EJOHG

10.5005/jp-journals-10018-1206
Management of Liver Abscess in Children: Our Experience
ORIGINAL ARTICLE

Management of Liver Abscess in Children: Our Experience

1
Mukta Waghmare, 1Hemanshi Shah, 1Charu Tiwari, 1Kiran Khedkar, 1Suraj Gandhi

ABSTRACT
Introduction: Liver abscess is common in pediatric population in India. Children have unique set of predis-
posing factors and clinical features. Liver abscesses are infectious, space-occupying lesions in the liver;
the two most common abscesses being pyogenic and amebic. Its severity depends on the source of the
infection and the underlying condition of the patient.
Materials and methods: A total of 34 patients less than 12 years were assessed in a retrospective study
from January 2012 to 2016. Patients were assessed in terms of age of presentation, etiology, bacteriology,
diagnosis, and modality of treatment.
Results: The mean age of presentation was 6.3 years. Average volume of abscess was 164 cc. Nine patients
(26.4%) underwent percutaneous needle aspiration under ultrasound guidance with wide bore needle
(18 G disposable needle). Three patients required more than two sittings of aspiration. Patients with volume
more than 80 cc were treated with catheter drainage. Twenty patients (58.8%) underwent ultrasound-guided
percutaneous catheter drainage. Two patients required catheter drainage for large abscess and needle
aspiration for the smaller abscess.
Conclusion: Antimicrobial therapy along with percutaneous drainage constitutes the mainstay of treatment,
whereas open surgical drainage should be reserved for selected cases.
Keywords: Catheter drainage, Liver abscess, Percutaneous aspiration, Predisposing factors.
How to cite this article: Waghmare M, Shah H, Tiwari C, Khedkar K, Gandhi S. Management of Liver
Abscess in Children: Our Experience. Euroasian J Hepato-Gastroenterol 2017;7(1):23-26.
Source of support: Nil
Conflict of interest: None
Copyright and License information: Copyright © 2017; Jaypee Brothers Medical Publishers (P) Ltd.
This work is licensed under a Creative Commons Attribution 3.0 Unported License. To view a copy of this license,
visit http://creativecommons.org/licenses/by/3.0/

INTRODUCTION aspiration or ultrasound-guided pigtail catheter drain-

age. The resolution of the abscess was monitored by serial
Liver is a major organ with dual blood supply, which
ultrasound examination. All patients were discharged on
predisposes it to an increased risk of infection. The inci-
oral metronidazole and regular follow-up.
dence of pyogenic liver abscess (PLA) has decreased in
the developed world, but it is still common in developing RESULTS
countries.1 Two common liver abscesses are pyogenic
and amebic. The PLA may be of biliary, portal, arterial, The mean age of presentation was 6.3 years, with age
traumatic, or cryptogenic in origin. range being 1.5 to 12 years. Around 16 patients (47.01%)
were less than 5 years of age. There were 19 girls (55.8%)
MATERIALS AND METHODS and 15 boys (44.1%). Most patients (64.7%) presented
during monsoon and postmonsoon season between
In this retrospective study, 34 patients less than 12 years June and November.
of age were included, and this study was carried out from Two patients were diagnosed with enteric fever
January 2012 to 2016 in a tertiary care center in West India. 15 to 20 days prior to presentation. One patient had a
Patients were analyzed in terms of age, sex, presenting preceding history of blunt trauma to the abdomen. Two
symptoms, and predisposing factors. Diagnostic workup patients had associated pleural effusion. No significant
included hemogram, liver function tests, coagulation predisposing factors were found in the rest (n = 30).
profile, and ultrasonogram findings (site, number, and Fever and abdominal pain were the most common
volume of liver abscess). Treatment modality included presenting complaints (33 patients). All patients had
intravenous antibiotics and ultrasound-guided needle right hypochondriac tenderness. None of patients had

1
Department of Pediatric Surgery, Topiwala National Medical College & B.Y.L. Nair Charitable Hospital, Mumbai, Maharashtra, India

