Saudi Journal of Gastroenterology
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Table of Contents   
ORIGINAL ARTICLE  
Year : 2011  |  Volume : 17  |  Issue : 3  |  Page : 199-202
Liver abscess in children: A 10-year single centre experience


1 Trauma Research Center, Iran, Shiraz, Sciences Medical of University Shiraz, Center Archrese, Shiraz, Iran
2 Transplant Research Center, Shiraz, Iran
3 Master of Organic Chemistry, Shiraz, Iran

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Date of Submission18-Mar-2010
Date of Acceptance02-Sep-2010
Date of Web Publication4-May-2011
 

   Abstract 

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 ttaken 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.

Keywords: Children, clinical findings, complications, liver abscess, treatment

How to cite this article:
Salahi R, Dehghani SM, Salahi H, Bahador A, Abbasy HR, Salahi F. Liver abscess in children: A 10-year single centre experience. Saudi J Gastroenterol 2011;17:199-202

How to cite this URL:
Salahi R, Dehghani SM, Salahi H, Bahador A, Abbasy HR, Salahi F. Liver abscess in children: A 10-year single centre experience. Saudi J Gastroenterol [serial online] 2011 [cited 2020 Jul 13];17:199-202. Available from: http://www.saudijgastro.com/text.asp?2011/17/3/199/80384


Liver abscess (LA) is a serious infectious disease, which is responsible for hospitalization and mortality worldwide. [1] LA is rare with an incidence of 25 per 100,000 admissions in USA; however, in studies conducted in developing nations it was reported in 1 out of 140 admissions. [2] Although it is supposed that in developing countries as in Iran, infectious diseases like LA are more prevalent than in developed countries, there is little data about the characteristics of pediatric liver abscess in our region, and management of our patients has been based on data provided through studies conducted and published in developed countries. The aim of this study has been to identify the characteristics of LA in children referred over the last decade to our center and to review their clinical features, predisposing factors, management, and mortality and compare them with the results in developed countries.


   Materials and Methods Top


The records of all patients less than 18 years who were admitted in pediatric wards at Nemazee Hospital, referral center in South of Iran, with diagnosis of LA between 1998 and 2008 were reviewed. Age, sex, symptoms and their duration, clinical signs at presentation and any underlying predisposing factors were noted. Results of the diagnostic work-ups including ultrasonography (US) findings and organisms isolated, management including details of antibiotic therapy and drainage procedure were all recorded. In-hospital mortality was defined as mortality that occurred within the same hospital. Length of hospital stay was defined as total days since admission to discharge. There was a two-year follow-up on all patients to check for any recurrences or complications. The patients were subsequently followed up in the clinic. Statistical package for social sciences (SPSS, version 15.0; Chicago, IL, USA) was used for data analysis.


   Results Top


There were 18 cases (11 boys and 7 girls) including PLA (n:16), amebic liver abscess (n:1), and candida LA (n:1). The median age was eight years (range, 50 days-17 years). The predisposing factors of LA were seen in six cases including immune system diseases with one case of severe combined immunodeficiency (SCID) and one case of chronic granulomatous disease (CGD), minor thalassemia (n:2), acute lymphocytic leukemia (n:1), and kala-azar (n:1). Median time of delay between the beginning of the symptoms and the diagnosis was 13 days (range, 3-90 days). Origin of LA was appendicitis in two cases (11.1%) and cryptogenic (i.e. without a definite cause) in sixteen cases (88.9%).

Fever and abdominal pain were seen in 94.4% and 88.9% respectively. Tenderness in the right hypochondrium was present in all cases [Table 1].
Table 1: Demographic data, clinical characteristics, imaging findings (location, size, number of liver abscess), type of management, and outcome of patients

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US showed single lesion in 12 cases, two abscesses in four cases, and multiple lesions in two cases. LA was seen in the right hepatic lobe in 11 cases, left lobe in five cases, and bilateral in two cases. The most common abnormal laboratory data included leukocytosis (94.4%), and anemia (88.9%). Laboratory data are shown in [Table 2]. Pus culture was positive in 50% of PLA (8 out of 16), including staphylococcus species in six cases (Staphylococcus auerus in five patients and staphylococcus coagulase negative in one case), Klebsiella in one case and Enterobacter in one case. Culture was negative in the rest of 10 patients (55.5%). Blood culture was positive only in one case of PLA which grew coagulase negative Staphylococcus aureus.
Table 2: Abnormal laboratory data findings in pediatric liver abscess

