Ruptura espontánea de absceso hepático del lóbulo izquierdo en hemitórax derecho / Spontaneous rupture of liver abscess of the left lobe in the right hemithorax

Introducción: La extensión transdiafragmática del absceso hepático piógeno constituye un caso raro de empiema pleural. Es una enfermedad de progresión rápida y con altas tasas de mortalidad, cercanas al 100 por ciento si no se trata a tiempo. Objetivo: Describir el caso de una paciente con empiema pleural derecho, secundario a ruptura de absceso piógeno del lóbulo hepático izquierdo. Caso clínico: Paciente femenina de 70 años de edad que acude al cuerpo de guardia con fiebre, dolor abdominal, síndrome general. La tomografía computadorizada mostró absceso hepático el lóbulo izquierdo con licuefacción casi total y posteriormente presentó como complicación un empiema torácico derecho. La paciente fue tratada con drenaje con sonda pleural. A pesar de los tratamientos antibióticos y quirúrgicos oportunos la paciente fallece en shock séptico. Conclusiones: Se reporta un caso raro de empiema secundario a absceso hepático del lóbulo izquierdo. La demora de la paciente en acudir a instituciones de salud conllevó al fallecimiento de la paciente a pesar del tratamiento antibiótico y quirúrgico(AU)

Introduction: The transdiaphragmatic extension of the pyogenic liver abscess constitutes a rare case of pleural empyema. It is a rapidly progressive disease with high mortality rates close to 100 percent if it is not treated in time. Objective: To describe the case of a patient with right pleural empyema secondary to a ruptured pyogenic abscess of the left hepatic lobe. Clinical case: A 70-year-old female patient who came to emergency with fever, abdominal pain and general syndrome. The computed tomography scan showed a liver abscess in the left lobe with almost total liquefaction, and later a right thoracic empyema was a complication. The patient was treated with chest tube drainage. Despite timely antibiotic and surgical treatments, the patient died of septic shock. Conclusions: A rare case of empyema secondary to liver abscess of the left lobe is reported. The delay of the patient in going to health institutions led to the death of the patient despite antibiotic and surgical treatment(AU)

Hypervirulent Klebsiella pneumoniae, a 5-year study in a French ICU.

PURPOSE: Hypervirulent Klebsiella pneumoniae (hvKp) has emerged as a leading cause of severe community-acquired pneumonia, liver abscess and disseminated infection in the Far East. Data regarding the incidence, clinical features and microbiological characteristics related to hvKp infections in the Western world are scarce. METHODOLOGY: The incidence, clinical features and microbiological characteristics of hvKp infections were investigated through a 5-year survey conducted in a single French intensive care unit. K. pneumoniae strains were screened for hypermucoviscosity based on a string test. Multilocus sequence typing and multiplex PCR analysis targeting virulence genes were performed on string test-positive strains. RESULTS: Over a 53-month period, a total of 59 infections due to K. pneumoniae were identified including 26 community-onset infections. Twelve hvKp infections were documented, accounting for 46.1 % of community-acquired K. pneumoniae. Community-acquired pneumonia (n=6), aspiration pneumonia (n=4) and liver abscess (n=2) represented initial sites and mode of infection. Compared to non-hvKp infections, patients with hvKp infections displayed higher rates of multi-organ failure (83.3 % vs 35.7 %; P=0.04), but mortality rates were not different (50 % vs 35 %; P=0.71). Strains K1/ST23 (n=5) and K2/ST86 (n=5) predominated. All hvKp strains displayed wild-type susceptibility. CONCLUSION: hvKp represent a potentially underestimated cause of fatal infections in the Western world.

Septic Pulmonary Embolism Requiring Critical Care: Clinicoradiological Spectrum, Causative Pathogens and Outcomes.

