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Frontiers of Medicine

Front Med Chin    2010, Vol. 4 Issue (3) : 308-316     DOI: 10.1007/s11684-010-0103-9
Early diagnosis and therapeutic choice of Klebsiella pneumoniae liver abscess
Jing LI, Ying FU, Ji-Yao WANG, Chuan-Tao TU, Xi-Zhong SHEN, Lei LI, Wei JIANG()
Department of Gastroenterology, Zhongshan Hospital, Fudan University, Shanghai 200032, China
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Nowadays, pyogenic liver abscess (PLA) is still a common and severe intra-abdominal infection, and Klebsiella pneumoniae had emerged as the most common pathogenic bacteria worldwide in the past ten years. Our study aims to achieve an early pathogenic diagnosis and rational therapy modality for Klebsiella pneumoniae liver abscess (KLA) through clinical data analysis. A total of 197 inpatients in Zhongshan Hospital, Shanghai, diagnosed as having liver abscess between March 2001 and September 2009 were enrolled. Patients with monomicrobial infection were divided into two groups: patients with K. pneumoniae liver abscess (KLA group, n=106) and those with non-Klebsiella pneumoniae liver abscess (NKLA group, n=56). A retrospective analysis was made between these two groups on the aspects of underlying diseases, clinical characteristics, laboratory data, culture results, and imaging findings. To evaluate the effects of different medical interventions, monomicrobial KLA patients were further divided into four subgroups (percutaneous liver aspiration, aspiration plus antibiotics flushing, aspiration plus retained catheter, and aspiration plus antibiotics flushing and retained catheter), and corresponding therapeutic effects were analyzed. KLA was more likely to occur in patients with coexisting diseases such as diabetes mellitus (53.77% vs 25.00%, P=0.001) and hepatic adipose infiltration (16.04% vs 5.36%, P=0.029). Compared to NKLA group, clinical characteristics including abdominal pain (40.57% vs 57.14%, P=0.044), hypodynamia (19.81% vs 46.43%, P=0.001), and hepatomegaly (4.72% vs 14.29%, P=0.033) were much milder, but with a higher fasting blood glucose level (7.84?±?0.36 vs 5.76?±?0.30, P=0.001) on admission in KLA group. In addition, KLA abscess often appeared singly in the right lobe of the liver with gas forming nature (32.88% vs 13.51%, P=0.039), unsmooth rim (71.23% vs 40.54%, P=0.002), and dynamic septum enhancement (41.10% vs 16.22%, P=0.009). Compared to mono aspiration subgroup, additional antibiotic flushing could not further improve clinical outcomes of KLA patients (P>0.05); however, the retained catheter showed obvious advantage in reducing abscess diameter (34.38?±?3.25 mm vs 22.67?±?2.37 mm, P=0.017). It can be concluded that the strong association with diabetes, milder clinical symptoms, and gas-forming nature in CT images makes early pathogenic diagnosis of KLA possible. Comparatively, ultrasonography-guided percutaneous liver aspiration with retained catheter may be the most rational intervention modality of KLA.

Keywords liver abscess      Klebsiella pneumoniae      computed tomography      therapy     
Corresponding Authors: JIANG Wei,   
Issue Date: 05 September 2010
 Cite this article:   
Jing LI,Ying FU,Ji-Yao WANG, et al. Early diagnosis and therapeutic choice of Klebsiella pneumoniae liver abscess[J]. Front Med Chin, 2010, 4(3): 308-316.
