Sonographically Guided Percutaneous Catheter Drainage Versus Needle Aspiration in the Management of Pyogenic Liver Abscess

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1 Sonography for Liver Abscess Drainage Interventional Radiology Original Research Enver Zerem 1 Amir Hadzic Zerem E, Hadzic A Keywords: antibiotic therapy, interventional sonography, liver abscess DOI: /AJR Received December 17, 2006; accepted after revision March 28, Both authors: Interventional Ultrasonography Department, University Clinical Center, Trnovac bb, Tuzla, Bosnia and Herzegovina. Address correspondence to E. Zerem (zerem@inet.ba). WEB This is a Web exclusive article. AJR 2007; 189:W138 W X/07/1893 W138 American Roentgen Ray Society Sonographically Guided Catheter Drainage Versus Needle Aspiration in the Management of Pyogenic Liver Abscess OBJECTIVE. The purpose of this study was to determine the effectiveness of percutaneous catheter drainage (PCD) and to compare PCD with percutaneous needle aspiration in the management of liver abscess. SUBJECTS AND METHODS. Sixty patients with pyogenic liver abscess were randomly assigned to two groups in a prospective study. Antibiotics were administered for 10 days, starting the day of the beginning of percutaneous treatment. One group was treated with sonographically guided PCD and the other group with repeated percutaneous needle aspiration. needle aspiration was attempted a maximum of three times. Lack of response to the third aspiration was considered failure of treatment; these patients were treated with PCD but were not included in the PCD group for analysis. Patient demographics, duration of hospital stay, treatment outcome, and complications were analyzed. RESULTS. needle aspiration was successful in 20 (67%) of the 30 patients after one (n = 12), two (n = 7), or three (n = 1) aspirations. PCD was curative in all 30 patients after one (n = 24) or two (n = 6) procedures. All abscesses 50 mm or less in longest diameter were successfully managed, 10 by percutaneous needle aspiration and 12 by PCD. None of patients in the percutaneous needle aspiration group with multiloculated abscesses (n =5) was successfully treated. Hospital stay did not differ significantly between the groups. There were no complications related to the procedure. CONCLUSION. PCD is more effective than percutaneous needle aspiration in the management of liver abscess. needle aspiration can be used as a valid alternative for simple abscesses 50 mm in diameter or smaller. iver abscess is a relatively uncommon lesion with a high mortality L rate because of delayed detection and treatment. The classic presentation of fever, right upper quadrant pain, and tender hepatomegaly is unusual. The frequency of any particular symptom varies widely among reports. Management of liver abscess was exclusively surgical in the past. Modern treatment has shifted toward IV broad-spectrum antibiotics and imaging-guided percutaneous needle aspiration or percutaneous catheter drainage (PCD). Surgical intervention is still indicated for inaccessible abscesses, multiple lesions that cannot be effectively managed percutaneously, and abscesses that do not respond to less invasive methods [1 3]. Continuous catheter drainage is widely accepted and in combination with antibiotics is considered a safe and effective method of management of liver abscess [4, 5]. Some authors prefer repeated needle aspiration, considering it as effective and safe as PCD but easier to perform, less complicated, less aggressive, less risky for postprocedure septicemia, and less expensive. This approach requires careful follow-up and often-repeated imaging procedures to monitor response to therapy [6 9]. The objective of our randomized study was to compare the efficacy and safety of PCD with those of percutaneous needle aspiration and to determine the firstline management of pyogenic liver abscess. Subjects and Methods Patients All patients with pyogenic liver abscess who were admitted to our hospital between February 2002 and March 2006 were considered candidates for the study. A patient was enrolled if he or she had symptoms and signs of pyogenic liver abscess and if liver abscess was confirmed at sonographic or CT examination. We excluded patients with coexisting malignant disease of biliary origin, which is the W138 AJR:189, September 2007

