CASE REPORT J ournal of the Indonesian Medical Association

J ima (4)1: April 2003: 455-464. 455

Pyogenic Liver Abscess

Sugitha IGAN,* Aryasa IKN,* Sukerena IN,** Supari IA***

*Department of Child Health, **Department of Pediatrics Surgery, ***Department of Radiology
Medical Faculty of Udayana University, Sanglah Hospital, Denpasar, Bali



























Abstract: Pyogenic liver abscess is one of the common liver abscesses. Worldwide, pyogenic liver abscess is much
less common than amoebic abscess, but in Western communities, pyogenic liver abscess is more frequent. Pyogenic
liver abscesses are rare in children. A three year old Balinese boy was admitted to the Department of Child Health,
Sanglah Hospital on February 13, 2002 with main complaint of the right-upper abdominal distension with pain,
fever, and loss of appetite. Laboratory results were leucocytosis, anaemia, elevated erythrocyte sedimentation rate
(ESR), normal serum transaminase, normal serum bilirubin, albumin more than 2g/dl, and negative amoeba serology.
The abdominal X-ray revealed elevated right hemidiaphragm. Liver ultrasonography revealed elevated right
hemidiaphragm. Liver ultrasonography revealed a solid mass within the right liver parenchyme. The mass margin
was clear and hypoechoic area was observed around it. Pus gram stain showed gram-negative bacilli bacteria. The
culture pus revealed Enterobacter aerogenes. An open surgical drainage was performed, combined with broad-
spectrum antibiotic therapy. The single pyogenic liver abscess was in the right liver. After an uneventful post open
surgical drainage, the child was discharged in good condition. The prognosis was good.
Key words: pyogenic liver abscess
Abstrak: Abses piogenik hati adalah salah satu abses hati yang paling sering ditemui. Umumnya abses piogenik hati
lebih jarang ditemui disbanding abses amuba, tetapi di populasi Barat, abses piogenik lebih sering dijumpai. Abses
piogenik jarang dijumpai pada anak. Seorang anak laki-laki berusia 3 tahun dating ke Bagian Kesehatan Anak
Rumah Sakit Umum Sanglah pada tanggal 13 Februari 2002 dengan keluhan utama kembung pada bagian kanan
atas perut disertai dengan nyeri, demam, dan hilangnya nafsu makan. Hasil laboratorium menunjukkan leukositosis,
anemia, ESR meningkat, serum transaminase normal, serum bilirubin normal, albumin > 2g/dl, dan uji serologi
amuba negatif. Foto abdomen menunjukkan hemidiafragma kanan yang meninggi. USG hepar menunjukkan massa
padat di parenkim kanan hepar, berbatas tegas, dikelilingi daerah hypoechoic. Pewarnaan gram dari pus
memperlihatkan bakteri basillus gram negatif. Kultur pus menghasilkan Enterobacter aerogenes. Telah dilakukan
operasi drainase terbuka, digabungkan dengan terapi antibiotik spectrum luas. Pascaoperasi, pasien dipulangkan
dalam keadaan baik. Prognosis kasus ini baik.
Kata kunci: abses piogenik hepar
CASE REPORT J ournal of the Indonesian Medical Association
J ima (4)1: April 2003. 456
Introduction
Pyogenic liver abscess is one of the
common liver abscesses. Worldwide,
pyogenic liver abscess is much less
common than amoebic abscess, but in
Western communities, pyogenic liver
abscess is more frequent. Pyogenic liver
abscesses are rare in children.
1-3
Pyogenic Liver Abscess (PLA)
continues to be a significant source of
morbidity in the pediatric population.
4

Although early reports in Milwaukee
Childrens Hospital between 1957-1977
quoted an incidence of 3 in 100,000
hospital admissions,
3,4
recent authors
have suggested an increasing rate of
PLA, conditionally attributed to
improved overall survival of immuno-
compromised patient.
4
Continuous
improvement in diagnosis and treatment
has greatly decreased the mortality from
as high as 80% before 1965 to 16% to
48% in the 1970s,
3,4
while a recent series
suggested 15%.
4