OBJECTIVES:: Septic pulmonary embolism is an uncommon but life-threatening disorder. However, data on patients with septic pulmonary embolism who require critical care have not been well reported. This study elucidated the clinicoradiological spectrum, causative pathogens and outcomes of septic pulmonary embolism in patients requiring critical care. METHODS:: The electronic medical records of 20 patients with septic pulmonary embolism who required intensive care unit admission between January 2005 and December 2013 were reviewed. RESULTS:: Multiple organ dysfunction syndrome developed in 85% of the patients, and acute respiratory failure was the most common organ failure (75%). The most common computed tomographic findings included a feeding vessel sign (90%), peripheral nodules without cavities (80%) or with cavities (65%), and peripheral wedge-shaped opacities (75%). The most common primary source of infection was liver abscess (40%), followed by pneumonia (25%). The two most frequent causative pathogens were Klebsiella pneumoniae (50%) and Staphylococcus aureus (35%). Compared with survivors, nonsurvivors had significantly higher serum creatinine, arterial partial pressure of carbon dioxide, and Acute Physiology and Chronic Health Evaluation II and Sequential Organ Failure Assessment scores, and they were significantly more likely to have acute kidney injury, disseminated intravascular coagulation and lung abscesses. The in-hospital mortality rate was 30%. Pneumonia was the most common cause of death, followed by liver abscess. CONCLUSIONS:: Patients with septic pulmonary embolism who require critical care, especially those with pneumonia and liver abscess, are associated with high mortality. Early diagnosis, appropriate antibiotic therapy, surgical intervention and respiratory support are essential.

Septic Pulmonary Embolism Requiring Critical Care: Clinicoradiological Spectrum, Causative Pathogens and Outcomes

OBJECTIVES: Septic pulmonary embolism is an uncommon but life-threatening disorder. However, data on patients with septic pulmonary embolism who require critical care have not been well reported. This study elucidated the clinicoradiological spectrum, causative pathogens and outcomes of septic pulmonary embolism in patients requiring critical care. METHODS: The electronic medical records of 20 patients with septic pulmonary embolism who required intensive care unit admission between January 2005 and December 2013 were reviewed. RESULTS: Multiple organ dysfunction syndrome developed in 85% of the patients, and acute respiratory failure was the most common organ failure (75%). The most common computed tomographic findings included a feeding vessel sign (90%), peripheral nodules without cavities (80%) or with cavities (65%), and peripheral wedge-shaped opacities (75%). The most common primary source of infection was liver abscess (40%), followed by pneumonia (25%). The two most frequent causative pathogens were Klebsiella pneumoniae (50%) and Staphylococcus aureus (35%). Compared with survivors, nonsurvivors had significantly higher serum creatinine, arterial partial pressure of carbon dioxide, and Acute Physiology and Chronic Health Evaluation II and Sequential Organ Failure Assessment scores, and they were significantly more likely to have acute kidney injury, disseminated intravascular coagulation and lung abscesses. The in-hospital mortality rate was 30%. Pneumonia was the most common cause of death, followed by liver abscess. CONCLUSIONS: Patients with septic pulmonary embolism who require critical care, especially those with pneumonia and liver abscess, are associated with high mortality. Early diagnosis, appropriate antibiotic therapy, surgical intervention and respiratory support are essential.

Risk factors for mortality in patients with septic pulmonary embolism.

Data regarding prognostic factors for patients with septic pulmonary embolism (SPE) are lacking. The purpose of the present study was to investigate the clinical features of SPE and to ascertain the risk factors for mortality in patients with this condition. Patients with SPE, whose data were retrospectively collected from a tertiary referral center in Korea, were categorized by the presence or absence of in-hospital death into two groups: death and survival groups. The two groups were compared for clinical and radiologic parameters. SPE was community-acquired in most patients (78%). The most common focus of primary infection was that of bone, joint, or soft tissue (33%), followed by liver abscess (17%). The in-hospital mortality was 12%. Multivariate analysis showed that tachypnea (odds ratio [OR] 4.73, 95% confidence interval [CI] 1.09-20.53, p = 0.038) and segmental or lobar consolidation on computed tomography (CT) scan (OR 10.79, 95% CI 2.51-46.43, p = 0.001) were independent predictors of in-hospital death in SPE patients. Taken together, the primary infectious foci of SPE in Korea are different from those reported in Western countries. Tachypnea and segmental or lobar consolidation on CT scan may be independent risk factors for in-hospital death in these patients.