2 Sonography for Liver Abscess Drainage Fig year-old man with two liver abscesses. A, Sonogram shows two abscess collections (arrows) in right lobe of liver. B, Sonogram shows top of needle (arrow) in abscess cavity. C, Sonogram shows appearance of abscess cavity (arrow) immediately after evacuation of pus. D, Sonogram shows small scar (arrow) in liver 3 months after treatment. leading cause of death from liver abscess, regardless of the type of percutaneous treatment. We also excluded patients who were initially treated with antibiotics other than cefazolin and gentamicin. All patients gave written informed consent, and the study was approved by the local ethics committee. Sealed envelopes containing the names of the treatments were used to randomly assign 60 eligible patients to undergo percutaneous needle aspiration or PCD (30 patients in each group). The allocation schedule was created with a computerized random number generation system. At presentation, all patients included for randomization were treated with IV cefazolin 1 g three times a day and gentamicin 1 mg/kg three times a day for 10 days. treatment was performed within 24 hours after admission. Immediately after catheter or needle placement into the abscess cavity, pus was obtained from all 60 patients. The antibiotics were adjusted according to the results of culture and sensitivity testing of the pus aspirated during the procedure. Patients with negative culture results were continuously treated with a combination of cefazolin and gentamicin. If antibiotic therapy was changed according to the results of A C sensitivity testing, new antibiotics were administered for 10 days. Patients were discharged earlier with an IV catheter inserted for completion of therapy if fever had subsided for at least 48 hours. IV antibiotic therapy was followed by a 4-week course of appropriate oral antibiotics. The drainage technique was a trocar method with an 8-French multiple-sidehole pigtail catheter (Boston Scientific) introduced into the abscess cavity. The procedure was performed with local anesthesia, the patient supine. Conscious sedation was not used. Careful localization of the abscess and proper selection of the entry site were required. The optimal route of access traversed the least possible amount of liver tissue and avoided bowel and pleura. Aspiration was performed with the catheter until no more pus was removed. The catheter then was secured to the skin for continuous external drainage and was left in place until production of content stopped. Residual cavities of abscesses were managed by catheter repositioning and aspiration or by introduction of a new catheter. B D Needle Aspiration Evacuation of pus from an abscess was performed with an 18-gauge disposable trocar needle. Sonography was performed every 3 days, and the size of the abscess cavity was recorded. If there was no significant reduction in the abscess cavity on control examination, aspiration was repeated. Repeated aspiration was attempted a maximum of twice for each patient not responding; lack of response to a third aspiration attempt was considered failure of treatment, and a catheter for continuous drainage was introduced. Patients who needed this treatment were not included in the PCD group. Follow-Up and Outcome All patients underwent clinical follow-up and monitoring during daily rounds until they were discharged from the hospital. Follow-up sonography was performed 24 hours after intervention and repeated every 3 days, and the size of the abscess was recorded. Criteria for successful treatment were clinical subsidence of infection and sonographic evidence of abscess resolution, such as disappearance or marked decrease in the abscess cavity (more than 50% reduction of longest diameter before treatment) (Fig. 1). After discharge from the hospital, patients underwent follow-up evaluations in the outpatient clinic at least once a week during treatment and biweekly until 6 months from the beginning of the treatment. Patients discharged with a catheter underwent followup sonography every 3 days until there was no catheter output for 24 hours, and then the catheter was removed. Patient outcome, including length of hospital stay, complications related to the procedure, and treatment failure, were recorded. Statistical Analysis Statistical analysis was done with statistical software (SPSS 12.0, SPSS). Descriptive and analytic statistics were used. Quantitative variables were compared by two-sample Student s t test for independent samples with adjustment for unequal variances when needed or by Mann-Whitney U test for variables not normally distributed. Categoric variables were analyzed by chi-square test. All statistical tests were performed with a 95% level of statistical significance. Results Seventy-one patients were initially enrolled in the study. Eleven of them were excluded, nine because of malignant disease of biliary origin and two because they were initially treated with antibiotic combinations other than cefazolin and gentamicin. Of the remaining 60 patients, 36 were women and 24 men. The mean age was 51.2 ± 14.4 (SD; AJR:189, September 2007 W139

