What Are Underlying Risk Factors for Liver Abscesses?

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Patient Presentation
An 8-year-old male came to clinic for his well-child care after moving to the area. He had a history of Alagille syndrome, liver transplantation and liver abscesses; all of which had been successfully treated and he continued to follow closely with the liver transplantation service. He was also being followed by nephrology for some mild hypertension that did not need current treatment. He was homeschooled and the family had already identified a small group of children that he regularly interacted with.

The pertinent physical exam showed a smiling male. His height and weight were 5-15% and his vital signs were normal. He had waxy skin and looked thin. He had multiple abdominal scars and other scars. A firm liver was palpable but there were no other specific masses.

The diagnosis of a child status-post liver transplantation who was being followed by multiple specialty services was made. The family already had local school and social services referrals and the pediatrician offered to help coordinate his medical needs such as lab testing with these services.

Discussion
Liver abscesses (LA) are not especially common in the developing world and are less common in the developed world. They can be caused by “…hematogenic spread, biliary tract infection, contiguous spread or by any trauma to the liver.” In tropical areas, pyogenic liver abscess (PLA) and amebic liver abscess (ALA) are the most common causes of liver abscesses with a few cases caused by tubercular and fungal etiologies. PLA is most commonly caused by Staphlococcus aureus, Klebsiella pneumoniae and Escherichia coli in both developed and developing countries. “ALA occurs in approximately 5-7% of patients after an amebic infestation of the intestinal tract.”

In a study in Northern India of 81 patients aged 3-9 years old with liver abscesses, 50% of patients had ALA and 39% had PLA. LA presentations overall varied quite a bit but a triad of fever, right upper quadrant tenderness and hepatomegaly was seen in 80% of these patients. Abnormal lab testing also varied with elevated transaminases, low protein and albumin, and abnormal coagulation testing. Patients usually (~75%) had a single LA. Complications were not uncommon with pleural effusions or pulmonary consolidations seen in ~33%, followed by abscess rupture, and vascular thrombosis. Patients needed prolonged treatment and followup (up to 88 days) but did well without recurrences.

In a study from Belgium of 24 children from 1-14 years with liver abscesses, PLA occurred in 55% and none had ALA. Patients presented with fever (83%), abdominal pain (58%) and hepatomegaly (38%). All patients had an elevated C-reactive protein, and other abnormal liver function testing occurred in 15-50% of patients depending on the specific test. Treatment duration again was lengthy for many (up to 154 days) and they had a survival rate of 95.8%.

In a study from the US of 4075 admissions nationwide (ages 6-19 years) from 2003-14 found a low but increasing incidence of PLA from 9.63 to 15.3 per 100,000 hospitalizations in 2014. Streptococcus (10.8%), Staphlococcus aureus (9.2%), Klebsiella pneumoniae (5.4%) and Escherichia coli (5.4%) were the most common causes of PLA. Mortality rate was 0.8%. This study specific excluded patients with ALA or candidemia.

LA treatment is usually antibiotics and less invasive surgical techniques such as aspiration or percutaneous catheter drainage, but other treatment including resection is sometimes needed Overall mortality from LA has decreased from 15-40% to as low as 0.8% in the pediatric populations as noted above.

Learning Point
LA can occur solely because of exposure to infectious organisms but is also commonly associated with hepatobiliary pathology as well.

In Northern India study, the “[m]ajority of …children had no predisposing factors for development of LA as well in developed countries as evinced by the negative immunologic work up in 79 or 81 cases.”

In the Belgium study, the most common underlying risk factor was hepatobiliary disease (e.g. biliary stenosis/atresia, cirrhoses, liver transplant), malignancy, intra-abdominal pathology (e.g. appendicitis, intestinal perforation) with only 2 cases due to parasitic infection.

In the US study, the most common underlying PLA risk factor was liver transplant with biliary disease, malignancy and intrabdominal pathology and severe sepsis being other common factors in this population.

Questions for Further Discussion
1. How is Alagille syndrome diagnosed and what is the natural history?
2. What are indications for liver transplantation?
3. What is the role of a primary care physician in patients with an organ transplantation?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Liver Disease and Abscess.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Thavamani A, Umapathi KK, Khatana J, Roy A, Augustin T, Radhakrishnan K. Incidence Trends, Comorbidities, and Outcomes of Pyogenic Liver Abscess Among Children: A Nationwide Population-based Analysis. J Pediatr Gastroenterol Nutr. 2020;71(1):106-111. doi:10.1097/MPG.0000000000002700

Lal SB, Venkatesh V, Kumar A, et al. Liver Abscess in Children-experience From a Single Tertiary Care Center of North India: Etiology, Clinical Profile and Predictors of Complications. Pediatr Infect Dis J. 2021;40(5):e179-e184. doi:10.1097/INF.0000000000003053

Grossar L, Hoffman I, Sokal E, Stephenne X, Witters P. Liver abscesses in the Western pediatric population. Acta Gastro Enterol Belg. 2022;85(3):439-445. doi:10.51821/85.3.10211

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

Published