Burden of Liver Abscess and Survival Risk Score in Thailand: A Population-Based Study.

In Thailand, the burden of liver abscess, a life-threatening infectious disease, has not been thoroughly evaluated. We developed a predictive scoring system to estimate survival of patients with liver abscess using information from the 2008-2013 Nationwide Hospital Admission Data to evaluate the burden of liver abscess in Thailand. All patients with primary diagnosis of pyogenic liver abscess (PLA) and amoebic liver abscess (ALA) were included. Epidemiological data, baseline characteristics, hospital course, and survival were analyzed. Overall, 11,296 admissions comprising 8,423 patients from 844 hospitals across Thailand were eligible for analysis. The mean age was 52 ± 17 years and 66.1% of patients were male. ALA was significantly prevalent in southern and western border regions of Thailand, and PLA occurred nationwide. The highest incidence of liver abscess occurred in the rainy season (June-November, P < 0.01). The median length of hospital stay was 8 days (interquartile range = 4-13 days), and mean direct cost of hospitalization was 846 ± 1,574 USD. The overall inhospital mortality rate was 2.8%. Incidence of ALA decreased over the 5-year study period, whereas PLA incidence increased (P < 0.01). Using multivariable Cox regression methods with stepwise variable selection, we developed a final model with five highly significant baseline parameters associated with increased 60-day mortality: older age, PLA, underlying chronic kidney disease, cirrhosis, and human immunodeficiency virus infection. Range of estimated probability of 60-day survival was 95-16% at cumulative risk score 0-13. This simplified score is practical, and may help clinicians prioritize patients requiring more intensive care.

Radioablation of liver malignancies with interstitial high-dose-rate brachytherapy : Complications and risk factors.

BACKGROUND: To evaluate complications and identify risk factors for adverse events in patients undergoing high-dose-rate interstitial brachytherapy (iBT). MATERIAL AND METHODS: Data from 192 patients treated in 343 CT- or MRI-guided interventions from 2006-2009 at our institution were analyzed. In 41 %, the largest tumor treated was ≥ 5 cm, 6 % of the patients had tumors ≥ 10 cm. Prior to iBT, 60 % of the patients had chemotherapy, 22 % liver resection, 19 % thermoablation or transarterial chemoembolization (TACE). Safety was the primary endpoint; survival data were obtained as the secondary endpoints. During follow-up, MRI or CT imaging was performed and clinical and laboratory parameters were obtained. RESULTS: The rate of major complications was below 5 %. Five major bleedings (1.5 %) occurred. The frequency of severe bleeding was significantly higher in patients with advanced liver cirrhosis. One patient developed signs of a nonclassic radiation-induced liver disease. In 3 patients, symptomatic gastrointestinal (GI) ulcers were detected. A dose exposure to the GI wall above 14 Gy/ml was a reliable threshold to predict ulcer formation. A combination of C-reactive protein ≥ 165 mg/l and/or leukocyte count ≥ 12.7 Gpt/l on the second day after the intervention predicted infection (sensitivity 90.0 %; specificity 92.8 %.) Two patients (0.6 %) died within 30 days. Median overall survival after the first liver treatment was 20.1 months for all patients and the local recurrence-free surviving proportion was 89 % after 12 months. CONCLUSIONS: Image-guided iBT yields a low rate of major complications and is effective.

Percutaneous needle aspiration versus catheter drainage in the management of liver abscess: a systematic review and meta-analysis.