Address reprint requests to: Hemanshi Shah, Department of Pediatric Surgery, Topiwala National Medical College & B.Y.L. Nair
Charitable Hospital, Mumbai, Maharashtra, India, Phone: +912223027671, e-mail: [email protected]

Euroasian Journal of Hepato-Gastroenterology, January-June 2017;7(1):23-26 23

Mukta Waghmare et al

icterus. Total leukocyte count was raised in 25 patients. DISCUSSION

Liver function tests including coagulation profile were
Pyogenic liver abscess constitutes the majority of cases,
normal in all patients. Diagnosis was confirmed on
followed by amebic and fungal. Pyogenic liver abscess
ultrasound and patients were started on intravenous
constitutes the majority (80%) of hepatic abscesses in
broad spectrum antibiotics (piperacillin + tazobactam
children.2-4
and metronidazole).
The incidence of PLA has been reported to be more
On ultrasound, the abscesses were localized in
than 79 per 100,000 pediatric admissions in India. 5
the right lobe in 25 patients (73.5%) and in left lobe in
Amebic liver abscess is rare in children6 and mostly
6 (17.6%); 3 patients had abscesses involving both lobes.
endemic in Thailand, India, Egypt, and South Africa.7
Single lesion was found in 26 patients (79.4%), 8 patients
Amebic liver abscess develops in less than 1% of patients
had two or more abscesses.
infected with Entamoeba histolytica.8
Depending upon location, size, volume, and state of
The predisposing factors are perforated appendici-
liquefaction of abscess, treatment modality was planned
tis, chronic granulomatous disease, sickle cell disease,
(Graph 1). Average volume of abscess was 164 cc. Three
immunocompromised status due to malignancy,
patients with small abscess not amenable to aspiration
postchemotherapy, and chronic malnutrition. When
were managed with intravenous antibiotics only. Nine
the biliary tract is the source of liver abscess, there are
patients (26.4%) underwent percutaneous needle aspira-
multiple abscesses. Protein calorie malnutrition also
tion under ultrasound guidance with wide bore needle
predisposes to liver abscess in children probably due to
(18 G disposable needle). Three patients required more
immunosuppressed state.1 Kumar et al5 reported moder-
than two sittings of aspiration. Patients with volume
ate to severe malnutrition in 27.8% patients with liver
more than 80 cc were treated with catheter drainage;
abscess. Hepatic trauma may cause localized hepatic
20 patients (58.8%) underwent ultrasound-guided per-
necrosis, intrahepatic hemorrhage, and bile leakage, thus
cutaneous catheter drainage. Two patients required
providing a suitable environment for bacterial growth.
catheter drainage for large abscess and needle aspiration
The other causes in immunocompetent patients are
for smaller abscess.
intestinal infection, chronic cholangitis, umbilical vein
Pus culture was negative in 26 patients (76.47%).
catheterization (in neonates), and systemic bacteremia
Staphylococcus aureus was grown in three patients, and
of any cause.
methicillin-resistant S. aureus, Pseudomonas, and Acineto-
Approximately two-third of liver abscesses occur
bacter species were grown in one patient each.
in the right lobe of the liver and the majorities are
Repeat ultrasound was done when drain output
solitary.1,5 The predilection for the right hepatic lobe
decreased to less than 10 cc per day or if there was
can be attributed to the volume of the right portal vein
no clinical improvement. Mean duration of drain was
flow and also that the right portal vein continues in
7.7 days (4–16 days). Patients were discharged on oral
the direction of the common portal vein, while the left
antibiotics for a duration of 3 weeks. All patients were
portal vein takes a more horizontal direction. Multiple
asymptomatic on follow-up and ultrasound examina-
liver abscesses constitute 20 to 25% of all cases.9
tion was normal.
Most of these patients are less than 5 years of age.
Clinical signs and symptoms of liver abscess are usually
nonspecific with variable duration like fever, abdominal
pain, and loss of appetite and nausea, which often delays
the diagnosis. Hepatomegaly is usually associated with
right upper quadrant tenderness.
Staphylococcus aureus is the most common etiological
agent for PLA. Other bacteria include Escherichia coli,
Klebsiella, Enterobacter, Pseudomonas, and sometimes
anaerobes. Anaerobes constitute an important propor-
tion of up to 30% of organisms and include microaero-
philic Streptococci.9 Recurrent pyogenic cholangitis may
be due to Salmonella typhi.10 Kumar et al11 have reported
liver abscess as an unusual complication of enteric
fever in the pediatric age group. Fungal hepatic micro-
Graph 1: Management modalities of 34 patients abscesses either alone or in association with splenic
with liver abscesses microabscesses may occur in children with leukemia.12

