Gas-forming Pyogenic Liver Abscess Research Articles

Gas embolism caused by gas-forming pyogenic liver abscess.

Gas embolism caused by gas-forming pyogenic liver abscess.

S3209 Unusual Cause of Liver Abscess: Clostridium perfringens

Introduction: Clostridium perfringens is a gas-forming, spore-forming, gram-positive bacillus that is typically found in soil or fresh water sources. Bacteremia due to C. perfringens is rare. Our case is a 52-year-old woman with C. perfringens bacteremia resulting in gas-forming liver abscess. Case Description/Methods: Our patient was a 52-year-old female with history of acute myelogenous leukemia who presented to the hospital with neutropenic fever. She was currently on consolidation chemotherapy with high dose cytarabine and her last treatment was four weeks prior to admission. Vitals signs show temperature of 103.0 Fahrenheit. She has pancytopenia with hemoglobin 4.0 g/dL, white blood cell count of 0.6 X 10^3/uL, and platelets are 7 X 10^3/uL. Her hepatic function testing on admission was abnormal with peak values of ALT 407 U/L, AST 474 U/L and total bilirubin 4.1 mg/dL (2.7 mg/dL was direct). Alkaline phosphatase was normal. Blood cultures were positive for C. perfringens. Computed tomography (CT) was obtained and showed gas within the right hepatic lobe (Figure 1A). An abdominal ultrasound showed a hyperechoic focus in the right hepatic lobe corresponding to the findings on CT (Figure 1B). Ultimately, the patient was treated with two weeks of cefepime and metronidazole for her C. perfringens bacteremia with hepatic focus. Her clinical course improved with antimicrobial therapy. Hepatic function tests were within normal limits by the time of discharge. Discussion: C. perfringens causes cytotoxic infection due to its alpha toxin, a lecithinase which breaks down cell membranes leading to cell lysis. Thus, our patient's severe acute anemia is explained in part by hemolysis due to clostridial infection. This organism is an uncommon cause of gas-forming liver abscess. A prior review of 119 cases of patients with gas-forming pyogenic liver abscess found only 8 to be infected with clostridia species. Malignancy and immunosuppression are both risk factors for C. perfringens infection and septicemia, both of which are present in our patient and thus made her more susceptible to clostridial infection. The etiology of her infection was potentially a bacterial translocation from the gastrointestinal tract. Mortality rate in patients with sepsis due to C. perfringens has been previously estimated at 70-100%. Thus, prompt recognition of this clinical syndrome is paramount so that early treatment can be initiated. Early appropriate antimicrobial therapy was essential to this patient's good outcome.Figure 1.: A) A CT scan of the abdomen showing a focus of gas in the right hepatic lobe (arrow). B) An ultrasound of the right upper quadrant showing focus of gas in the right hepatic lobe (arrow).

Outcomes of Gas-Forming Pyogenic Liver Abscess (PLA) Are Comparable to Non-Gas-Forming PLA in the Era of Multimodal Care: A Propensity Score Matched Study

Gas-forming pyogenic liver abscess (GFPLA) occurs in 7-24% of all pyogenic liver abscess (PLA) and has been traditionally associated with high mortality. Studies suggest that use of a proactive approach of prompt resuscitation, parenteral antibiotics, percutaneous drainage and a dedicated multidisciplinary team may improve clinical outcomes. Hence, we aim to investigate if the clinical outcomes of PLA are determined by gas formation. This is a retrospective study of patients with PLA from 2007 to 2011. A 1:2 propensity score matching (PSM) analysis was performed using age, co-morbid diabetes, presence of septic shock, haemoglobin levels, international normalized ratio, creatinine, total bilirubin, positive blood culture and pus culture, and the size of abscess. Demographics, clinical profile and perioperative data were compared. 213 patients had PLA: 41(19.2%) patients had GFPLA and 172(80.8%) patients had non-GFPLA. 1:2 PSM resulted in a total of 108 patients (36 GFPLA and 72 non-GFPLA). Clinical profile and microbiology are shown in Table 1. Median duration of parenteral antibiotics was significantly lower in the GFPLA group (9.5 days vs 14 days, p=0.044), but median total duration of antibiotics use was comparable (GFPLA 39 days vs non-GFPLA 37 days, p=0.634). Median length of stay (days) did not differ significantly between GFPLA and non-GFPLA (14 vs 15, p=0.299). There were no statistically significant differences between GFLPA and non-GFLPA in the need for percutaneous drainage (26/36(72.2%) vs 47/72(65.3%) respectively, p=0.467) and in-hospital all-cause mortality (4/36(11.1%) vs 7/72(9.7%), p=0.822). Outcomes of GFPLA are comparable to non-GFPLA in the era of multimodal care.Table 1Clinical profile and microbiology of patients with gas-forming pyogenic liver abscess (GFPLA) and non-GFPLA before and after matchingOverall cohort (n=213)Matched cohort (n=108)GFPLA (n=41)Non-GFPLA (n=172)p-valueSMD (standardised mean difference)GFPLA (n=36)Non-GFPLA (n=72)p-valueSMDAge (interquartile range)61 (53 - 69)62 (51 - 74)0.7870.01061.5 (52.3 - 68.8)62.5 (53.3 - 73.8)0.6460.047Gender, male (%)27 (65.9)104 (60.5)0.524-24 (66.7)45 (62.5)0.671-Diabetes mellitus, yes (%)18 (43.9)56 (32.6)0.1700.23313 (36.1)24 (33.3)0.7740.058Pus culture, yes (%)21 (70)61 (66.3)0.7080.30717 (65.4)37 (78.7)0.2140.083Klebsiella pneumoniae (%)17 (81)51 (82.3)13 (76.5)33 (89.2)Clostridium perfringes (%)1 (4.8)1 (1.6)1 (5.9)1 (2.7)Others (%)3 (14.3)9 (14.8)3 (17.6)3 (8.1)Size of largest abscess (cm)6.6 (4.9 - 8.3)5.4 (3.6 - 7.0)0.0050.4886.3 (4.5 - 7.5)6.1 (5.0 - 7.6)0.6690.131 Open table in a new tab

