Liver Abscesses and Cysts

oPatientPlus articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use, so you may find the language more technical than the condition leaflets.

Avoid percutaneous aspiration in the investigation of hepatic cysts and abscesses. Evaluation of simple cyst fluid is non-diagnostic. There is also a small risk of inducing anaphylaxis due to leakage from the hydatid cyst, or of causing abscess formation in a previously sterile cyst.[1]

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Epidemiology

Hepatic cysts are usually asymptomatic and are often found incidentally. Therefore, it is difficult to predict the exact prevalence. It is estimated that about 5% of the population have hepatic cysts.[1]

Cystic lesions of the liver include:

  • Simple cysts.
  • Multiple cysts due to polycystic liver disease.
  • Neoplastic cysts.
  • Hydatid (echinococcal) cysts.
  • Abscesses.

Other cysts can occur in the liver region but these are separated from hepatic cysts because they involve the bile ducts. They include:

  • Ductal cysts.
  • Choledochal cysts: a congenital dilatation of part or whole of the common bile duct. See separate article entitled Choledochal Cysts.
  • Cysts related to Caroli's disease: Caroli's disease is the combination of cystic dilatation of the intrahepatic bile ducts and infantile polycystic kidney disease. It has autosomal recessive inheritance.[2] It can present with fever, abdominal pain and recurrent attacks of cholangitis.

Simple cysts[1]

  • Pathophysiology: these are thought to be congenital. Lined with biliary-type epithelium but cyst fluid does not contain bile. Because the fluid is continuously secreted, they reaccumulate after aspiration.
  • Presentation: they are usually asymptomatic; they can cause right upper quadrant pain and bloating symptoms if large. If very large, they may be palpable abdominally. Rupture, torsion and jaundice caused by bile duct obstruction are rare.
  • Investigations: ultrasound and CT scanning can show cyst anatomy. Liver function tests may be mildly abnormal.
  • Treatment: this is only needed if symptoms occur. 'Deroofing' of the cyst can be performed laparoscopically, excising the portion of the wall that extends to the surface of the liver so that cystic fluid can drain into the peritoneal cavity.[3]
  • Prognosis: deroofing results in a cure rate of 90%.

Polycystic liver disease

  • Pathophysiology: adult polycystic liver disease is congenital and is usually associated with autosomal dominant polycystic kidney disease with mutations in PKD1 and PKD2 genes.[1][4] A considerable amount of research has been done on the genetic defects involved. Rarely, cases can occur in isolation and are associated with mutations in a third gene - polycystic liver disease gene.[5]
  • Presentation: kidney cysts usually occur before liver cysts and renal failure is common. However, polycystic liver disease rarely leads to hepatic fibrosis and liver failure. Hepatomegaly and abdominal pain may be present. Cysts are usually first noticed during puberty. Rupture, haemorrhage and infection are rare.
  • Investigations: examination of the kidneys and renal function needs to be carried out. Liver function tests may be abnormal but liver failure is rare. Ultrasound and CT scanning will show multiple liver cysts.
  • Treatment: this is only needed if symptoms occur. Similar 'deroofing' procedures can be carried out as well as liver resection. However, symptom recurrence is high as new cysts form. Liver transplantation is rarely used.[1]
  • Prognosis: small studies have reported variable success rates as defined by a lack of recurrence (40-78%).[1]

Neoplastic cysts

Cystadenomas and cystadenocarcinomas are rare. Cystadenoma is the premalignant lesion.

  • Presentation: usually asymptomatic or vague symptoms including bloating, nausea and fullness can occur. Abdominal pain and biliary obstruction can result as they enlarge.
  • Investigations: liver function tests may be normal. Carbohydrate antigen (CA) 19-9 levels may be raised. This can also be measured in cyst fluid.[1] Typical patterns may be seen on CT scanning. MRI and enhanced ultrasound can also be useful.[6]
  • Treatment: this is by resection. Despite complete resection, cystadenocarcinomas can recur.[7]

Hydatid (echinococcal) cysts

  • Pathophysiology: these are caused by infestation with the parasite Echinococcus granulosus - a tapeworm. Carnivores such as dogs and wolves act as definitive hosts. They pass out eggs with their stools which can then be ingested by sheep, cattle and humans. The egg larvae then invade the gastrointestinal tract and mesenteric vessels of these intermediate hosts and can pass to the liver. In the liver, the larvae grow and the hydatid cyst develops, producing daughter cysts. Other carnivores who eat the liver of the intermediate hosts can then become infected and adult worms can develop in their gastrointestinal tract. The parasite is found worldwide. Human infection most often occurs in those who raise sheep or cattle or who have contact with dogs.[8]
  • Presentation: can be asymptomatic (for up to 10-20 years)[8] or can present with pain and large right upper quadrant mass. Large cysts can rupture into the biliary tree (causing jaundice or cholangitis), through the diaphragm into the chest, or into the peritoneal cavity (causing anaphylactic shock). Secondary infection and hepatic abscesses can result from hydatid cyst rupture. Hydatid cysts may also form in the lungs and other organs.[8]
  • Investigations: eosinophilia may be present. Echinococcal antibody titres are positive in about 80% of patients.[1] A classic appearance may be seen on CT or MRI scanning (daughter cysts within a thick-walled main cavity).[1]
  • Treatment: this is needed to prevent complications due to cyst growth and rupture. It uses chemotherapy with albendazole or mebendazole, percutaneous procedures and conventional surgery. For treatment details, see separate article entitled Hydatid Disease, which includes hydatid disease management.

