from PLA. Classically, aspiration of ALA reveals anchovy
gastrointestinal tract. ALA is the most common extraintes- sauce–­like aspirate. Microbiologically, trophozoites are rarely
tinal involvement in amoebiasis, seen in 3% to 9% of demonstrated in aspirate. In addition, serology for E. histolyt-
cases.2 The disease usually occurs in male patients in the ica may be relevant in travelers returning from high-­endemic
20 to 45 years age group. Risk factors include chronic al- areas, being of limited value in residents of highly endemic
cohol use, diabetes, cirrhosis, and retroviral disease. The areas. Molecular and antigen testing, if available, may be
clinical presenting features include fever, pain in the abdo- useful. Noninvasive testing, such as use of polymerase chain
men, and anorexia. Jaundice can be seen in about 15% reaction, is increasingly being used for detection of E. histol-
of patients with ALA and is usually associated with a large ytica DNA in other body fluids, such as blood, pus, saliva, and

Abbreviations: ALA, amoebic liver abscess; IV, intravenous; PCA, percutaneous aspiration; PCD, percutaneous catheter drainage;
PLA, pyogenic liver abscess; PO, orally.
From the Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India.
Potential conflict of interest: Nothing to report.
Received February 25, 2021; accepted April 25, 2021.

View this article online at wileyonlinelibrary.com

© 2021 by the American Association for the Study of Liver Diseases

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Review Liver Abscess: Complications and Treatment Sharma and Ahuja

TABLE 1. COMPLICATIONS OF ALA TABLE 2. POOR PROGNOSTIC FACTORS IN PATIENTS

Local complications WITH ALA
Pleural effusion
Clinical
Rupture*
-­ Encephalopathy
-­ Pleural cavity: empyema
-­ Jaundice
-­ Peritoneal cavity: peritonitis/abdominal collection
Biochemical
-­ Pericardial cavity: pyopericardium
-­ Serum bilirubin > 3.5 mg/dL
-­ Biliary tree: spontaneously or after catheter drainage
-­ Serum albumin < 2 g/dL
Compression
Sonographic
-­ Biliary tree: jaundice
-­ Large volume of abscess
-­ Inferior vena cava: ascites, pedal edema
-­ Multiple abscess
Vascular thrombosis
Underlying chronic liver disease
-­ Hepatic venous thrombosis
-­ Portal venous thrombosis
Systemic complications
Systemic inflammatory response syndrome management, evidence for guiding treatment decisions,
Encephalopathy such as timing and indications of radiological interven-
Shock
tion, is limited.
Acute kidney injury
Acute respiratory distress syndrome
*Risk factors for rupture include left lobe liver abscess and abscess
Medical Management. Tissue amebicides such as
with a thin rim (<10 mm) of hepatic parenchyma. nitroimidazoles form the mainstay of management of
all patients with ALA (Table 3). Oral or intravenous (IV)
administration (in patients unable to take orally [PO]) of
urine.5 Newer tests such as lateral flow assays using markers
metronidazole results in resolution of fever, toxemia, and
in serum can potentially be used for rapid noninvasive diag-
pain in 80% of 90% of patients with uncomplicated ALA
nosis of ALA if available on a widespread basis.6
within 48 to 72 hours of treatment. Tinidazole is better
tolerated and has the advantage of shorter duration of
Management treatment. Other options include nitazoxanide, which has
Management of ALA comprises medical manage- an advantage of being both tissue and luminal amebicide.
ment, radiological drainage, and surgical manage- The treatment with tissue amebicides should be followed
ment (Fig. 1). In the absence of formal guidelines on with luminal amoebicidal agents to eradicate the luminal

FIG 1 Suggested algorithm for the management of liver abscess.

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Review Liver Abscess: Complications and Treatment Sharma and Ahuja

TABLE 3. DRUGS USED IN THE MANAGEMENT OF ALA

Drugs Dose and Duration Adverse Events
Tissue amoebicidal drugs
Metronidazole 800 mg three times a day PO or 500 mg IV three times a day Gastrointestinal: anorexia, nausea, vomiting, metallic
for 7-­10 days taste
Neurological: dizziness, peripheral neuropathy, seizures
Tinidazole 1.2 g PO per day for 7 days Gastrointestinal-­like metronidazole
Luminal amoebicidal drugs
Diloxanide furoate 500 mg three times a day for 20 days Gastrointestinal: nausea, vomiting
Paromomycin 30 mg/kg for 10 days (in 3 divided doses) Gastrointestinal: diarrhea, nausea
Tissue plus luminal amoebicidal drug
Nitazoxanide 500 mg twice a day for 10 days Gastrointestinal: nausea, vomiting