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Management of Liver Abscess in Children: Our Experience

A large number of cases have been found without any with aggressive percutaneous techniques that include
apparent cause and have been labeled as cryptogenic.13 disruption of loculations and placement of large bore
As high as 33 to 35% cases of cryptogenic liver abscess sump catheters.15 Percutaneous drainage is indicated
have been reported by Donovan et al14 and Bari et al.13 when there is a large volume abscess and there is risk
The abscess may also be sterile because the patient has of spontaneous rupture (specially left lobe abscesses).15
received prior antibiotic therapy. In our study, low level When there is lack of response to medical therapy with
of positive cultures could partly be due to prior antibiotic clinical signs of persistent sepsis or enlarging abscesses,
therapy received by patients before admission as most or persistent symptoms.9
of patients were referred from small peripheral health A review of various studies shows that the overall
centers. Blood investigations may show leukocytosis, failure rate of PD ranges from 5 to 28%.16-18 Herman
anemia, and altered liver function tests. et al19 analyzed 48 patients with PLA and found that the
Ultrasonography of abdomen serves initial investiga- failure rate of PD was 30.8%, whereas the failure rate
tion to assess the site, size, and number of liver abscess of open surgical drainage was only 8.5%. Percutane-
(Fig. 1). Contrast-enhanced computed tomography (CT) ous management failed in patients with thick-walled
is more sensitive in detecting even small abscesses any- abscess or containing viscid pus and in the presence
where in the liver. Liver abscesses on magnetic resonance of loculations. Percutaneous drainage is not indicated
imaging appear hypointense on T1-weighted and hyperin- in the presence of ascites or when liver abscess is close
tense in T2-weighted sequences. On gadolinium-enhanced
to the pleura.
sequences, there is early and continued enhancement of
The indications of open laparotomy include nonre-
wall, which persists on delayed images.
sponse to PD together with antibiotic therapy, or when
Initial treatment of PLA is broad spectrum antibio­
the pus is thick, multiloculated abscess or rupture into
tics, which cover gram positive, gram negative, and
peritoneal cavity.
anaerobic organisms. A course of 6 weeks antibiotic
Facility of prompt diagnosis with imaging, PD, and
therapy alone, including 2 weeks intravenously, fol-
better antibiotics has remarkably improved survival in
lowed by 4 weeks orally is recommended, when multiple
last three decades. With modern management, mortality
abscesses are too small (less than 2 cm) to be drained
is less than 15%.9
percutaneously.
Aspiration can be attempted in solitary, unilocular
lesions and on carefully selected patients. CONCLUSION
Percutaneous drainage (PD) has now come to a cen- In conclusion, liver abscess in children is still very
terstage in management of liver abscesses that require common in developing countries; PLA is more common
more than just a medical management. Percutaneous than amebic, fungal, or other etiologies. Imaging with
aspiration in conjunction with antibiotics has been ultrasonography and/or CT is diagnostic. Antimicro-
recommended for unilocular liver abscess.13,14 bial therapy along with PD constitutes the mainstay of
Safety and efficacy of percutaneous abscess drain- treatment, whereas open surgical drainage should be
age in selected patients is now well established.15 reserved for selected cases.
Even multiloculated liver abscesses can be managed
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