Ruptured liver abscess presenting as pneumoperitoneum caused by Klebsiella pneumoniae: a case report

BackgroundSpontaneous gas-forming pyogenic liver abscess (GFPLA) is a rare complication with a high fatality rate in spite of aggressive management. Clinical spectrum of GFPLA can mimic hollow viscus perforation as it usually accompanied by pneumoperitoneum and peritonitis. Up to now, GFPLA has not been well studied in Vietnam.Case presentationWe reported here a case with pneumoperitoneum caused by ruptured liver abscess in a 41-year-old man with a history of treated duodenal ulcer and uncontrolled type II diabetes mellitus. He had an epigastric pain associated with a high fever. Patient was diagnosed peritonitis and pneumoperitoneum presumed to be secondary to perforation of a hollow viscus and subjected to emergency laparotomy. We did not find any gastrointestinal perforation. Surprisingly, we detected a 4 cm × 4 cm pus-containing abscess in the left liver lobe of the liver. The abscess was ruptured. Pus was running into abdominal cavity through one hole. The abscess and abdominal cavities were cleaned up and abscess and abdominal drainages were performed. K. pneumoniae was isolated from culture of the abscess. The histopathological examination of the abscess did not yield any evidence of malignancy. Blood glucose levels were controlled. Antibiotic therapy was used according to antibiogram. A reassessment chest X-ray showed no air-fluid level or subdiaphragmatic air by the hospital day 14. Patient eventually made a full recovery and was discharged home 23 days after the operation.ConclusionsRuptured GFPLA is a life-threatening complication. It is usually accompanied by peritonitis and pneumoperitoneum and can imitate hollow viscous perforation. In these cases, CT scan should be performed whenever it is possible to make a correct diagnosis. When the abscess has small size, partial hepatectomy might not be necessary and could be replaced by a careful cleaning and drainage of the abscess. Patient could show a good postoperative recovery following an appropriate antibiotic therapy.

Multiple Air-Fluid Levels Under Right Dome of the Diaphragm

A 50-year-old male patient presenting with recurrent pain abdomen and fever was diagnosed to have multiple liver abscesses. An erect X-ray abdomen showed multiple air-fluid levels in the region of the liver raising the possibility of abscess by gas-forming pyogenic abscess which was later confirmed by CECT scan. He was managed conservatively with antibiotic therapy followed by complete resolution. The X-ray, which usually shows single air-fluid level for a gas-forming pyogenic liver abscess (GPLA), was quite remarkable and unusual in this case.

Outcomes of Gas-Forming Pyogenic Liver Abscess Are Comparable to Non-Gas-Forming Pyogenic Liver Abscess in the Era of Multi-Modal Care: A Propensity Score Matched Study.

