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Hepatic abscess
Dr Rohit Sharma and A.Prof Frank Gaillard ◉ ◈ et al.

Hepatic abscesses, like abscesses elsewhere, are localized collections of necrotic inflammatory tissue caused by
bacterial, parasitic or fungal agents.

On this page:
Article:

Epidemiology
Clinical presentation
Pathology
Radiographic features
Treatment and prognosis
Differential diagnosis
Related articles
References

Images:

Cases and figures

Imaging differential diagnosis

Epidemiology

The frequency of individual infective agents as causes of liver abscesses are intimately linked to the
demographics of the affected population:

in developing countries, parasitic abscesses are the most common 2

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in developed countries, liver abscesses are rare in healthy individuals, with imported infections from visits
overseas accounting for the majority of cases

Risk factors

In developed countries, bacterial abscesses are most common, usually in the setting of comorbidities such as:

infection elsewhere (most common)

abdominal sepsis most common 1
necrotizing enterocolitis (portal venous drainage)
immunocompromised
diabetes mellitus found in up to 15% of patients with hepatic abscess 1
HIV/AIDS
elderly
chemotherapy/transplant recipients
malignancy
end-stage renal disease 18
intravenous drug use
trauma
ERCP 3
cryptogenic: 15% 1
liver cirrhosis 19
biliary disease 20
inflammatory bowel disease 21

Clinical presentation

The typical presentation is one of right upper quadrant pain, fever and jaundice. Anorexia, malaise and weight
loss are also frequently seen. Depending on the immune status of the patient, and the organism involved, the
presentation may be dramatic or insidious.

Pathology

Hepatic abscesses can occur via different routes such as 16:

haematogenous spread of infection via the portal vein or hepatic arteries

biliary spread of infection from ascending cholangitis or cholecystitis
direct inoculation in the setting of penetrating trauma or iatrogenic following a procedure

Bacteria

Most abscesses in this setting are polymicrobial, with the most common bacterial agents being 1:

gram-negative aerobic and anaerobic organisms

Escherichia coli
Klebsiella pneumoniae
the hypervirulent Asian strain has a particular predilection 24
Bacteroides
gram-positive
anaerobic and microaerophilic streptococci

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enterococci

Parasites

Parasitic abscess in patients from developing countries include:

amoebae: amoebic hepatic abscess (anchovy paste appearance of drained contents)

echinococcal (hydatid disease of the liver): this will be discussed separately
protozoa
helminths

Radiographic features

As a general rule, bacterial and fungal abscesses are often multiple, whereas amoebic abscesses are more
frequently single. Amoebic abscesses are more common in a sub-diaphragmatic location and are more likely to
spread through the diaphragm and into the chest.

When the infection spreads to the liver through the portal veins it arises more commonly in the right lobe,
probably due to an unequal distribution of superior and inferior mesenteric vein contents within the portal
venous distribution.

Plain radiograph

A plain abdominal radiograph is not sensitive for evaluating liver abscesses. Indirect signs visible include:

gas within the abscess or biliary tree (pneumobilia) or beneath the diaphragm
right-sided pleural effusion

Ultrasound

Liver abscesses are typically poorly demarcated with a variable appearance, ranging from predominantly
hypoechoic (with some internal echoes) to hyperechoic. Gas bubbles may also be seen 7. Color Doppler will
demonstrate the absence of central perfusion.

Contrast-enhanced ultrasound shows wall enhancement during arterial phase and progressive washout during
portal or late phases. The liquefied necrotic area does not enhance. The use of contrast allows one to characterize
the lesion, to measure the size of the necrotic area, and to depict internal septations for management purposes. In
small abscesses (under 3 cm) and in highly septated abscesses, drainage is not recommended.

In patients with monomicrobial K. pneumoniae abscesses, the lesion may appear solid and mimic a hepatic
tumor 6.

CT

As with other modalities, the appearance of liver abscesses on CT is variable. In general, they appear as
peripherally enhancing, centrally hypoattenuating lesions 8. Occasionally they appear solid or contain gas
(which is seen in ~20% of cases 14). The gas may be in the form of bubbles or air-fluid levels 11. Segmental,
wedge-shaped or circumferential perfusion abnormalities, with early enhancement, may be seen 8,11.

The "double target sign" is a characteristic imaging feature of hepatic abscess demonstrated on contrast-
enhanced CT scans, in which a central low attenuation lesion (fluid filled) is surrounded by a high attenuation

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inner rim and a low attenuation outer ring 10,11. The inner ring (abscess membrane) demonstrates early contrast
enhancement which persists on delayed images, in contrast to the outer rim (edema of the liver parenchyma)
which only enhances on delayed phase 11.