The patients at risk include those
with impaired host defenses, chronic
granulomatous disease and leukemia are
commonly noted.
4-6

Clinical manifestation of PLA in
children are nonspecific.
3-6
Diagnosis of
PLA is generally made by way of a high
index of clinical suspicion in
conjunction with appropriate imaging
techniques.
4

The purpose of this paper is to report
a rare case of pyogenic liver abscess due
to Enterobacter aerogenes in a three-
year old boy.

Case
KM, a three-year-old Balinese boy
was admitted to the Department of Child
Health, Sanglah Hospital on February
13, 2002 with main complaint of the
right-upper abdominal distension. The
complaints first appeared about two
weeks before admission. On the
admission the right-upper quadrant of
abdominal distension became more
severe, and there were abdominal pain
and redness on the right hipocondrium.
Since one and a half months before
admission, fever and abdominal pain had
appeared. Loss of appetite began since
two weeks before. Three days before
admission, he had vomiting. There were
no cough, jaundice, and abnormalities of
bowel habits nor urination noted.
Prenatal and labour history was
uneventful. No history of abdominal
surgery or trauma was found.
CASE REPORT J ournal of the Indonesian Medical Association
J ima (4)1: April 2003. 457
On physical examination, he was
alert with a pulse rate of 120/minute,
respiration rate 24/minute, and rectal
temperature was 38
0
C. His body weight
was 13,5 kg (25
th
percentile).
Conjunctive was pale but no jaundice on
sclera. There was no enlargement of the
cervical, axial or inguinal lymph nodes.
The physical examination of the
chest revealed symmetrical thorax with
no retraction. There were no crackles nor
wheezing heard. The heart sound was
within normal limit. On palpation there
was enlargement of the right-upper
quadrant of abdomen with hyperaemia
and pain. Hepatomegaly was also
revealed. The spleen was not palpable.
The bowel sound was normal on all
quadrants. On percussion, shifting
dullness was negative. The palms of the
hands and feet were pale, without
cyanosis.
Laboratory examination showed
white blood cell count 21,500/L,
neutrophil 15,000//L, haemoglobin
concentration 8.5 g/dl, haematocrite
25.2%, platelet count 586,000/L,
erythrocyte sedimentation rate 150
mm/hr. Blood smear: erythrocyte
normochromic-normocyter. Liver
function test revealed: SGOT 26 IU/L,
SGPT 8 IU/L, total bilirubin 0.52 mg/dl,
direct bilirubin 0.16 mg/dl, alkaline
phosphatase 390 IU/L, total protein 6.65
g/dl, albumin 2,97 g/dl. Stool
examination showed on macroscopy:
blood negative; on microscopic: white
blood cell, erythrocyte and amoeba
negative.
The abdominal radiographs showed
elevated right hemidiaphragm. There
were not revealed radiopaque stone,
calcification and mass with real border.
The ileus sign was not found.
The liver ultrasonography revealed
enlargement of the liver;
echoparenchyme was normal. There was
a solid mass within the liver
parenchyme. The margin of mass was
clear and hypoechoic area around it was
found. Size of the round mass was
approximately 67 X 66 mm. The gall
bladder was difficult to be evaluated.
The conclusion of liver ultrasonography
was hepatomegaly and intrahepatic mass
with the first differential diagnosis of
carcinoma hepatocellular and the second
differential diagnosis of liver abscess.
The history, physical examination,
abdominal X-ray, and liver
ultrasonography suggested working
diagnosis of pyogenic liver abscess with
CASE REPORT J ournal of the Indonesian Medical Association
J ima (4)1: April 2003. 458
differential diagnosis of amoebic liver
abscess and anaemia normochromic-
normocyter.
The patient was given intravenous
Amicillin 500 mg three times a day.
Intravenous metronidazole 200 mg
divided three times a day. He was
referred to The Paediatric Surgery
Department and was diagnosed as a liver
abscess with anaemia and so open
surgical drainage was planned.
Intravenous Cefotaxime 500 mg three
times a day was given.
Three days later open surgical
drainage was done. There was pus on the
right lobe of liver, 200 ml yellow pus
emerged 200 ml.
After the open surgical drainage,
haemoglobin concentration decreased
(6,6 g/dl), and then blood transfusion
was administered. Haemoglobin
concentration after transfusion increased
(9,5 g/dl). Pus gram stain revealed gram-
negative bacilli bacteria and leukocyte 1-
9/large field.
Five days after open surgical
drainage, the result of pus culture-
resistance emerged as Enterobacter
aerogenes that is sensitive to Ampicillin-
sulbactam (16), Aztreonam (30),
Cefotaxime (30), Ceftazidime (26),
Ceftriaxone (28), Cefuroxime (20),
Cephalexin (32), Chloramphenicol (30),
Erythromycin (26), Gentamycin (28),
Imipenem (22), Kanamycin (22).
Cytology of pus showed acellular
specimen with amorph only. The
malignant cell was not found.
The amoeba serology was negative.
On serial stool examination, amoeba was
found negative.
Then diagnosis pyogenic liver
abscess was made. Medicament therapy
was given for 7 days with intravenous
cefotaxime followed by oral sefradine
for 7 days. Metronidazole was stopped.
The following day after the abscess
drainage, the result of laboratory
examination returned to normal. White
blood cell count 15,300/L,
haemoglobin concentration 9.62 g/dl,
haematocrite 27.7%, platelet count
726,000/L, erythrocyte sedimentation
rate 58 mm/hr. Liver function test
revealed: SGOT 36 IU/L, SGPT 16
IU/L, total bilirubin 0.32 mg/dl, direct
bilirubin 0.04 mg/dl, alkaline
phosphatase 173 IU/L.
After an uneventful post abscess
drainage recovery, the child was
discharged from hospital in good
condition.
CASE REPORT J ournal of the Indonesian Medical Association
J ima (4)1: April 2003. 459
Discussion
Pyogenic liver abscess is a disease of
middle-aged and older people
7
both
sexes are affected about equally.
7