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Jing LI
Ying FU
Chuan-Tao TU
Xi-Zhong SHEN
Lei LI
culture results of 197 enrolled patientsnumber of cases
Klebsiella pneumoniae116
Escherichia coli27
Pseudomonas aeruginosa13
Staphylococcus aureus5
Citrobacter freumdii4
Enterobacter cloacae3
coagulase negative staphylococcus2
Staphylococcus epidermidis2
Morganella morganii2
short wave unit cell bacteria1
Tab.1  Microbiological data of pyogenic liver abscess patients
underlying diseasesKLA (n=106)NKLA (n=56)P value
diabetes mellitus57 (53.8%)14 (25.0%)<0.001a
biliary diseases24 (22.6%)17 (30.4%)NSa
abdominal surgeries18 (17.0%)30 (35.4%)<0.001a
liver cirrhosis3 (2.8%)1 (1.8%)NSb
chronic hepatitis B4 (3.8%)5 (8.9%)NSb
malignant tumors3 (2.8%)7 (12.5%)<0.05a
hepatic adipose infiltration17 (16.0%)3 (5.4%)<0.05a
chemo-radiotherapies2 (1.9%)6 (10.7%)<0.05a
diabetes+ biliary diseases11 (10.4%)2 (3.6%)NSa
Tab.2  Underlying diseases of . liver abscess patients
clinical parametersKLA (n=106)NKLA (n=56)P value
chill78 (73.58%)38 (67.86%)NSa
abdominal pain43 (40.57%)32 (57.14%)<0.05a
vomiting26 (24.53%)12 (21.43%)NSa
anorexia53 (50.00%)30 (53.57%)NSa
fatigue21 (19.81%)26 (46.43%)0.001a
highest body temperature/°C39.41±0.0939.10±0.13NSa
hepatic percussion pain41 (38.68%)27 (48.21%)NSa
liver tenderness31 (29.25%)21 (37.50%)NSa
hepatomegaly5 (4.72%)8 (14.29%)<0.05a
leucocyte count (×109/L)13.30±0.5912.73±1.07NSc
percentage of neutrophils /%80.64±1.1479.33±1.46NSc
blood glucose/mmol·L-17.84±0.365.76±0.300.001c
Tab.3  Clinical characteristics and laboratory parameters of KLA patients
ultrasonography findingsKLA (n=106)NKLA (n=56)P value
solitary (n=1)60 (82.19%)30 (81.08%)NSa
multiple (n>1)13 (17.81%)7 (18.92%)NSa
left lobe11 (15.07%)5 (16.67%)NSa
right lobe47 (64.38%)24 (64.87%)NSa
junction of left and right lobe2 (2.74%)1 (2.74%)NSb
diameter of abscess/mm73.85±2.4073.77±3.22NSc
gas-formation in abscess27 (25.47%)6 (10.71%)<0.001a
abscess with compartments41 (38.67%)20 (35.71%)NSa
CT findingsKLA (n=73)NKLA (n=37)P value
plain scan
abscess with clear edge21 (28.77%)22 (59.46%)NSa
abscess with blurring edge52 (71.23%)15 (40.54%)<0.05a
gas-formation in abscess24 (32.88%)5 (13.51%)<0.05a
biliary pneumatosis7 (9.59%)3 (8.11%)NSa
pleural effussion25 (34.25%)11 (29.73%)NSa
hepatic arterial phase
no enhancement0 (0)0 (0)NSb
septal enhancement30 (41.10%)6 (16.22%)<0.05a
abnormal perfusion5 (6.85%)2 (5.41%)NSb
portal venous phase
no enhancement0 (0)2 (5.4%)NSb
peripheral enhancement28 (38.36%)12 (32.4%)NSa
non-peripheral enhancement2 (2.74%)2 (5.4%)NSb
Tab.4  Imaging findings of liver abscess in KLA patients
treatment responsesgroup I (n=24)group II (n=52)group III (n=23)
decline in percentage of neutrophils/%17.72±2.4116.21±1.5915.20±2.18
reduction of abscess diameter/mm22.67±2.3724.45±3.1734.38±3.25 *#
time to defervescence/day5.79±1.245.35±0.845.18±1.57
Tab.5  Treatment responses to different aspiration modalities of liver abscess patients
Fig.1  Typical abdominal CT images of a 77-year-old female KLA patient. (a) Plain scan: the abscess is the low-density lesion with blurring edge in the right lobe of the liver. Red arrow indicates gas cavities of the abscess, which are at a relatively-upper location within the abscess. (b)-(d) Hepatic arterial phase: during enhanced period, the margin of lesion still cannot be clearly shown. Red arrow indicates the gas cavities; blue arrow indicates the imaging signs of septal enhancement and disarranged internal structure of the abscess; yellow arrow indicates little flocculent shadow in the hepatorenal recess with its unclear boundaries to the upper pole of the right kidney. (e)-(f) Hepatic parenchymal phase: during hepatic parenchymal phase, delayed and weakened enhancement of the abscess is shown in CT images. Its margin is unclear with still visible gas cavities indicated by red arrow. KLA: liver abscess.
Fig.2  Comparison of abdominal CT images between KLA and NKLA. (a) CT images of a 57-year-old male KLA patient with concomitant diabetes: circular shadow of low and uneven density can be seen in the caudate lobe near the second hepatic portal. With a diameter of 90 mm, a shadow of much lower density and gas cavities can be seen in the center of the abscess. During enhanced scanning, the margin and internal septations of abscess shows a honeycomb-like structure. Intrahepatic bile ducts show slight dilation. (b) CT images of a 51-year-old female patient with liver abscess: irregular low-density lesion with a honeycomb-like structure can be seen in the right lobe of the liver. Obvious cystic wall enhancement can be seen during enhanced scanning. There is no stenosis or filling defect of hepatic vessels. (c) CT images of a 65-year-old female patient with liver abscess: patchy shadow of low-and-even density and clear edge can be seen in the right lobe of the liver. By enhanced CT scan, the peripheral enhancement is more dramatic than non-peripheral enhancement. Septation is visible inside the abscess and hepatic blood vessels are evenly distributed. KLA: liver abscess; NKLA: non- liver abscess.
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