The "cluster sign" is a feature of pyogenic hepatic abscesses 12. It is an aggregation of multiple low attenuation
liver lesions in a localized area to form a solitary larger abscess cavity.

MRI

Signal characteristics include:

T1
usually hypointense centrally
heterogeneous
maybe slightly hyperintense in fungal abscess
T2
tends to have hyperintense signal
perilesional edema manifests as high signal intensity on T2-weighted images and can be identified
in 35% of liver abscesses 13
T1 C+ (Gd)
enhancement of the capsule, although this may be absent in immunocompromised patients 5
multiple septations may be visible
DWI: tends to have high signal within the abscess cavity 9
ADC: tends to have low signal within the abscess cavity 9

Treatment and prognosis

Medical antimicrobial therapy is required in all cases and sometimes suffices if abscesses are small.

Radiology has a major role to play in the percutaneous drainage of hepatic abscesses, which can be performed
either under ultrasound or CT guidance.

Surgery is limited to those patients where percutaneous drainage is impossible or has proven ineffective.
Additionally, the source of the abscess may require surgical treatment at which time the abscess may also be
drained.

Prognosis is highly variable, depending not only on the organism involved and size of the abscess but also the
co-morbidities present. Figures range from 9-80% 3.

Complications

hepatic vein thrombosis: ~22% 15

portal vein thrombosis: ~24% 15
rupture into:
right subphrenic space
abdominal cavity
pericardium 17
gastrointestinal tract 22
sepsis 17
thrombosis of the inferior vena cava 22

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Differential diagnosis

General imaging differential considerations include:

liver metastases (especially necrotic metastases): cystic lesions are usually not clustered or septated
hepatocellular carcinoma: more heterogeneous, irregular infiltrating border in the setting of cirrhosis
hemorrhagic liver cysts can appear multiloculated
biliary cystadenoma
hepatic peliosis
hydatid cyst: large cystic liver mass with peripheral daughter cysts
hepatic hemangioma
hepatic adenoma
hepatic infarct: peripheral, segmental distribution, wedge-shaped

Quiz questions
References
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hypoechoic halo sign / target lesions
simple hepatic cyst
hepatic hemangioma
focal nodular hyperplasia
hepatic adenoma
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cystic hepatic metastases
hepatic abscess
periportal hyperechogenicity
periportal hypoechogenicity
diffuse
acute hepatitis
cirrhosis
hyperechoic liver
diffuse hepatic steatosis
grading of hepatic steatosis
coarsened hepatic echotexture
generalized decrease in hepatic echogenicity
"starry sky appearance" of the liver
hepatic vasculature
normal hepatic vein Doppler
portal hypertension
portal vein thrombosis
developed collaterals / portosystemic shunts

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URL of Article

Article information
rID: 1942
System: Hepatobiliary
Tags: rg_38_3_edit, infection, infectiousdisease, oncology
Synonyms or Alternate Spellings:

Pyogenic liver abscess

Liver abscess
Liver abscesses
Hepatic abscesses

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Cases and figures

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Case 1: with "double target" and "cluster" signsCase 1: with "double target" and "cluster" signs
Drag here to reorder.

Case 2: echinococcal abscess - hydatid cystystCase 2: echinococcal abscess - hydatid cystyst

Drag here to reorder.

Case 3: pyogenic bacterialCase 3: pyogenic bacterial

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Case 4: pyogenicCase 4: pyogenic

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Case 5: with ruptureCase 5: with rupture

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Case 6: with rupture into pleural spaceCase 6: with rupture into pleural space
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Case 7: with rupture into pleural space Case 7: with rupture into pleural space
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Case 8: with ruptureCase 8: with rupture

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Case 9: amoebic abscessCase 9: amoebic abscess

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Case 10: subcapsularCase 10: subcapsular

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Case 11: rupture into subcutaneous planeCase 11: rupture into subcutaneous plane
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Case 12: pyogenicCase 12: pyogenic

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Case 13: amoebicCase 13: amoebic

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Case 14: contrast enhanced ultrasoundCase 14: contrast enhanced ultrasound

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Case 15Case 15
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Case 16 Case 16
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Case 17Case 17
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Case 18: subcapsular hepatic abscess post laparoscopic cholecystectomyCase 18: subcapsular hepatic abscess
post laparoscopic cholecystectomy
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Case 19Case 19
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Case 20: on MRICase 20: on MRI

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Imaging differential diagnosis

MetastasisMetastasis
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Simple hepatic cystSimple hepatic cyst

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HepatoblastomaHepatoblastoma
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Infected liver cystInfected liver cyst

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