Geographic variation in disease
frequency are not obvious, and there is
no racial susceptibility.
7
Our patient is a
rare case, because he was three years
old.
Clinical manifestations of PLA in
Children commonly include malaise,
anorexia, nausea, vomiting, and loss of
weight.
3,7
Fever, abdominal pain, right-
upper quadrant tenderness, and
hepatomegaly are common sign.
4,6

J aundice is uncommon.
6
In our case, the
patient had similar symptom and sign
including anorexia, vomit, fever,
abdominal pain, right-upper quadrant
distension, and hepatomegaly. J aundice
was not present.
Routine laboratory study, like
clinical presentation, is not specific for
liver abscess and generally reflects any
underlying disease of the patient.
3,5,8

White blood count is generally elevated
with an increased proportion of
polymorphonuclear neutrofil.
1,5

Although there is no comparable
paediatric figure available, anaemia is
found in 50% and elevated
sedimentation rate in 90% of adult
patients.
3,6
Liver function test revealed
elevated bilirubin and alkaline
phosphatase in the presence of biliary
obstruction.
1,3,5,7
Transaminases are
usually mildly elevated
3,5,7
and may be
in normal range.
3
Albumin levels reflect
disease severity, and levels below 2 g/dl
carry a poor prognosis.
7
In our case,
Laboratory examination showed white
blood cell count was elevated with
neutrophilia, haemoglobin concentration
less than normal, erythrocyte
sedimentation rate was high. Liver
function test revealed serum
transaminases were normal, bilirubin
was normal, alkaline phosphatase was
high, albumin was no less than 2 g/dl.
Chest radiographs were found to be
abnormal in more than 50% of adults
with liver abscess, with findings
including right-side atelectasis,
infiltrates, pleural effusion, and elevation
of the right hemidiaphragm
5,6,7
If
infection is with gas-forming organisms,
air-fluid level may be seen below the
diaphragm on chest or abdominal film.
5,7