OBJECTIVE: The aim of this study was to compare the effectiveness of percutaneous needle aspiration (PNA) and percutaneous catheter drainage (PCD) in the management of liver abscess. METHODS: Electronic searches (Cochrane Library, MEDLINE, EMBASE, SCIE) were conducted to identify randomized controlled trials (RCTs) comparing PNA and PCD. A meta-analysis was subsequently performed. RESULTS: A total of five RCTs covering 306 patients were included. The meta-analysis showed that outcomes in patients treated with PCD were superior to those in patients treated with PNA in terms of success rate [relative risk (RR): 0.81, 95% confidence interval (CI) 0.66-0.99; P = 0.04], clinical improvement [standardized mean difference (SMD): -0.73, 95% CI 0.36-1.11; P = 0.0001] and days to achieve a 50% reduction in abscess cavity size (SMD: -1.08, 95% CI 0.64-1.53; P < 0.00001). No significant differences were found in duration of hospitalization (mean difference: -0.17, 95% CI -2.10 to 1.75; P = 0.86) or procedure-related complications (RR: 0.50, 95% CI 0.10-2.63; P = 0.41). Days to achieve the total or near total resolution of the abscess cavity and mortality were not calculated because data in the RCTs in the meta-analysis were insufficient. CONCLUSIONS: Both PNA and PCD are safe methods of draining liver abscesses. However, PCD is more effective than PNA because it facilitates a higher success rate, reduces the time required to achieve clinical relief and supports a 50% reduction in abscess cavity size. However, among successfully treated patients, the outcomes of PNA are comparable with those of PCD.

Epidemiology and mortality of liver abscess in end-stage renal disease dialysis patients: Taiwan national cohort study.

BACKGROUND AND OBJECTIVES: To determine the incidence rates and mortality of liver abscess in ESRD patients on dialysis. DESIGN SETTING PARTICIPANTS & MEASUREMENTS: Using Taiwan's National Health Insurance Research Database, we collected data from all ESRD patients who initiated dialysis between 2000 and 2006. Patients were followed until death, end of dialysis, or December 31, 2008. Predictors of liver abscess and mortality were identified using Cox models. RESULTS: Of the 53,249 incident dialysis patients identified, 447 were diagnosed as having liver abscesses during the follow-up period (224/100,000 person-years). The cumulative incidence rate of liver abscess was 0.3%, 1.1%, and 1.5% at 1 year, 5 years, and 7 years, respectively. Elderly patients and patients on peritoneal dialysis had higher incidence rates. The baseline comorbidities of diabetes mellitus, polycystic kidney disease, malignancy, chronic liver disease, biliary tract disease, or alcoholism predicted development of liver abscess. Overall in-hospital mortality was 10.1%. CONCLUSIONS: The incidence of liver abscess is high among ESRD dialysis patients. In addition to the well known risk factors of liver abscess, two other important risk factors, peritoneal dialysis and polycystic kidney disease, were found to predict liver abscess in ESRD dialysis patients.

Clinical and radiological features of invasive Klebsiella pneumoniae liver abscess syndrome.

BACKGROUND: Recently, a striking new clinical manifestation of Klebsiella pneumoniae (KP) infection referred to as invasive KP liver abscess syndrome (IKPLAS), defined by liver abscess with contemporaneous metastatic KP infections at other body sites has been documented. Until now, however, there have been relatively few reports regarding its radiologic features. PURPOSE: To describe the clinical and radiological features of IKPLAS patients, and to compare them with those with KP liver abscess without metastatic infections to ascertain possible predictors of IKPLAS. MATERIAL AND METHODS: From January 2008 to May 2010, 35 patients (26 men and 9 women; mean age, 59.4 years) with both liver abscess and metastatic KP infections were diagnosed with IKPLAS. Their clinical and radiological features were retrospectively evaluated and compared with those of 25 contemporaneous non-metastatic patients to investigate predictive factors for metastatic infections. RESULTS: The rate of intensive care unit admissions and overall mortality was 34.3% and 17.1% in IKPLAS patients, and was significantly higher than those of the non-metastatic group (8% and 0%, respectively). As for metastatic infections, the lung was the most common site and multiple nodules or masses (n = 9) were the most common manifestations. Univariate analysis revealed that liver abscess ≤5.8 cm, bilobar involvement of abscess and altered mentality were significantly related with IKPLAS. At multivariate analysis, liver abscess ≤5.8 cm was proven to be a significant independent predictor of IKPLAS (OR, 3.6; P = 0.038). In addition, altered mentality was present solely in IKPLAS (25.7% vs. 0%) although its P value (P = 0.052) did not reach a statistical significance at multivariate analysis. CONCLUSION: IKPLAS has significantly worse prognosis than non-metastatic KP abscess patients. In patients with KP liver abscess, liver abscess ≤5.8 cm can be used as an independent predictor of IKPLAS and altered mentality as a very specific feature in diagnosing IKPLAS.