Background: Gas-forming pyogenic liver abscess (GFPLA) occurs in 7%-24% of all PLAs and has been associated traditionally with high mortality rates. Studies have suggested that the use of a proactive approach of prompt resuscitation, parenteral antibiotic agents, percutaneous drainage, and a dedicated multi-disciplinary team may improve clinical outcomes. Hence, we aim to investigate whether the clinical outcomes of PLA are determined by gas formation. Methods: This is a retrospective study of patients with PLA from 2007 to 2011. A 1:2 propensity score matching (PSM) analysis was performed using age, co-morbid diabetes mellitus, presence of septic shock, hemoglobin levels, international normalized ratio, creatinine, total bilirubin, positive blood culture and pus culture, and the size of abscess. Baseline demographics, clinical profile, and peri-operative data were compared. Results: There were 213 patients who had PLA: 41 (19.2%) patients had GFPLA and 172 (80.8%) patients had non-GFPLA. The PSM analysis resulted in a total of 108 patients (36 GFPLA and 72 non-GFPLA). Median duration of parenteral antibiotic agents was significantly lower in the GFPLA group (9.5 d vs. 14 d, p = 0.044), but median total duration of antibiotic use was comparable (GFPLA 39 d vs. non-GFPLA 37 d, p = 0.634). Median length of stay (days) did not differ significantly between GFPLA and non-GFPLA (14 vs. 15, p = 0.299). There were no statistically significant differences between GFLPA and non-GFLPA in the need for percutaneous drainage (26/36 (72.2%) vs. 47/72 (65.3%), respectively, p = 0.467) and in-hospital all-cause death (4/36 (11.1%) vs. 7 (9.7%), p = 0.822) Conclusions: Outcomes of GFPLA are comparable to those of non-GFPLA in the era of multi-modal care.

Gas-forming pyogenic liver abscess

Gas-forming pyogenic liver abscess (GFPLA) is uncommon and reported high mortality rate. Diabetes mellitus and Klebsiella pneumoniae are the most frequent associated conditions and causativeorganism. Gas collection is not often detected by plain film abdomen. On ultrasonography, gas appeared as hyperechoic foci with dirty shadowing, reverberation and ring-down artifacts. CT scan is the mostsensitive test for GFPLA. Early diagnosis, appropriate antibiotics, adequate drainage and plasma glucose control are essential management.
 Figure 1 Plain film abdomen พบ multiple round and oval hypodensity gas pockets with air-fluid levels at right subphrenic region

Gas-forming pyogenic liver abscess: A world review.

Backgrounds/AimsGas-forming pyogenic liver abscess (GFPLA) has an incidence of up to 30% of all pyogenic liver abscesses (PLA). GFPLA has higher mortality compared to non-GFPLA. Mere presence of gas within abscess may not determine clinical outcome. Hence it is important to study biologic characteristics that make GFPLA a distinct clinical entity. The aim of this study was to conduct a world review on GFPLA.MethodsWe conducted literature searches in PubMed using the following MeSH terms: “gas forming” AND “Liver abscess, pyogenic”, “gas” AND “Liver abscess, pyogenic”, “gas” AND “Liver abscess”, “gas forming” AND “Liver abscess”. Thirteen case series including 313 GFPLA patients were included. Age, gender, diabetes mellitus (DM), bacteriology, underlying etiology, symptoms, investigations, operative indications, and mortality rates were tabulated.ResultsGFPLA is often cryptogenic. There was no difference in age, gender, or symptomatology between GFPLA and non-GFPLA patients. DM was more common in patients with GFPLA compared to that in non-GFPLA patients (mean: 83.5% vs. 38.3%). Klebsiella pneumoniae is the most common causative pathogen. GFPLA has higher mortality compared to non-GFPLA (mean: 30.3% vs. 9%).ConclusionsGFPLA is associated with DM and monomicrobial Klebsiella pneumoniae infection. GFPLA has high mortality. It needs to be recognized as a distinct clinical entity.

Outcomes of gas-forming pyogenic liver abscess in the era of multimodal care

Introduction: Gas-forming pyogenic liver abscess (GfPLA) represents 7-24% of all pyogenic liver abscess (PLA) cases. It is associated with higher mortality compared to non-gas-forming PLA. Provision of integrated multimodal care can improve outcomes. We aim to evaluate the outcomes of GfPLA in the era of multimodal care. Methods: A retrospective analysis of all patients with PLA treated at a tertiary hospital from 2007 to 2011. GfPLA is defined when gas locules are detected on index imaging (CT or Ultrasound). Demography, clinical profile and outcomes were studied and reported. SPSS version 17 was used for data analysis. Results: 213 patients were treated for PLA from 2007-2011. 41 (19.2%) patients had GfPLA. Mean age of patients was 60 years old (range 25–89). Majority of patients with GfPLA presented with nonspecific constitutional symptoms (95%) and fever (78%). 12.2% of patient with GfPLA had septic shock compared to only 5.8% in non-gas-forming group. The most prevalent causative organism was Klebsiella pneumoniae (81%) for GfPLA. Mean size of GfPLA was 6.62 cm ( ranged from 2.6 to 10.9 cm ) Significantly more GfPLA patients (30 out of 41 = 73%) had percutaneous drainage compared to 53.5% in non-gas-forming group.( p = 0.02) Overall 30-day mortality for GfPLA and non-gas-forming PLA was 9.8% and 13.95% respectively (p = 0.475). Conclusion: High index of clinical suspicion is important for early diagnosis of GfPLA in view of non-specific clinical presentations. Outcomes of GfPLA are similar to non-gas forming PLA in the setting of multimodal care.