In our patient, the abdominal
radiographs showed elevated right
hemidiaphragm, but pleural effusion was
not found. We could not see air-fluid
CASE REPORT J ournal of the Indonesian Medical Association
J ima (4)1: April 2003. 460
level because we did not do postero-
anterior chest radiographs.
Ultrasonography showed pyogenic
liver abscess as round, ovoid, or elliptic
lesions within the liver parenchyme,
most often not contiguous with the liver
capsule. The margin of each lesion is
irregular and echo-poor. Abscesses are
mostly hypoechoic compared with
normal liver parenchyme, which
contained a variable number of internal
echoes. A hyperechoic appearance is
occasionally seen, particularly when gas-
forming organisms are present.
7

Pyogenic liver abscess is usually found
in the right hepatic lobe,
7,9
and mostly
solitary liver abscess(77,8%).
10
In our
case, the liver ultrasonography revealed
the enlagement of the liver;
echoparenchyme was normal. There was
a solid mass within the right liver
parenchyme. The margin of mass was
clear and hypoechoic area around it was
found. Size of the round mass was
approximately 67 X 66 mm. The gall
bladder was difficult to evaluate. The
conclusion of liver ultrasonography was
hepatomegaly with mass intrahepatic.
The first differential diagnosis of
carcinoma hepatocellular and the second
differential diagnosis of liver abscess
were established.
CT scanning is highly sensitive for
diagnosis of intraabdominal abscess
including liver abscess.
5,7
In liver the
lesion appeared as areas of decreased
attenuation. An advantage of CT
scanning over ultrasonography is that the
quality of the scan is not affected by
bowel gas or foreign objects such as
tubes and dressings.
7
In our case, CT
scanning was not done.
Blood cultures should be taken
before the initiation of therapy. Although
many authors quote 50% as the expected
rate of positive culture, in some reports,
the success rate has been almost 100%.
7

Paediatric patients with multiple
abscesses are even more likely to have
positive blood cultures than those with
single abscesses.
3
If aspiration is
performed, pus, not swabs, should be
submitted to the laboratory, as promptly
as possible. Aspirate pus is variably
coloured, usually not dark brown or red-
brown as is amoebic abscess content,
and frequently is foul smelling.
7
Gram
stain usually shows organisms unless
there has been substantial preceding
antibiotic treatment. The submitted
material should be cultured for aerobic,
CASE REPORT J ournal of the Indonesian Medical Association
J ima (4)1: April 2003. 461
anaerobic, and microaerophilic
organisms.
7

In our case, pus aspiration was not
performed. We took the pus from open
surgical drainage of abscess. The colour
of pus was yellow with foul smelling.
The result of the pus gram stain was
gram-negative bacilli bacteria and
leukocyte 1-9/large field. Blood culture
was not done.
The presence of a liver abscess may
be suggested by the patients history,
physical examination, results of
laboratory test and is confirmed by
imaging techniques.
7
In most cases, a
confident diagnosis is reached
combining epidemiological, clinical, and
radiological features with the results of
blood cultures and amoebic serology.
7