Clinical characteristics and the usefulness of the QuantiFERON-TB Gold In-Tube test in hematologic patients with hepatic or splenic lesions.

BACKGROUND/AIMS: Hepatic or splenic lesions in hematologic patients are not defined well because they are not easy to evaluate due to limitations of invasive procedures. Management typically depends on the clinical diagnosis with few microbiological data. METHODS: We reviewed the medical records of consecutive hematologic patients with hepatic or splenic lesions in the infectious diseases unit from April 2009 to December 2010 at the Catholic Hematopoietic Stem Cell Transplantation Center in Korea. RESULTS: Twenty-six patients were identified. Their mean age was 46.0 ± 14.7 years, and 16 (61.5%) were male. Underlying diseases were acute myelogenous leukemia (n = 15, 57.7%) and myelodysplastic syndrome (n = 6, 23.1%). Among the nine nontuberculous infectious lesions, two bacterial, six fungal, and one combined infection were identified. The numbers of confirmed, probable, and possible tuberculosis (TB) cases were one, three, and four, respectively. Two patients had concurrent pulmonary TB. QuantiFERON-TB Gold In-Tube (QFT-GIT, Cellestis Ltd.) was positive in seven cases, among which six were diagnosed with TB. The sensitivity and specificity of QFT-GIT were 75% and 81.3%. Nine (34.6%) were defined as noninfectious causes. CONCLUSIONS: Causes of hepatic or splenic lesion in hematologic patients were diverse including TB, non-TB organisms, and noninfectious origins. TB should be considered for patients not responding to antibacterial or antifungal drugs, even in the absence of direct microbiological evidence. QFT-GIT may be useful for a differential diagnosis of hepatosplenic lesions in hematologic patients.

Serine/threonine phosphatase Stp1 contributes to reduced susceptibility to vancomycin and virulence in Staphylococcus aureus.

The genetic mechanisms that contribute to reduced susceptibility to vancomycin in Staphylococcus aureus are complex and heterogeneous. In addition, debate is emerging as to the true effect of reduced susceptibility to vancomycin on staphylococcal virulence. To investigate this, comparative genomics was performed on a collection of vancomycin-exposed isogenic S. aureus pairs (14 strains in total). Previously described mutations were observed in genes such as vraG, agrA, yvqF, and rpoB; however, a new mechanism was identified involving a serine/threonine phosphatase, Stp1. After constructing an stp1 deletion mutant, we showed that stp1 is important in vancomycin susceptibility and cell wall biosynthesis. Gene expression studies showed that stp1 also regulates virulence genes, including a hemolysin, superantigen-like protein, and phenol-soluble modulin, and that the deletion mutant is attenuated in virulence in vivo. Stp1 provides a new link between vancomycin susceptibility and virulence in S. aureus.

Abscesos hepáticos en pacientes pediátricos: estudio multicéntrico / Liver abscesses in pediatric patients: multicenter study