TABLE 4. OVERVIEW OF PLA

Causative organism Associated conditions Predisposing host factors
-­ Klebsiella pneumoniae -­ Biliary tract infection: cholangitis in biliary obstruction, acute -­ Diabetes
-­ Escherichia coli cholecystitis -­ Immunosuppression
-­ Pseudomonas -­ Abdominal infections: diverticulitis, appendicitis -­ Malnutrition
-­ Enterobacter -­ Hematogenous spread: endocarditis, bloodstream infection, -­ Advanced age
-­ Proteus central venous catheter–­associated infection
-­ Streptococcus* -­ Trauma
-­ Staphylococcus* -­ Postoperative conditions
Diagnosis Treatment: combination of antibiotics and drainage of abscess and Outcomes
-­ Imaging source control
-­ Microbiological
Antibiotics (duration: 2-­6 weeks)† Mortality rate: 2%-­15% across different series
-­ Third generation cephalosporins
-­ Aminoglycosides
-­ Piperacillin tazobactam
-­ Carbapenems
-­ Vancomycin (if suspecting gram positive)
-­ Metronidazole (for anaerobic coverage)
Drainage (imaging guided) Poor prognostic factors
-­ <3-­cm abscess: antibiotics alone -­ Advanced age
-­ 3-­to 5-­cm abscess: percutaneous aspiration -­ Immunosuppression
-­ >5-­cm abscess: PCD -­ Comorbid medical conditions, such as cirrhosis,
malignancy, etc.
-­ Abscess associated with systemic complications,
such as acute kidney injury, shock, etc.
Surgery
-­ Abscess not amenable to percutaneous drainage
-­ Rupture abscess
-­ No improvement with antibiotics and percutaneous drainage
-­ Underlying surgical cause of liver abscess
Source control
-­ Biliary tract obstruction: drainage of biliary tract
-­ Diverticulitis: drainage if associated with abscess
-­ Hematogenous spread: appropriate antibiotics, drainage if asso-
ciated with abscess, removal of catheter (in cases of catheter-­
associated sepsis)
*Causative agents in case of bloodstream infections.
†
Usual duration of 2 weeks of IV antibiotics followed by oral antibiotics.

amebae and to prevent subsequent tissue invasion and parenchyma (<10 mm) around it, (3) multiple liver abscesses,
spread of the infection through cyst.7 (4) impending rupture recognized on imaging, and
(5) nonresponse to medical therapy after 3 to 5 days. In the
Drainage of Abscess. The indications for drainage of absence of these high-­risk features, the evidence for upfront
liver abscess together with medical management are: (1) drainage is controversial. Faster resolution of clinical and
left lobe liver abscess, (2) abscess with thin rim of hepatic biochemical features is seen in some but not in other

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Review Liver Abscess: Complications and Treatment Sharma and Ahuja

TABLE 5. DIFFERENTIATING FEATURES OF ALA AND Patients with PLA usually have more pronounced systemic
PLA features with multiple liver abscess on imaging compared
with those with ALA. Unlike ALA, the principles of treat-
Variables ALA PLA
ment of PLA involve drainage of abscess, use of appropri-
Etiology E. histolytica -­
Klebsiella pneumoniae
-­E. coli
ate antibiotics, and control of primary source of infection
-­
Pseudomonas (Table 4).13 The differentiating features of ALA and PLA are
-­Enterobacter summarized in Table 5.
-­Proteus
Risk factors -­ Alcohol -­
Advanced age
consumption -­
Diabetes
-­ Immunosuppression -­
Biliary tree and other CONCLUSION
-­ Retroviral disease abdominal infections
Radiological features Usually solitary and Multiple abscesses in Recent advances in interventional radiology, intensive
situated in right either lobe
care, and use of effective antibiotic therapy have resulted
lobe
Management Amebicides ± Antibiotics and drainage in a decline in the mortality rates of liver abscess in India
drainage from 24% in earlier series to 1% to 3% in more recent
studies.1 The course of ALA is usually benign in the ab-
randomized trials comparing the strategy of combination of sence of poor prognostic factors. Management involves
drainage and medical management with that of medical medical management in all patients along with drainage of
management alone. A recent systematic review found abscess in certain patients with high-­risk features. Unlike
a combination strategy to be effective in reducing the ALA, patients with PLA require an upfront combination of
abdominal pain and local tenderness, but not in resolution of drainage and appropriate antibiotics, along with appropri-
fever, healing of abscess, and length of hospital stay, with ate treatment of primary infection.
benefits limited to abscesses of more than 5 cm.8 Hence CORRESPONDENCE
routine drainage of abscess is not recommended in patients
with ALA but may be used in selected patients with size Vineet Ahuja, M.D., D.M., Department of Gastroenterology and
Human Nutrition, All India Institute of Medical Sciences, New Delhi
greater than 5 cm. Percutaneous catheter drainage (PCD) is 110029, India. E-­mail: vineet.aiims@gmail.com
preferred over percutaneous needle aspiration, particularly
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