Pyogenic abscess of the liver

Abstract 1. 1. An analysis is presented of 830 cases of pyogenic hepatic abscess collected from the world literature and a presentation of 47 additional cases is made. 2. 2. During the ten-year period, 1928–1937 inclusive, there were 186 cases of abscess of the liver admitted to Charity Hospital and Touro Infirmary in New Orleans. Of this number, 139 (74.7 per cent) were amebic abscesses and 47 (25.2 per cent) were pyogenic. During this same period there were 540,776 total admissions to the Charity Hospital, among which there were 160 (0.029 per cent) abscesses of the liver, and 1,152 patients diagnosed as having liver disease, of which 10.2 per cent were amebic abscesses and 3.6 per cent were pyogenic abscesses. The sex incidence of pyogenic hepatic abscess reveals a preponderance of occurrence in the male, 67.4 per cent in the collected series and 70.2 per cent in the authors'. This is probably explained by the fact that the etiologic agents occur more frequently in the male. The greatest age incidence is from the third to the fifth decades. There is no significant racial predisposition. 3. 3. Pyogenic liver abscess is primarily a complication of an intra-abdominal suppurative process with the antecedent lesions in the portal area. Of these lesions, suppurative appendicitis is the most frequent. Appendicitis was the etiologic agent in 34.2 per cent of the collected cases and 10.6 per cent of the authors' cases. This discrepancy is due to the fact that the majority of reports in the literature represented primarily the author's interest in pylephlebitis and liver abscess as complications of appendicitis. Pyogenic liver abscess can be caused also by direct extension from contiguous suppurative processes, trauma, and by transportation of microorganisms through the hepatic artery from distant foci. There is a relatively large group (59.5 per cent) of the authors' series termed “cryptogenic,” idiopathic, or primary pyogenic hepatic abscess in which the antecedent lesion could not be determined. 4. 4. The most frequently found organisms in pyogenic hepatic abscess are B. coli, streptococci, and staphylococci. 5. 5. Pyogenic hepatic abscess may be multiple or single, and usually involves the right lobe. The abscesses were single in 28.8 per cent, multiple in 71.1 per cent, and involved the right lobe alone in 41.8 per cent of the collected cases. In the authors' forty-seven cases these incidences were 54.5 per cent, 45.4 per cent, and 68.1 per cent, respectively. 6. 6. The principal symptoms and signs of pyogenic hepatic abscess are fever, pain and tenderness over the hepatic area, liver enlargement, chills, and jaundice. Characteristically, there is a leucocytosis with a proportionate increase in polymorphonuclear leucocytes. The characteristic roentgenologic changes are elevation and immobility of the diaphragm, usually the right. The diagnosis was positive in 82.1 per cent of 28 cases in the authors' series in which roentgenologic studies were made. 7. 7. The prognosis in pyogenic hepatic abscess depends upon: (1) the multiplicity of the lesions; (2) the presence or absence of complications; and (3) the type of drainage instituted. Whereas of the twenty-four cases in the authors' series with single abscess of the liver nine (37.5 per cent) died, of the twenty cases with multiple abscesses, nineteen (95 per cent) died. The mortality rate was 90.9 per cent in those cases with complications and 36 per cent in the cases without complications. The total mortality rate was 79.6 per cent in the collected cases and 72.3 per cent in the authors' series. Whereas in those cases not operated upon the mortality rate was 100 per cent in both series, in the cases in which operation was performed the mortality was 50.9 per cent in the collected series and 64.8 per cent in the authors' series. 8. 8. The complications of pyogenic hepatic abscess are usually the result of rupture or direct extension into one of the adjacent viscera. 9. 9. The treatment of pyogenic hepatic abscess may be divided into: (1) prophylactic and (2) surgical. Prophylaxis is particularly applicable to multiple hepatic abscesses which are preceded by appendicitis and pylephlebitis, because once the development has proceeded to the stage of multiple abscess formation, surgical therapy offers only the slightest hope. The treatment of solitary pyogenic hepatic abscess consists of incision and drainage. 10. 10. The employment of that type of drainage which completely avoids the slightest possibility of contamination of the peritoneal or pleural cavity is of paramount importance. The results obtained in the authors' series of cases clearly demonstrate this fact. Of the twenty-two cases in which the transperitoneal approach was employed for the institution of drainage, there were sixteen deaths (72.7 per cent). The transpleural method of drainage was used in nine cases with six deaths (66.6 per cent). In contrast to these high mortality rates is the 33.3 per cent mortality obtained in six cases in which the extraserous approach was used.