Abdominal Examination Findings in Segment II Liver Abscess
A liver abscess in segment II (left lateral superior segment) typically presents with left upper quadrant tenderness and may be associated with left-sided chest findings due to the segment's proximity to the diaphragm, though physical examination findings are often subtle or absent in hepatic abscesses. 1, 2
Expected Physical Examination Findings
Abdominal Findings
- Left upper quadrant tenderness is the most common finding when segment II is involved, as this segment occupies the superior-lateral portion of the left hepatic lobe 3
- Hepatomegaly may be palpable in up to 30% of cases, though this is not a reliable indicator of abscess presence 4
- Peritoneal signs (guarding, rebound tenderness) are typically absent unless rupture has occurred into the peritoneal cavity 5
- Abdominal wall swelling can occur in rare cases of spontaneous rupture through the anterior abdominal wall, though this is extremely uncommon 5
Associated Findings
- Left-sided pleuritic chest pain may be present due to diaphragmatic irritation from the superior location of segment II 3
- Left shoulder pain (referred pain via phrenic nerve) can occur with diaphragmatic involvement 3
- Respiratory findings including decreased breath sounds or dullness to percussion at the left lung base may indicate sympathetic pleural effusion 4
Critical Clinical Context
Absence of Classic Findings
- 31% of patients with hepatic abscess are afebrile at presentation 6
- 23% have normal white blood cell counts despite active infection 6
- 13% have completely normal liver function tests 6
- The absence of fever, leukocytosis, or elevated liver enzymes does not exclude hepatic abscess 6
Segment-Specific Considerations
- Left lobe abscesses (including segment II) are rare, accounting for only approximately 6% of all hepatic abscesses 3
- Left lobe abscesses have a particular propensity for rupture compared to right-sided lesions, making early diagnosis critical 3
- Segment II location in the hepatic dome makes these abscesses more difficult to detect on ultrasound compared to CT imaging 7, 6
Diagnostic Approach When Physical Findings Are Subtle
Initial Imaging
- Contrast-enhanced CT is the gold standard with 97% sensitivity for detecting hepatic abscesses and should be performed when clinical suspicion exists despite unremarkable physical examination 1, 7, 6
- Ultrasound may miss segment II abscesses located in the hepatic dome, with only 79% overall sensitivity 6
- CT is superior to ultrasound for dome lesions and should be the preferred initial study when segment II involvement is suspected 7
Laboratory Markers
- Elevated CRP ≥50 mg/L is highly suggestive of active hepatic abscess infection 2
- Elevated alkaline phosphatase or bilirubin should prompt abdominal imaging even without abdominal signs 4
- Serial monitoring of inflammatory markers (leukocytes, CRP, procalcitonin) helps assess treatment response 1
Common Pitfalls to Avoid
- Do not rely on physical examination alone to exclude hepatic abscess—imaging is mandatory when clinical suspicion exists based on fever, laboratory abnormalities, or risk factors 4, 6
- Do not assume normal vital signs or laboratory values exclude the diagnosis—nearly one-third of patients lack classic findings 6
- Do not use ultrasound as the sole imaging modality for suspected segment II lesions due to the dome location—proceed directly to CT if ultrasound is negative but suspicion remains high 7, 6
- Recognize that left upper quadrant pain with fever warrants imaging even with a benign abdominal examination, given the high rupture risk of left lobe abscesses 3