El absceso hepático (AH) sigue siendo causa de alta mortalidad y morbilidad en el mundo relacionadas con las condiciones sociodemográficas de los países en desarrollo. Analizar las características epidemiológicas, clínicas, diagnósticas y terapéuticas de los AH en pacientes pediátricos en nueve centros asistenciales del país. Estudio descriptivo, retrospectivo, donde se revisaron las historias clínicas en pacientes menores de 17 años de edad con diagnóstico de AH ingresados entre Enero-1998 a Mayo-2011. Se incluyeron 161 pacientes: predominaron los masculinos 59,01% (95/161), preescolares 42,24% (68/161), procedencia tipo urbana: 68,33% (110/161). Tiempo promedio de enfermedad prehospitalaria: 10 días y de hospitalización: 22 días. Los principales hallazgos fueron: fiebre: 96,27% (155/161), dolor abdominal 88,19% (142/161), leucocitosis: 91,30% (147/161) con neutrofilia 86,34% (139/161), comorbilidades por migración errática por Ascaris lumbricoides 19,88% (32/161), desnutrición 15,13% (23/152), AH único: 77,64% (125/161), lóbulo derecho: 82,61% (133/161), tipo piógeno 62,9% (56/89). El 96,89% recibieron Metronidazol (156/161) asociado en su mayoría con cefalosporina de tercera generación más aminoglicósido 24,22% (39/161). Se les realizó drenaje del AH 28,57% (46/161). La Mortalidad fue: 1,86%. Los hallazgos clínicos-epidemiológicos y estudios imagenológicos permiten establecer el diagnóstico preciso e instaurar la antibioticoterapia ideal, reduciendo significativamente su morbilidad y mortalidad

Liver abscess (AH) remains a leading cause of mortality and morbidity in the world related to the sociodemographic conditions of developing countries. To analyze the epidemiological, clinical, diagnostic and treatment of AH in pediatric patients in nine centers throughout the country. A descriptive, retrospective, which reviewed the medical records for patients under 17 years of age diagnosed with AH admitted between January 1998 to May-2011. Results: We included 161 patients: male predominance of 59.01% (95/161), preschool 42.24% (68/161), urban-type origin: 68.33% (110/161). Average time of prehospital illness: 10 days, and hospitalization: 22 days. The main findings were: fever: 96.27% (155/161), abdominal pain 88.19% (142/161), leukocytosis: 91.30% (147/161) with neutrophilia 86.34% (139/161), comorbidities by erratic migration Ascaris lumbricoides 19.88% (32/161), malnutrition 15.13% (23/152), AH only: 77.64% (125/161), right lobe: 82.61% (133/161), pyogenic type 62.9% (56/89). The 96.89% received metronidazole (156/161) associated mostly with third-generation cephalosporin, aminoglycoside 24.22% (39/161). Underwent drainage of AH 28.57% (46/161). Mortality was: 1.86%. The clinical-epidemiological and imaging studies allow us to establish accurate diagnosis and institute the perfect antibiotic, significantly reducing morbidity and mortality

Liver abscess after liver metastasectomy is a poor prognostic factor in patients with colorectal cancer.

PURPOSE: More and more complications of extensive hepatic resection are being encountered in patients treated for liver metastases from colorectal cancer. This study aimed to determine the impact of liver abscess after hepatic resection on overall survival (OS) and the role of adjuvant chemotherapy. METHODS: This is a retrospective study of 252 patients treated by liver metastasectomy between 2001 and 2010. RESULTS: The 5-year survival rate was 55.8%. Twenty-one (8.3%) patients developed liver abscess after liver metastasectomy. Multivariate analysis identified the size of liver metastasis, surgical margin, and the presence of liver abscess as significant prognostic factors. Patients (whether or not they developed liver abscess after hepatic resection) had similar progression-free survival (median, 9.8 vs. 12.4 months, P = 0.476), but patients who developed liver abscess had significantly shorter OS (26.6 vs. 76.0 months, P = 0.004). Subsequent adjuvant therapy significantly improved OS in these patients (16.9 vs. 38.5 months, P = 0.032). CONCLUSIONS: Liver abscess after liver metastasectomy is an independent prognostic factor, and adjuvant chemotherapy is warranted in those patients who develop liver abscess.

Emerging severe and fatal infections due to Klebsiella pneumoniae in two university hospitals in France.

Severe infections caused by hypermucoviscous Klebsiella pneumoniae have been reported in Southeast Asian countries over the past several decades. This report shows their emergence in France, with 12 cases observed during a 2-year period in two university hospitals. Two clones (sequence type 86 [ST86] and ST380) of serotype K2 caused five rapidly fatal bacteremia cases, three of which were associated with pneumonia, whereas seven liver abscess cases were caused by K1 strains of ST23.