Gas-Forming Pyogenic Liver Abscess in a Splenectomized Adult with Diabetes

Pyogenic liver abscess (PLA) is uncommon in North America. A recent study has reported that persons with diabetes have increased risk of experiencing PLA and a higher 30-day post discharge mortality rate, compared with those without diabetes. Poor glycemic control has been linked to a higher likelihood of gas-forming PLA and metastatic infection due to Klebsiella pneumoniae. Here we present a patient with a history of total pancreatectomy and splenectomy for intraductal papillary mucinous neoplasm (IPMN) complicated by poorly controlled diabetes mellitus, who developed a gas-forming pyogenic liver abscess and was found to have bacteremia with extendedspectrum beta lactamase (ESBL) producing K. pneumoniae. During her hospital course, the abscess changed in appearance to multiloculated. Management was initially with broad spectrum empiric antibiotics, later changed to ertapenem along with abscess drainage. Patients with diabetes are particularly at risk of a gas-forming PLA and may have atypical presentation. Due to significantly increased mortality and morbidity from a gas-forming PLA, empiric antibiotic therapy should be started without waiting for culture results. Improved glycemic control is essential for management because sustained hyperglycemia has been linked to a poor outcome in gas-forming PLA.

Gas-Forming Pyogenic Liver Abscess with Septic Shock.

The pyogenic liver abscess caused by Clostridium perfringens (C. perfringens) is a rare but rapidly fatal infection. The main virulence factor of this pathogen is its α-toxin (lecithinase), which decomposes the phospholipid in cell membranes leading to cell lysis. Once the bacteria are in blood stream, massive intravascular hemolysis occurs. This can present as anemia on admission with evidence of hemolysis as indicated by low serum haptoglobin, high serum lactate dehydrogenase (LDH), elevated indirect bilirubin, and spherocytosis. The clinical course of C. perfringens septicemia is marked by rapidly deteriorating course with a mortality rate ranging from 70 to 100%. The very rapid clinical course makes it difficult to diagnose on time, and most cases are diagnosed at autopsy. Therefore it is important to consider C. perfringens infection in any severely ill patient with fever and evidence of hemolysis. We present a case of seventy-seven-year-old male with septic shock secondary to pyogenic liver abscess with a brief review of existing literature on C. perfringens.

An unusual cause of acute abdomen—Gas-forming liver abscess due to Salmonella enteritidis

Gas-forming pyogenic liver abscess (GFPLA) is considered to be a very severe form of PLA and carries a high mortality. Klebsiella pneumoniae is the most common pathogen responsible for the disease, whereas cases where Salmonella is cited as the cause are very uncommon. We report the first case of a 53-year-old lady suffering from GFPLA due to Salmonella, who was successfully treated with surgical drainage. To the best of our knowledge, this is the first case of GFPLA caused by Salmonella enteritidis to be reported in the English literature.

Gas-Forming Pyogenic Liver Abscess Suspected on a Plain Chest X-Ray

A 70-year-old man with a history of diabetes mellitus presented with weakness and poor oral intake for 1 month. On physical examination, he was febrile and had mild right upper quadrant tenderness. The patient's white cell count was 14,900/mm3, with 79.0% neutrophils. A chest radiograph showed an air-fluid level in the right-upper abdomen (Fig. 1). Computed tomography (CT) revealed a huge gas-forming liver abscess (Fig. 2). The patient underwent sonography-guided drainage, and was given intravenous antibiotics and insulin to control his diabetes. The culture of the pus grew Klebsiella pneumoniae. He recovered and was discharged. Figure 1 The chest radiograph showed an air-fluid level in the right-upper abdomen. Figure 2 Computed tomography revealed a huge gas-forming liver abscess (arrows). The diagnostic tools for gas-forming pyogenic liver abscess (GPLA) are sonography and CT. On plain films, an air-fluid level or mottled gas pattern is the most common finding. Gas within the liver parenchyma is reported to be visible in up to 36% of patients with GPLA. Unless suspected, this may be mistaken for bowel gas. In our case, we saw an air-fluid level in the right upper abdomen in the plain X-ray, which enabled us to detect GPLA early.

Clinical significance and mechanism of gas formation of pyogenic liver abscess due to Klebsiella pneumoniae.

We enrolled 22 patients with gas-forming pyogenic liver abscess in a study to assess the mechanism of gas formation. Klebsiella pneumoniae was cultured from specimens from all patients. Gas and pus samples from abscesses revealed four major components: nitrogen, oxygen, carbon dioxide, and hydrogen; this implicates mixed acid fermentation of glucose as the mechanism of gas formation.