Liver abscesses are caused by bacterial, parasitic, or fungal organisms. In developed countries, pyogenic abscesses are the most common but worldwide, amoebae are the most common cause.[10]

Epidemiology

A retrospective study over a 10-year period of patients >16 years old admitted to the Royal Hallamshire Hospital in Sheffield with a diagnosis of liver abscess found 4 patients with amoebic liver abscesses and 65 with pyogenic liver abscesses. They estimated an annual incidence for liver abscesses of 2.3 per 100,000 people per year in the UK.[11] In children, liver abscess is rare except in underdeveloped countries where the incidence remains high, mainly due to Staphylococcus aureus infection.[12]

Aetiology

  • Pyogenic liver abscess:
    • This can be single or multiple. The right lobe is affected twice as often as the left; 5% have bilateral involvement.[9]
    • Most are secondary to infection originating in the abdomen (cholangitis secondary to stones or stricture or malignancy is the most common, diverticulitis, appendicitis, Crohn's disease, perforated peptic ulcer).
    • It may be iatrogenic secondary to liver biopsy or a blocked biliary stent.
    • Bacterial endocarditis and dental infection are other causes.
    • No cause is found in 15%.
    • It is more common in the immunocompromised.
    • 15% of adults with liver abscesses have diabetes.[10]
    • Liver cirrhosis is a strong risk factor.[13]
    • Liver abscess is a complication of umbilical vein catheterisation in infants. In children and adolescents there is usually immune compromise or trauma.
    • It tends to be polymicrobial. Organisms are usually of bowel origin. Klebsiella pneumoniae has emerged as the most common organism seen.[14] Other organisms include Escherichia coli and Bacteroides spp., enterococci and anaerobic streptococci. Staphylococci and haemolytic streptococci are more likely if secondary to endocarditis/dental infection. Fungal (Candida spp. is the most common) or opportunistic organisms are more likely if the patient is immunocompromised.[10]
  • Amoebic liver abscess:
    • 10% of the world's population is chronically infected with Entamoeba histolytica.[10] Infection occurs most commonly in tropical and subtropical areas and is more likely if there is poor sanitation and overcrowding.
    • Transmission is via the faecal-oral route. Amoebae invade intestinal mucosa and can gain access to the portal venous system.
    • E. histolytica causes amoebic colitis and dysentery but liver abscess is the most common extra-intestinal manifestation of infection.[15]
    • Liver abscess can present without a preceding history of colitis. It can also present months to years after travel to an endemic area.
    • It affects the right lobe in 80%.[10]

Presentation

  • Multiple abscesses tend to present more acutely and single ones more indolently.
  • Right upper quadrant pain, tenderness, hepatomegaly, possible palpable mass.
  • Swinging fever.
  • Night sweats.
  • Nausea and vomiting.
  • Anorexia and weight loss.
  • Cough and dyspnoea due to diaphragmatic irritation.
  • Referred pain to the right shoulder.
  • Jaundice (in 25% of cases, more common with disease of the biliary tree and multiple abscesses).[9]
  • Pyogenic liver abscesses can present as pyrexia of unknown origin (PUO) in some people who may not have right upper quadrant pain; pain is a prominent feature in amoebic liver abscess
  • Check history for travel to an E. histolytica endemic area.

Differential diagnosis

Investigations

  • Raised white cell count.
  • Raised erythrocyte sedimentation rate (ESR).
  • Mild normochromic normocytic anaemia.
  • Abnormal liver function tests (raised alkaline phosphatase, low albumin, raised serum transaminases, raised bilirubin).
  • Blood culture is positive in 50%.[9]
  • Stools can contain cysts or trophozoites of E. histolytica.
  • Serology should be carried out if E. histolytica is suspected.
  • Raised right hemidiaphragm on CXR. May be atelectasis or pleural effusion.
  • Ultrasonography can show abscess and also allow guided percutaneous aspiration and drainage. Aspirated fluid should be sent for culture and sensitivity. It also allows biliary tree examination.
  • CT scanning can show the abscess, allow guided aspiration and drainage and show other intra-abdominal abscesses or a possible cause such as diverticular disease, appendicitis, etc. It is good for the detection of small abscesses.
  • Endoscopic retrograde cholangiopancreatography (ERCP) can show the site and cause of biliary obstruction and allow stenting and drainage.
  • Investigation should always seek to determine the underlying cause.