Liver abscess in children: a 10-year single centre experience.

BACKGROUND/AIM: Although liver abscess is more prevalent in developing countries than in developed countries, there is scant data about the characteristics of pediatric liver abscess in our region. We aimed to analyze the characteristics of pediatric liver abscess in our region and compare these with those of developed countries. MATERIALS AND METHODS: The clinical features, laboratory, imaging, microbiologic findings, management strategy, and final outcome were extracted from the patients' records retrospectively. RESULTS: There were 18 cases of liver abscess including 16 pyogenic liver abscess, one amebic liver abscess and one candida liver abscess. Fever and abdominal pain were the most common clinical findings and leukocytosis was the most common laboratory finding. The most predisposing factors of liver abscess were immune deficiency, minor thalassemia. Origin of liver abscess was appendicitis in two patients, the rest were considered as cryptogenic. While one patient was treated with antibiotics alone, five cases were taken for open drainage, and 12 cases were treated with percutaneous aspiration. Percutaneous aspiration failed in two patients who were later taken for open drainage, with an overall mortality rate of 5.5%. CONCLUSION: The overall characteristics of liver abscess in children in our society are not so different from developed countries. However, in contradiction to cases reported in developed countries, most cases of liver abscess were seen in healthy patients in our centre. Moreover, liver abscess was reported in our patients at a younger age and was more commonly seen in male children. Mortality rate was similar to that of developed countries.

The fatal risk in hepatic artery embolization for hemostasis after pancreatic and hepatic surgery: importance of collateral arterial pathways.

PURPOSE: To assess retrospectively the cause of hepatic failure related to hepatic arterial embolization (HAE) for hemostasis after pancreaticoduodenectomy or hepatic lobectomy. MATERIALS AND METHODS: Between June 1993 and March 2006, Twenty HAEs in 17 patients (15 men, two women; mean age, 64 years) were performed. Angiographic findings, including portal vein stenosis, collateral arterial pathways after HAE, and the difference of embolic materials, were recorded. The morbidity (hepatic failure and abscess) and mortality were detailed according to collateral arterial pathways, portal vein stenosis, and embolic material used. RESULTS: Bleeding was controlled in all patients, although two patients required repeat embolization. Hepatic failure (n = 8) and abscess (n = 2) arose in nine of 20 HAEs. Death occurred after six of eight HAEs complicated by hepatic failure. The morbidity and mortality rates of HAE were 45% and 30%, respectively. Hepatic complication was eight times more likely to occur (P = .005) in cases with no hepatic collaterals involving hepatic, replaced, or accessory hepatic arteries. Death was observed only in the cases without hepatic collaterals (P = .011). The correlation between the embolization outcome and the presence of portal vein stenosis or the difference of embolic materials was not significant (P > .61). CONCLUSIONS: HAE can be used to successfully control bleeding secondary to hepatic arterial rupture. In the absence of hepatic collaterals, collateral circulation distal to the occlusion from nonhepatic sources may be inadequate and lead to hepatic failure after HAE.

Do neutrophils play a role in establishing liver abscesses and distant metastases caused by Klebsiella pneumoniae?

Serotype K1 Klebsiella pneumoniae is a major cause of liver abscesses and endophthalmitis. This study was designed to identify the role of neutrophils in the development of distant metastatic complications that were caused by serotype K1 K. pneumoniae. An in vitro cellular model was used to assess serum resistance and neutrophil-mediated killing. BALB/c mice were injected with neutrophils containing phagocytosed K. pneumoniae. Serotype K1 K. pneumoniae was significantly more resistant to serum killing, neutrophil-mediated phagocytosis and intra-cellular killing than non-K1 isolates (p<0.01). Electron microscopic examination had similar findings as in the bioassay findings. Intraperitoneal injection of neutrophils containing phagocytosed serotype K1 K. pneumoniae led to abscess formation in multiple sites including the subcutaneous tissue, lung, and liver, whereas no abscess formation was observed in mice injected with non-K1 isolates. The resistance of serotype K1 K. pneumoniae to complement- and neutrophil-mediated intracellular killing results in the dissemination of K. pneumoniae via the bloodstream. Escape from neutrophil intracellular killing may contribute to the dissemination and establishment of distant metastases. Thus, neutrophils play a role as a vehicle for helping K. pneumoniae and contributing to the establishment of liver abscess and distant metastatic complications.

