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Pyogenic Liver Abscess: An Audit of 10 Years’ Experience and Analysis of Risk Factors / with Invited CommentaryLee K.-T. · Wong S.-R. · Sheen P.-C.
Division of Hepatobiliary Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
Background/Aims: Despite continuous improvement in image modalities, availability of potent antibiotics and advancement in the knowledge and treatment of pyogenic liver abscess, mortality remains high. The high mortality rate has underlined the important role of prognostic factors and prompts a number of studies to identify the risk factors. The present study aims to audit our experience in managing patients with pyogenic hepatic abscess during the period of 1989–1999, and to document changes in etiology, bacteriology and outcome, and to identify any risk factor associated with mortality. Methods: One hundred and thirty-three patients with pyogenic hepatic abscess were studied to determine the demographic characteristics, clinical features, laboratory, bacteriological findings, methods of treatment, final outcome and risk factor analysis. All patients were treated with parenteral antibiotics. One hundred and twelve patients were subjected to ultrasound-guided percutaneous aspiration of the abscess. A percutaneous drainage catheter was inserted after aspiration in all patients. Laparotomy was done in 21 patients. Results: The overall hospital mortality rate was 6% (8/133). Biliary tract disease was the most frequently identified cause. Leukocytosis, hypoalbuminemia and hyperbilirubinemia were common laboratory findings. The most common microorganism cultured was Klebsiella pneumoniae. The most common concomitant disease was diabetes mellitus. On univariate analysis, large abscess, diabetes mellitus and sepsis were significantly associated with hospital mortality. On multivariate logistic regression analysis, the presence of sepsis (p = 0.0031) was found to be an independent risk factor. Conclusions: In addition to early diagnosis and prompt treatment, making every effort to treat patients with adverse prognostic factors and systemic complications, the hospital mortality rate will be decreased significantly.
© 2001 S. Karger AG, Basel
Department of General Surgery, Karl Franzens University, Graz, Austria
The prognosis for pyogenic abscesses has improved steadily over the years. Since Oschner’s description in 1938, there have been substantial changes in liver abscess with respect to etiology, diagnosis, therapeutic management and survival. There is also strong evidence in the literature of a significant shift in pathogens in pyogenic hepatic abscesses over the past four decades. The mortality rate has improved thanks to the introduction of percutaneous drainage of liver abscesses as well as improvements in care and therapeutic techniques.
Lee et al. report their experience in 133 patients with pyogenic liver abscesses, all of whom were free of amebic infection, during the period of 1989–1999. During this time the percutaneous technique has developed into a standard procedure. The influence of this new form of liver abscess management on outcome is compared to an earlier report from the same institution.
The etiologies Lee et al. report differ from other series, wherein abscesses of biliary origin or due to tumors of systemic infections are most common. Lee et al. give diabetes (29.3%) followed by biliary stones as the most frequent cause of pyogenic liver abscesses. Hepatolithiasis is more commonly associated with liver abscesses in Asia than in the Western world. The large number of cryptogenic pyogenic abscesses is also unusual (42.1%).
As far as microbiology is concerned, streptococcal species are the most commonly isolated gram-positive aerobes; this reflects the bacteriologica trend in other series. The incidence of Escherichia coli infection has, however, decreased, while Klebsiella, Streptococcus, Staphylococcus and Pseudomonas species have increased significantly, as have fungi . A special syndrome described in Taiwan is the occurrence of a pyogenic liver abscess caused by Klebsiella pneumoniae in diabetic patients. This combination carries not only a higher risk of infection, but also a significantly higher mortality rate compared to nondiabetic patients.
Both the underlying etiology and the number of liver abscesses are key determinants of therapeutic outcome. In this study, only multivariate logistic regression analysis showed sepsis to be independently significant in predicting mortality. The literature shows no general consensus on the risk factors. The discrepancies may be explained by the heterogeneity of factors influencing the outcome data given in different reports and reflecting different patient populations.
Lee et al. also report a dramatic change in management with percutaneous drainage being applied in 82% of cases. Compared to their earlier series, percutaneous drainage was used twice as often as first-line therapy.
The overall mortality in the series of Lee et al. was 6%. It is remarkable in view of other reports that there were no deaths in the surgical group while 7 deaths (6.4%) occurred in the percutaneous drainage group. This raises the question as to whether multiple, bilobular or very large abscesses required repeated percutaneous drainage and/or led to surgery, and it would be desirable to know more about the circumstances surrounding mortality in the percutaneous drainage group. Admittedly, the authors mention that multiple drainage procedures were performed in cases of multiple abscesses (n = 8, 6.4%), but data on the number of patients with multiple unilobular or bilobular abscesses are not available.
In our own series we had a significantly higher number of patients with multiple abscesses (33%), with a mortality rate nearly twice as high as in cases with single abscesses . Additionally, it should be noted that, in most series, surgical groups represent a rather negative selection of patients with complicated clinical courses who require additional surgical intervention and/or do not respond to percutaneous drainage.
The relatively small percentage of patients with multiple abscesses (6.4%) or ruptured abscesses (3.2%) and the low number of patients with underlying malignancy (2.2%) probably contribute significantly to the low mortality in the series of Lee et al.
Lee et al. provide interesting data and offer a statistical evaluation of a considerable number of patients (n = 133). Furthermore, Lee et al. should be complimented on the low overall mortality of 6%, which means a significant improvement in clinical outcome when compared with their previous series with a mortality rate of 19.3% at the same institution.
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