3 TABLE 1: Characteristics of Patients with Pyogenic Liver Abscesses Managed with and Needle Aspiration Characteristic Needle Aspiration Group Age (y) a 50.3 ± ± Sex Men 12 (40) 12 (40) 1.00 Women No. of patients with temperature > 37.5 C 24 (80) 21 (70) 0.55 No. of patients with right upper quadrant tenderness 16 (53) 15 (50) 0.80 WBC count ( 10 9 /L) a 12.8 ± ± Neutrophil count ( 10 9 /L) a 10.2 ± ± C-reactive protein a 49.3 ± ± Total bilirubin a 27.2 ± ± Alkaline phosphatase a ± ± Prothrombin time (s) a 15.0 ± ± Alanine aminotransferase (U/L) a 76.4 ± ± Aspartate aminotransferase (U/L) a 41.0 ± ± Hemoglobin (g/l) 10.9 ± ± Note Values in parentheses are percentages. a Mean ± SD. TABLE 2: Characteristics of Liver Abscesses Managed with and Needle Aspiration Characteristic (n=30) Needle Aspiration Group (n =30) p Diameter of abscess (mm) 0.99 Mean ± SD 73.5 ± ± 40.3 Range Volume of pus drained in first treatment (ml) 0.70 Mean ± SD ± ± 99.3 Range Site of abscess 0.77 Right lobe Left lobe Both lobes 1 2 No. of abscesses NS Single Multiple 2 2 Multiloculated 6 5 Cause of abscess 0.83 Biliary disease Portal disease 9 8 Cryptogenic factor 6 8 Note NS = not significant. range, 22 75) years. Before admission, patients had symptoms for a mean of 5.9 ± 2.9 days (range, 2 14 days). The patient groups did not differ significantly with respect to baseline characteristics, clinical features, or biochemical values (Table 1). There was no statistically significant difference between the two groups with regard to underlying pathologic condition and abscess characteristics. A potential underlying condition for liver abscess was found in 46 (77%) of the 60 patients (Table 2). The most common coexisting disease was diabetes in 17 (28%) of the patients. A microbial pathogen was isolated in 23 (77%) of the patients in the PCD group and 22 (73%) of the patients in the percutaneous needle aspiration group. All patients who had positive results of both blood and abscess cultures had identical pathogens. Bacteria in the positive cultures were predominantly gramnegative, Klebsiella pneumoniae being the leading species. In seven patients in the drainage group and five patients in the needle group, antibiotics were changed after the results of pus culture and sensitivity tests were obtained (Table 3). Details on the outcome of the procedure are shown in Table 4. Repeated aspiration was attempted for 18 of 30 patients not responding to the first aspiration. The outcome was successful in seven of the 18 patients after the second and in only one of 11 patients after the third attempt. Ten patients did not respond even after three aspirations, and the outcome was considered failure of treatment. In nine of the 10 patients, abscess collection was successfully managed by catheter drainage. One patient had persistence of the abscess on sonography along with fever and pain in the right upper quadrant of the abdomen and abnormal laboratory test results. That patient underwent surgery with a favorable outcome. In the percutaneous needle aspiration group, the average longest diameter of the abscess collection was significantly greater in patients with unsuccessful (97 ± 42 mm) than in patients with successful (62 ± 35 mm) needle aspiration (p = 0.02). Although the average volume of frank pus was larger in patients who underwent unsuccessful percutaneous needle aspiration (178 ± 98 ml) than in those who underwent successful percutaneous needle aspiration (121 ± 96 ml), the difference was not significant (p = 0.14). Intermittent needle aspiration was successful for all patients with abscesses 50 mm in longest diameter or smaller. However, this treatment was unsuccessful for all five patients with multiloculated abscesses. In the PCD group, all patients were successfully treated, clinical features and laboratory abnormalities subsiding (Table 4). In four of six patients with multiloculated ab- W140 AJR:189, September 2007

4 Sonography for Liver Abscess Drainage TABLE 3: Microbiologic Data on Liver Abscesses Managed with and Needle Aspiration Microbiological Data Catheter Drainage Needle Aspiration Group Blood culture positive (n) 1 1 NS Abscess culture positive (n) NS Blood and abscess culture positive (n) 8 6 NS No. of patients with positive culture results (total) NS Organisms cultured NS Escherichia coli 2 3 Klebsiella pneumoniae 11 8 Pseudomonas species 1 0 Staphylococcus species 2 1 Enterococcus species 1 2 Streptococcus milleri 2 2 Staphylococcus + Streptococcus + E. coli + Klebsiella 4 6 No. of patients with negative culture results 7 8 NS No. of patients with antibiotics changed after sensitivity test 7 5 NS Imipenem 3 1 Vancomycin 2 2 Ciprofloxacin 0 1 Clarithromycin 2 1 Note NS = not significant; p > TABLE 4: Clinical Outcome Among Patients with Liver Abscess Managed with and Needle Aspiration Result Needle Aspiration No. of patients with successful treatment Total 30 (100) 20 (67) < First procedure 24 (80) 12 (40) Second procedure 6 (20) 7 (23) Third procedure 0 1 (3) Rate of success of