Characteristics of undiagnosed liver abscesses on initial presentation at an emergency department.

Liver abscesses often present with nonspecific symptoms and laboratory examination abnormalities, resulting in missed diagnoses at emergency departments (ED). The purpose of this study was to determine if there are differences in presentation and prognosis between patients in whom liver abscess is diagnosed at an ED or once the patient has been transferred to a ward. Patients with a liver abscess who were discharged from our hospital between 2005 and 2007 were retrospectively reviewed. We compared the clinical characteristics between patients with liver abscess diagnosed at an ED or in a ward. Patients with liver abscess diagnosed at an ED had more abdominal pain (73.4%vs. 42.9%, p < 0.001), longer duration of symptoms before hospitalization (5.5 days vs. 3.8 days, p = 0.034) and fewer respiratory tract symptoms (12.5%vs. 24.5%, p = 0.05). Fewer cases with abnormal chest X-rays also existed for these patients (4.7%vs. 14.7%, p = 0.048). Cases not diagnosed at ED had delayed diagnoses for 4.41 +/- 3.16 days. Rates of mortality (6.3%vs. 8.2%, p = 0.740), shock (19.5%vs. 20.4%, p = 0.896), and length of hospital stay (19.6 days vs. 22.4 days, p = 0.173) were not significantly different between the patients diagnosed at an ED and those diagnosed later in a ward. Most information collected at the ED could not be used to aid diagnosis. Only abdominal pain was highly associated with liver abscess diagnosed at the ED. Undiagnosed liver abscess presented less abdominal pain and more symptoms or examination abnormalities related to infection of the respiratory and urinary tracts. Abdominal sonography should be performed more frequently at EDs to exclude liver abscess from differential diagnosis. However, further diagnosis and treatment while the patient with liver abscess is attending a ward does not affect prognosis.

Hepatic abscesses after liver transplant: 1997-2008.

OBJECTIVES: Infectious complications (such as liver abscesses) remain one of the major causes of posttransplant morbidity and mortality. Management may be problematic and is often based on experience with hepatic abscess in nontransplant patients. We reviewed our experience with hepatic abscess in liver transplant recipients to assess their presentation, clinical features, treatment, and outcome. MATERIALS AND METHODS: A retrospective review of all liver transplant in Shiraz transplant center from September 1997 through September 2008 was performed. Hepatic abscess was defined as a parenchymal hepatic lesion consistent with abscess (as described by a radiologist), positive liver or concurrent blood cultures, or both (within 24 hours), and compatible clinical findings. RESULTS: Of 560 liver recipients, we identified 5 patients (23-42 y) who had experienced 7 episodes of hepatic abscess, 30-240 days after transplant. All patients had received liver from deceased donors. Biliary reconstruction was done by duct-to-duct anastomosis in 4 and hepatico-jejunostomy in 1 case. Pretransplant diagnoses included hepatitis B cirrhosis, autoimmune hepatitis (2 cases), Caroli disease, and cryptogenic cirrhosis. Liver aspirates showed E. coli in 4 cases, and Aspergillus in 1 case. The main predisposing factor was bile-to-duct anastomosis stricture in 3, diabetes mellitus in 2, and hepatic artery thrombosis in 1 of the patients. Two patients died owing to liver and multiorgan failure, despite percutaneous and operative drainage with broad spectrum antibiotics and antifungals. CONCLUSIONS: Hepatic abscess, a rare complication after liver transplant, was associated with hepatic artery thrombosis, biliary anastomosis stricture, and diabetes mellitus. Mortality was higher than in patients who had not undergone transplant. Prolonged antibiotic therapy and drainage are required to improve the outcome in these patients.