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A combination of ampicillin plus aminoglycoside plus metronidazole were used in patients with PLA for two weeks intravenously and continued for four weeks orally till about three years ago; but because of growing antibiotic resistance, we now use vancomycin plus imipenem, as empirical therapy, and then change antibiotics according to the results of culture. Out of 16 cases of PLA, one patient was treated with antibiotics alone. Percutaneous aspiration was done in 11 cases (68.75%) of whom two patients (cases 2, 11) did not show much improvement, and had to undergo open drainage. The most common complications included right sided pleural effusion (n:4), which resolved without any treatment, and recurrence of LA which happened in one patient after two months (case 3) and in the other patient (case 16), two years after percutaneous aspiration. These patients underwent open drainage with good clinical response. In these patients, immunological studies such as absolute lymphocyte and neutrophil counts, serum immunoglobulins, and nitroblue-tetrazolium test were normal and there were no underlying predisposing factors. Rest of the four patients of pyogenic group (case 3, 4, 6, and 12) underwent open drainage at presentation due to rupture of LA into peritoneum (n:1), rupture of appendicitis into peritoneum (n:2) and CGD (n:1).

Amebic liver abscess (ALA) was seen in a three-year-old boy who was referred due to fever and anorexia. The diagnosis of ALA was established by US evidence of a single hypoechoic lesion in right lobe of the liver with positive indirect hemagglutination test (>1:250). He was treated with intravenous metronidazole, followed by percutaneous drainage due to non-improvement in clinical situation. Liver aspirate showed eosinophil cells and charcot leidon body in favor of ALA.

Diffuse candidiasis occurred in a 50 days infant with SCID. US showed numerous target lesions in liver in favor of candidiasis and urine culture grew candida. Abscess was multiple and located in both lobes. Despite open drainage and broad spectrum antifungal treatment, he did not respond to therapy and died two weeks after admission due to septic shock and multiorgan failure.


   Discussion Top


PLA has been described to be rare in infancy and childhood, but it still remains a major cause of high mortality in children. [1] In developed countries, LA occurred in children with immune system disease especially CGD. [3] However in our center like other developed countries, [4] the majority of patients were healthy. This might be due to high rate of environmental infection in developing countries.

The median age at presentation was eight years which is similar to other developing countries like Taiwan [5] and Brazil. [2] However, in United Kingdom, median [6] age at diagnosis was 10 years. These findings suggest an earlier age trend of LA in patients in developing countries compared to that in developed countries which may be due to earlier contact with infection. Despite studies from both developing and developed countries that reported no difference between girls and boys, [5],[6],[7] in our series boys were involved more than girls.

Staphylococcus is the most common cause of LA in children, [6] which is similar to our study. Pus and blood culture was positive for 55% and 58% of patients. [8] The most common organism identified was Klebsiella species followed by  Escherichia More Details coli. [8] Anerobic organisms are increasingly being reported as a causative agent in PLA in children. [3],[9] The low level of positive blood culture in our study could partly be due to prior antibiotic therapy before admission and non availability of facility for anerobic culture in most cases.

There were no differences about symptoms and signs of LA [10] and also initial use of US to diagnose LA. [6] Increased alkaline phosphatase and low albumin have been reported as the most common abnormal laboratory findings; [11] however, elevated levels of billirubin and aminotransferase and leukocytosis are also common. [12] In our cases leukocytosis was the most common abnormal finding, followed by anemia (Hb<11 mg/dl).

Controversy exists on whether to treat LA with medical treatment alone or to use percutaneous or surgical drainage together with antibiotic therapy. A course of six weeks antibiotic therapy alone, including two weeks intravenously, followed by four weeks orally is recommended, when multiple abscesses are too small (less than 2 cm), to be drained percutaneously. [13] Percutaneous drainages are recommended when the abscess is large or seems to rupture on US, or does not respond to antibiotic therapy after 72 h. [10],[13] The indications of open laporotomy include nonresponse to percutaneous drainage together with antibiotic therapy, or when the pus is thick, in multiloculated abscess [10],[13],[14] and LA in CGD patients [15] because in these patients the response of abscesses to drainage procedures and antibiotic therapy is poor and high rate of recurrence was reported with these methods. [16] However, in our center three pediatric surgeons have the same protocol as in other developing and developed countries to manage liver abscess. We treated pyogenic liver abscess in children with ampicillin plus aminoglycoside plus metronidazole empirically till about three years ago but due to growing antibiotic resistance we use vancomycin plus imipenem now as empirical therapy, and then change antibiotics according to the results of culture. If the abscess is assessable we drained it percutaneously under sonographical guidance. However, the indication of laporotomy includes the following: 1. Multiseptated abscess 2. LA in CGD patients 3. Associated disease like appendicitis 4. Rupture of liver abscess 5. When response to percutaneous drainage together with antibiotic therapy is not favorable.