treatment of patients 12/12 10/ with abscesses 50 mm in diameter No. of patients with disappearance of 16/30 (53) 9/20 (45) 0.77 abscess at the end of treatment No. of patients with > 50% decrease in 14/30 (47) 11/20 (55) 0.77 abscess at end of treatment Total hospital stay (d) 0.98 a Median (first through third quartiles) Range Note Values in parentheses are percentages. Mann-Whitney U test; Z = 0.02; p = scesses, catheter drainage was performed twice because drainage was inadequate with the first attempt. Total duration of catheter drainage for each patient in the drainage group ranged from 3 to 25 days with a mean of 11.0 ± 6.4 days. At the end of treatment, the abscess cavity had disappeared completely in 25 of 50 successfully treated patients and had decreased more than 50% in the other 25 patients (Table 4). On final control examination 6 months after the beginning of treatment, abscesses were absent in all successfully treated patients. Hospital stay did not differ significantly between the groups (Mann-Whitney U test; Z = 0.02; p = 0.98) (Table 4). Neither group of patients had procedure-related complications such as bleeding of any degree or septicemia. Discussion The trend in management of liver abscesses has been moving strongly toward nonsurgical methods. Several investigations [1 9] have shown that a large proportion of patients can be treated with excellent results with a combination of parenteral antibiotics and image-guided percutaneous treatment. Whether to perform percutaneous catheter drainage or intermittent needle aspiration remains controversial. In two early randomized studies [4, 8] in which use of continuous catheter drainage was compared with repeated needle aspiration in the management of liver abscess, recommendations for first-line percutaneous treatment differed. Rajak and colleagues [4] compared percutaneous needle aspiration and PCD in a randomized study involving 50 patients with liver abscess. Those investigators concluded that PCD was more effective than percutaneous needle aspiration. In that study, lack of response to a second attempt at percutaneous needle aspiration was considered failure of treatment. Yu and colleagues [8] performed a randomized trial involving 64 patients with pyogenic liver abscess. needle aspiration was repeated if there was either lack of clinical improvement or lack of size reduction of the abscess cavity. Those investigators concluded that percutaneous needle aspiration was probably as effective as continuous PCD. They recommended percutaneous needle aspiration as a first-line approach because of procedure simplicity, patient comfort, and reduced price and suggested a multicenter study to provide a definitive answer. Unlike the aforementioned investigators [4, 8], we considered a third unsuccessful attempt at percutaneous needle aspiration failure of treatment. That only one of 11 aspirations was successful on the third attempt confirmed that further needle aspiration is AJR:189, September 2007 W141

5 rarely successful. This result supported the design of the study by Rajak et al. [4]. The results of our study confirmed that repeated percutaneous needle aspiration and PCD are equally efficient in the management of liver abscesses 50 mm or less in longest diameter. needle aspiration of all multiloculated abscesses failed, and PCD was necessary. As in other investigations [10 12], K. pneumoniae was the most commonly isolated microorganism in our series. Some authors have presented their experience in nonrandomized studies showing that percutaneous needle aspiration is a safe and effective approach and should be considered a first-line treatment in the management of liver abscess. Most of the abscesses required no more than two aspirations irrespective of size [6 9]. Use of catheters was reserved for cases of rapid reaccumulation of exudate and for those without general improvement in the patient s condition [13]. Other authors prefer continuous catheter drainage as a reliable and effective approach to the management of liver abscess [14 17]. On the basis of previous findings, we excluded patients with coexisting malignant disease of biliary origin, which is a poor prognostic factor and the leading cause of death among patients with pyogenic liver abscess [18, 19]. This exclusion is probably why we had a better overall success rate with percutaneous treatment (only one patient referred for surgery) than have other investigators [11, 16, 20, 21] and is probably why there were no deaths in our series. In conclusion, continuous PCD is more efficient than intermittent percutaneous needle aspiration. Intermittent percutaneous needle aspiration is a valid alternative for abscesses 50 mm or less in longest diameter. PCD is more efficient for multiloculated liver abscesses. 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