Treatment

  • Antibiotics:
    • Pyogenic liver abscess: broad spectrum antibiotics should be started before waiting for culture results. Use a penicillin, an aminoglycoside and metronidazole. A third-generation cephalosporin can be considered in the elderly or if renal function is impaired.[10] Antibiotic therapy can be modified once culture results are available. Treatment may be needed for up to 12 weeks and should be guided by the clinical picture and radiological monitoring.
    • Amoebic liver abscess: metronidazole is the treatment of choice. 95% of patients with amoebic liver abscess recover with this alone. Most patients show a response to treatment within 72-96 hours.[16] Diloxanide furoate should be prescribed for 10 days to eliminate intestinal amoebae after the abscess has been successfully treated.
    • Antifungal agents such as amphotericin B are used if fungal abscess is suspected.
  • Drainage:
    • Most patients with pyogenic liver abscess and those with very large amoebic abscesses, may not recover with antibiotics alone and need drainage guided by ultrasonography or CT.
    • Percutaneous aspiration can be carried out for small abscesses although catheter drainage has become the standard of care. Larger abscesses may also need catheter drainage which is also CT- or ultrasound-guided. Drainage should also be carried out if there is impending rupture.
    • Open surgery may be necessary if the abscess has ruptured and there are signs of peritonitis, if the abscess is larger than 5 cm or multiloculated, or if there is a known abdominal pathology such as appendicitis.
  • Supportive measures:
    • Fluids
    • Nutrition
    • Pain relief

Complications

  • Overwhelming sepsis.
  • Rupture of the abscess into adjacent structures (pleural, peritoneal and pericardial spaces).
  • Secondary infection of amoebic liver abscesses.

Prognosis

  • Pyogenic liver abscess: early diagnosis and treatment with antibiotics improves outcome but mortality rates are still 5-30%.[9] Factors that affect prognosis include presence of shock or disseminated intravascular coagulation (DIC), immunodeficiency, diabetes, associated malignancy, ineffective surgical drainage.[10]
  • Amoebic liver abscess: since the introduction of rapid diagnosis and effective medical treatment, mortality rates have fallen to 1-3%.[16][17]

In the Hallamshire series, described under Epidemiology above, mortality rate was 12.3%.[11]

Further reading & references

  1. Jackson HH et al; Hepatic Cysts, eMedicine, Mar 2010
  2. Sgro M, Rossetti S, Barozzino T, et al; Caroli's disease: prenatal diagnosis, postnatal outcome and genetic analysis. Ultrasound Obstet Gynecol. 2004 Jan;23(1):73-6.
  3. Garcea G, Pattenden CJ, Stephenson J, et al; Nine-year single-center experience with nonparastic liver cysts: diagnosis and management. Dig Dis Sci. 2007 Jan;52(1):185-91. Epub 2006 Dec 8.
  4. Janssen MJ, Waanders E, Woudenberg J, et al; Congenital disorders of glycosylation in hepatology: the example of polycystic J Hepatol. 2010 Mar;52(3):432-40. Epub 2009 Dec 24.
  5. Everson GT, Taylor MR, Doctor RB; Polycystic disease of the liver. Hepatology. 2004 Oct;40(4):774-82.
  6. Ren XL, Yan RL, Yu XH, et al; Biliary cystadenocarcinoma diagnosed with real-time contrast-enhanced World J Gastroenterol. 2010 Jan 7;16(1):131-5.
  7. Yu J, Wang Y, Yu X, et al; Hepatobiliary mucinous cystadenoma and cystadenocarcinoma: report of six cases Hepatogastroenterology. 2010 May-Jun;57(99-100):451-5.
  8. Chrieki M; Echinococcosis--an emerging parasite in the immigrant population. Am Fam Physician. 2002 Sep 1;66(5):817-20.
  9. Peralta R et al; Liver Abscess, eMedicine, Sep 2009
  10. Krige JE, Beckingham IJ; ABC of diseases of liver, pancreas, and biliary system. BMJ. 2001 Mar 3;322(7285):537-40.
  11. Mohsen AH, Green ST, Read RC, et al; Liver abscess in adults: ten years experience in a UK centre. QJM. 2002 Dec;95(12):797-802.
  12. Mishra K, Basu S, Roychoudhury S, et al; Liver abscess in children: an overview. World J Pediatr. 2010 Aug;6(3):210-6. Epub 2010 Aug 13.
  13. Molle I, Thulstrup AM, Vilstrup H, et al; Increased risk and case fatality rate of pyogenic liver abscess in patients with liver cirrhosis: a nationwide study in Denmark. Gut. 2001 Feb;48(2):260-3.
  14. Nazir NT, Penfield JD, Hajjar V; Pyogenic liver abscess. Cleve Clin J Med. 2010 Jul;77(7):426-7.
  15. Wells CD, Arguedas M; Amebic liver abscess. South Med J. 2004 Jul;97(7):673-82.
  16. Stanley SL Jr; Amoebiasis. Lancet. 2003 Mar 22;361(9362):1025-34.
  17. Thompson JE Jr, Forlenza S, Verma R; Amebic liver abscess: a therapeutic approach. Rev Infect Dis. 1985 Mar-Apr;7(2):171-9.

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.

Original Author:
Dr Michelle Wright
Current Version:
Last Checked:
19/11/2010
Document ID:
2388 (v22)
© EMIS