History and exam

Key diagnostic factors

common

presence of risk factors

Strongly associated risk factors for pyogenic liver abscess: underlying biliary tract abnormalities, aged >50 years, malignancy, diabetes mellitus, and interventional biliary or hepatic procedures.

Strongly associated risk factor for amoebic liver abscess: origin in or having visited endemic areas for amoebiasis.

fevers and chills

Most patients present with non-specific constitutional symptoms such as fever or chills and weight loss.[3]​​​[4][15]

Onset of symptoms may be insidious with pyogenic liver abscess but is more likely to be acute with amoebic abscess.

RUQ tenderness

Indicates liver or gall bladder abnormality.[3]​​ Commonly occurs with liver abscess, although absence of this finding does not exclude the diagnosis.

Over one half of patients have abdominal tenderness on examination.[4][15]​​

hepatomegaly

Liver enlargement with tenderness can be present.

Other diagnostic factors

common

weight loss

Frequent feature but non-specific.

fatigue

One of the most common symptoms but non-specific.

abdominal pain

Common symptom, but absence of pain does not exclude the diagnosis.

nausea and vomiting

Present in approximately one third to one half of patients.[15]

cough, shortness of breath, or chest pain

One third of patients have chest symptoms, including cough, shortness of breath, and chest pain.[4]

Cough, shortness of breath, or pleuritic pain (possibly also felt in the right shoulder tip) may occur if the diaphragm is inflamed.

uncommon

jaundice

Only a few patients with liver abscess have jaundice, which typically occurs late in the illness.​​[3]​

signs of pleural effusion in the right lower zone

May be present, including dullness to percussion, absent breath sounds, decreased tactile fremitus, and decreased vocal transmission.

signs of shock

Indicates severe illness, often with bacteraemia or cholangitis.

ascites

Very rare.

Risk factors

strong

biliary tract disease

Biliary tract abnormalities were the most common source of pyogenic liver abscess in several studies (28%-43% of patients).[4][7][18]

age >50 years

The mean age at presentation is typically 50 to 60 years.[8][15]

People aged ≥65 years are 10 times more likely than younger people to have a diagnosis of liver abscess.​[3]

underlying malignancy

Approximately 10% to 20% of people with liver abscess have underlying malignancy in retrospective analyses.[15][18]

Underlying malignancy (not solely hepatic in origin) confers a relative risk of 13.3 (95% CI 6.9-24.4) for liver abscess.​[3]

diabetes mellitus

An important risk factor, identified by several studies.[3]​​[15][18]

Associated with an increased risk of pyogenic liver abscess, with an odds ratio of 3.6 (95% CI 2.9-4.5).[22]

interventional biliary or hepatic procedures

May occur after biliary endoscopic interventions (e.g., endoscopic biliary sphincterotomy, stent insertion) or after other invasive procedures involving the liver (e.g., chemoembolisation or percutaneous ablation of hepatic neoplasms, hepatic cryotherapy, transjugular intra-hepatic portosystemic shunt insertion, or even liver biopsy).​[24]

living in or visiting area endemic for amoebiasis

Most cases of amoebic infections occur in Central and South America, Africa, and Asia.[11]

In developed countries, amoebiasis (and subsequent amoebic liver abscess) is seen most commonly in immigrants and travellers from endemic areas.[2]​[12][13]​​

weak

cirrhosis

Associated with a 15-fold increased incidence of pyogenic liver abscess compared with patients without cirrhosis.[23]

liver transplantation

Not well characterised as a risk factor. One study found a high relative risk of liver abscess in post-liver transplant patients.​[3]

Risk association is largely a consequence of hepatic artery thrombosis or hepatic ischaemia, or due to an association with Roux's loop (which is also a risk in the non-transplant situation).

alcoholism

May increase risk.​[3]

male sex

Men are more likely than women to acquire pyogenic liver abscess, with a relative risk of 2.6 (95% CI 1.5-4.6).[3]​​

cardiopulmonary disease

Underlying cardiopulmonary disease may increase risk.[15]

immunocompromised state

Underlying immunocompromise may increase risk.[2]​ These patients are more likely than people with normal immune status to develop fungal liver abscess.

penetrating abdominal trauma

Possible source of intra-abdominal infection, resulting in liver abscess.

inflammatory bowel disease, pancreatitis, appendicitis, diverticulitis, or peritonitis

The portal vein drains the gastrointestinal tract, gall bladder, and pancreas. Pylephlebitis (portal vein inflammation) due to these conditions can result in pyogenic liver abscess.

bacteraemia, endocarditis, or other intravascular infection

Infrequent cause of liver abscess.

poor dentition

Dental infection and oral abscesses can be the the initial source of infection that subsequently leads to liver abscess.[25][26]​

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