Negative amoebic serology virtually
excludes the diagnosis of hepatic
amoebiasis, despite rare cases in which
serologic test becomes positive after the
patients initial presentation.
7
In our
patient, before the open surgical
drainage, diagnosis of single liver
abscess on the right liver was
established.
Differential diagnosis of pyogenic
liver abscess were amoeba liver abscess,
subphrenic abscess, malignancy of the
liver, or acute cholecystitis.
1
In our patient, Cefotaxime and
Metronidazole was given combined with
open surgical drainage. The result of
pus-culture Enterobacter aerogenes,
indicated while amoebic serology was
negative, and the diagnosis of pyogenic
liver abscess was established. After that
Metronidazole was stopped, the patient,
was also given transfusions of blood
after open surgical drainage. On the
literature, the traditional treatment for
pyogenic liver abscess has been open
surgical drainage combined with broad-
spectrum antibiotics. In recent time,
percutaneous drainage has been applied
to hepatic abscesses because it has more
safety more safe and effective
procedure.
7,11-13
Small abscess of less
than 3-4 cm may be resolved with
prolonged antibiotic therapy.
5

Pyogenic liver abscess may arise
from (1) the portal circulation in patient
with pyleplebitis or intra-abdominal
sepsis (appedicitis, inflammatory bowel
disease); (2) generalized sepsis; (3)
cholangitis associated with biliary tract
obstruction, such as gallstones, in
inflammatory bowel disease, after a
Kasai procedure, and with choledochal
CASE REPORT J ournal of the Indonesian Medical Association
J ima (4)1: April 2003. 462
bowel cyst; (4) Systemic spread from an
intra-abdominal infection or contiguous
spread (which usually produces large
abscess); and (5) cryptogenic biliary
tract infection.
3,6
Small abscesses
(microabscesses) are most commonly
secondary to bacteremia, or candidemia.
6

In our case, PLA was large abscess that
may arise from systemic spread from an
intra-abdominal.
Most pyogenic liver abscesses are
secondary to infection originating in the
abdomen.
14
E. coli remains the single
bacterium most frequently isolated in
most reported series.
7
Other important
aerobic organisms are various gram-
negative bacilli, including species of
Klebsiella, Proteus, and Pseudomonas,
and gram-positive enteric organisms,
such as Streptococcus faecalis and
Streptococcus faecum. The latter two
agents are referred to as enterococci.
5,7

The importance of anaerobic and
microaerophilic organisms in liver
abscess are a recent recognition. As
many as one third to one half of patients
may be infected with such organisms.
Anaerobic organism incriminated
include Bacteroides sp, Fusobacterium
sp, anaerobic streptococci
(Peptostreptococcus and Peptococcus
spp), and rarely, Clostridium sp.
Microaerophilic streptococci are
considered by some authors as the most
common of all organisms that cause liver
abscess. Streptococcus milleri is the
most important member of the group.
7

Unusual organisms documented as
causing liver abscess on occasion
includes species of Salmonella,
Haemophilus, and Yersinia.
Actinomycosis, tuberculosis, and
melioidosis may also be associated with
liver abscess.
5,7

Complications of PLA are rupture
into the peritoneum or biliary system,
septicaemic empyema, curiously
endophthalmitis,
5
septicemias, metastatic
abscess, direct extension, hypotension
and shock, respiratory distress
syndrome, mental obtundation, and renal
failure. This complication was not found
in our patient.
Delay in diagnosis and treatment of
pyogenic liver abscess has a major effect
on outcome.
7,15
Reports of successful
medical management, with or without
aspiration, describe case-fatality rate as
low as 10%. The prognosis is also
related to underlying disease.
7
Mortality
seems greater in patients with multiple
abscesses.
7
Our patients prognosis is
CASE REPORT J ournal of the Indonesian Medical Association
J ima (4)1: April 2003. 463
good, because the cause of liver abscess
is clear; single abscess, with albumin
more than 2 g/dl, and diagnosis and
treatment were performed early.

Summary
A case of pyogenic liver abscess in a
three-years-old Balinese boy has been
reported. The diagnosis of pyogenic liver
abscess was suspected by way of the
patients history, physical examination,
results of laboratory test, imaging
techniques and confirmed by pus-
culture. The single pyogenic liver
abscess was in the right liver. The
treatment of choice was open surgical
drainage combined with antibiotic
therapy. The prognosis of this patient
was good.

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