Uncomplicated ALA is treated medically by metronidazole. Percutaneous aspiration is also added if LA is larger than 6 cm or shows features of rupture on US, or nonresponse to medical therapy, or if the patient is septicemic. [13],[17],[18] Failure rate with percutaneous drainage was reported in 20% of cases in recent studies. [19] In our center, percutaneous drainage was the most common type of treatment in the management of PLA. The high rate of failed percutaneous drainage (18.18%) in our center, may be due to the fact that only needle aspiration was done and no percutaneous catheter drainage was inserted which might be a better procedure. Mortality of LA has decreased significantly during recent years from 36% in 1998 [11] to 5.5% in 2007. [13] In our center mortality was seen in one patient (5.5%) which was a case of SCID with candida liver abscess.

 
   References Top

1.Vanni LA, Lopez PB, Porto SO. Solitary pyogenic liver abscess in children. Am J Dis Child 1978;132:1141-2.  Back to cited text no. 1
    
2.Ferreira MA, Pereira FE, Musso C, Dettogni RV. Pyogenic liver abscess in children: Some observations in the Espírito Santo State, Brazil. Arq Gastroenterol 1997;34:49-54.   Back to cited text no. 2
    
3.Pineiro-Carrero VM, Andres JM. Morbidity and mortality in children with pyogenic liver abscess. Am J Dis Child 1989;143:1424-7.  Back to cited text no. 3
    
4.Mehta RB, Parija SC, Chetty DV, Smile RR. Management of 240 cases of liver abscess. Int Surg 1986;71:91-4.  Back to cited text no. 4
    
5.Tsai CC, Chung JH, Ko SF, Liu PM, Su CT, Li WC, et al. Liver abscess in children: A single institutional experience in southern Taiwan. Acta Paediatr Taiwan 2003;44:282-6.  Back to cited text no. 5
    
6.Muorah M, Hinds R, Verma A, Yu D, Samyn M, Mieli-Vergani G, et al. Liver abscesses in children: A single center experience in the developed world. J Pediatr Gastroenterol Nutr 2006;42:201-6.  Back to cited text no. 6
    
7.Chou FF, Sheen-Chen SM, Chen YS, Chen MC. Single and multiple pyogenic liver abscesses: Clinical course, etiology, and results of treatment. World J Surg 1997;21:384-8.  Back to cited text no. 7
    
8.Wong W, Wong B, Kin Hui C, Ng M, Cuen Lai K, Kuen Tso W, et al. Pyogenic liver abscess: Retrospective analysis of 80 cases over a 10-year period. J Gastroenterol Hepatol 2002;17:1001-7.  Back to cited text no. 8
    
9.Barnes PF, De Cock KM, Reynolds TN, Ralls PW. A comparison of amoebic and pyogenic abscess of the liver. Medicine (Baltimore) 1987;66:472-83.  Back to cited text no. 9
    
10.Kumar A, Srinivasan S, Sharma AK. Pyogenic liver abscess in children-South Indian experiences. J Pediatr Surg 1998;33:417-21.  Back to cited text no. 10
    
11.Donovan AJ, Yellin AE, Ralls PW. Hepatic abscess. World J Surg 1991;15:162-9.  Back to cited text no. 11
    
12.Israeli R, Jule JR, Hom J. Pediatric pyogenic liver abscess. Pediatric Emergency Care 2009;25:107-8.  Back to cited text no. 12
    
13.Bari S, Sheikh KA, Malik AA, Wani RA, Naqash SH. Percutaneous aspiration versus open drainage of liver abscess in children. Pediatr Surg Int 2007;23:69-74.  Back to cited text no. 13
    
14.Kaplan SL. Pyogenic liver abscess in normal children with fever of unknown origin. Paediatrics 1979;58:4.  Back to cited text no. 14
    
15.Chen LE, Minkes RK, Shackelford PG, Strasberg SM, Kuo EY, Langer JC. Cut it out: Managing hepatic abscesses in patients with chronic granulomatous disease. J Pediatr Surg 2003;38:709-13.  Back to cited text no. 15
    
16.Lublin M, Bartlett DL, Danforth DN, Kauffman H, Gallin JI, Malech HL, et al. Hepatic abscess in patients with chronic granulomatous disease. Ann Surg 2002;235:383-91.  Back to cited text no. 16
    
17.Kapoor OP. Multiple amoebic liver abscesses. In: Kapoor OP, editor. Amoebic liver abscess. Bombay: SS publishers; 1979. p. 95-102.  Back to cited text no. 17
    
18.Moazam F, Nazir Z. Amoebic liver abscess: Spare the knife save the child. J Pediatric Surg 1998;33:119-22.  Back to cited text no. 18
    
19.Balint TD, Bailey BM, Mendelson KG, Pofahl W. Hepatic abscess: Current concepts in diagnosis and treatment. Curr Surg 2001;58:381-4.  Back to cited text no. 19
    

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Correspondence Address:
Heshmatollah Salahi
Professor of Liver Transplant, Transplant Research Center, Nemazee Hospital, Shiraz University of Medical Sciences, Shiraz
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1319-3767.80384

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