What is the management for a 20-year-old male with fever, epigastric pain, jaundice, and epigastric tenderness, who has a hypodermic mass with peripheral enhancement on abdominal ultrasound (US)?

Management of Liver Abscess in a Young Adult with Fever, Epigastric Pain, and Jaundice

Percutaneous drainage with appropriate antibiotic therapy is the treatment of choice for this patient with a suspected liver abscess. 1

Diagnostic Confirmation

The clinical presentation of fever, epigastric pain, jaundice, and epigastric tenderness along with a hypoechoic mass with peripheral enhancement on abdominal ultrasound strongly suggests a liver abscess. The American College of Radiology guidelines specifically state that percutaneous catheter drainage (PCD) is the appropriate management for liver abscesses >3 cm, particularly in patients with symptoms of right upper quadrant pain, fever, jaundice, and malaise 1.

Management Algorithm

1. Initial Stabilization:

   • Assess hemodynamic stability
   • Obtain baseline laboratory studies (complete blood count, liver function tests, coagulation profile)
   • Blood cultures before antibiotic initiation

2. Imaging Confirmation:

   • The abdominal ultrasound already shows a hypoechoic mass with peripheral enhancement
   • Consider contrast-enhanced CT if available to better characterize the abscess and plan drainage 2

3. Definitive Treatment:

   • Percutaneous drainage (Option B) is the first-line intervention 1
   • Surgical drainage is reserved for cases with failed percutaneous drainage, multiloculated abscesses, or rupture 1

4. Antibiotic Therapy:

   • Start broad-spectrum antibiotics with anaerobic coverage
   • Metronidazole (Option A) should be included in the regimen but is not sufficient as monotherapy 3
   • Combine with a broad-spectrum antibiotic (e.g., third-generation cephalosporin like ceftriaxone) 4, 5

Evidence-Based Rationale

The ACR Appropriateness Criteria specifically addresses this clinical scenario in Variant 8, stating: "PCD only is usually appropriate for a patient with... worsening right upper quadrant pain, fever, jaundice, and malaise. A CT scan reveals two liver abscesses >3 cm... Treatment includes antibiotics." 1

Percutaneous drainage is superior to antibiotic therapy alone for abscesses >3-5 cm in diameter. Clinical success rates of 83% have been reported for unilocular hepatic abscesses >3 cm treated with PCD and antibiotic therapy 1.

Metronidazole is essential for anaerobic coverage but should not be used as monotherapy. It should be combined with broad-spectrum antibiotics to cover both aerobic and anaerobic organisms 3, 5.

Important Considerations

• Drainage sample collection: Send aspirate for culture and sensitivity to guide targeted antibiotic therapy
• Biliary communication: Some hepatic abscesses may communicate with the biliary system, requiring additional biliary drainage if the abscess fails to resolve with PCD alone 1
• Duration of therapy: Antibiotics typically continued for 2-4 weeks depending on clinical response
• Follow-up imaging: To confirm resolution of the abscess

Pitfalls to Avoid

1. Delaying drainage: Waiting too long for antibiotics to work without drainage can lead to sepsis and increased mortality
2. Inadequate antibiotic coverage: Failing to cover both aerobic and anaerobic organisms
3. Missing underlying causes: Not investigating for potential sources of the abscess (e.g., biliary disease, portal pyemia from intra-abdominal infection)
4. Premature catheter removal: Removing drainage catheter before complete resolution

In summary, this patient requires percutaneous drainage combined with appropriate antibiotic therapy including metronidazole plus a broad-spectrum antibiotic. Surgical drainage would be excessive for an initial approach, while antibiotics alone would be insufficient for an abscess of this size.