Liver abscess

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Last reviewed: 9 Apr 2025

Last updated: 31 Oct 2024

Liver abscess is a localized infection in the liver parenchyma that may be bacterial, fungal, or parasitic in origin.

Patients typically present with nonspecific constitutional symptoms, right upper quadrant abdominal pain, and tenderness.

The most common underlying condition in people with pyogenic liver abscess is biliary tract disease.

Treatment of pyogenic abscess focuses on both timely administration of broad-spectrum antibiotics and drainage of the abscess. People with fungal abscess require antifungal therapy. Amebic abscess is treated with a nitroimidazole, followed by a luminal agent.

Definition

Liver abscesses are purulent collections in the liver parenchyma that result from bacterial, fungal, or parasitic infection. Infection can spread to the liver through the biliary tree, hepatic vein, or portal vein, by extension of an adjacent infection, or as a result of trauma.[1] One or multiple abscesses can be present. Fungal liver abscess can occur in immunocompromised hosts. Amebic liver abscess is a complication of amebiasis.

History and exam

Key diagnostic factors

fevers and chills
RUQ tenderness
hepatomegaly

Full details

Other diagnostic factors

weight loss
fatigue
abdominal pain
nausea and vomiting
cough, shortness of breath, or chest pain
jaundice
signs of pleural effusion in the right lower zone
signs of shock
ascites

Full details

Risk factors

biliary tract disease
age >50 years
underlying malignancy
diabetes mellitus
interventional biliary or hepatic procedures
living in or visiting area endemic for amebiasis
cirrhosis
liver transplantation
alcoholism
male sex
cardiopulmonary disease
immunocompromised state
penetrating abdominal trauma
inflammatory bowel disease, pancreatitis, appendicitis, diverticulitis, or peritonitis
bacteremia, endocarditis, or other intravascular infection
poor dentition

Full details

Diagnostic tests

1st tests to order

CBC
serum LFTs
blood cultures
prothrombin time and activated partial thromboplastin time
liver ultrasound
contrast-enhanced abdominal CT scan
Gram stain and culture of aspirated abscess fluid

Full details

Tests to consider

CXR
serum antibody test for Entamoeba histolytica
stool Entamoeba histolytica antigen detection test
antigen testing or polymerase chain reaction (PCR) of aspirated abscess fluid
liver MRI
CRP

Full details

Treatment algorithm

INITIAL

suspected pyogenic abscess

suspected amebic abscess

ACUTE

pyogenic abscess: following response to intravenous antibiotic therapy

amebic abscess: following response to nitroimidazole therapy

ONGOING

abscess recurrence

Contributors

Authors

Rachel P. Simmons, MD

Assistant Professor of Medicine

Division of General Internal Medicine

Warren Alpert Medical School of Brown University

Providence

Disclosures

RPS declares that she has no competing interests.

Lawrence S. Friedman, MD

Professor of Medicine

Harvard Medical School and Tufts University School of Medicine

Boston

Disclosures

LSF has received royalties from Elsevier, Wiley, McGraw-Hill, Harvard Health Publications, Wolters Kluwer, and UpToDate.

Peer reviewers

James Neuberger, BM, BCh

Consultant Physician

Liver Unit

Queen Elizabeth Hospital

Birmingham

Disclosures

JN declares that he has no competing interests.

Nancy Reau, MD

Assistant Professor of Medicine

University of Chicago

Center for Liver Disease

Chicago

Disclosures

NR declares that she has no competing interests.

References

Our in-house evidence and editorial teams collaborate with international expert contributors and peer reviewers to ensure that we provide access to the most clinically relevant information possible.

Key articles

Feldman M, Friedman LS, Brandt LJ. Brandt. Sleisenger and fordtran's gastrointestinal and liver disease - 2: pathophysiology, diagnosis, management. 11th ed. Elsevier; 2022.

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials
- Ascending cholangitis
- Cystadenoma or cystadenocarcinoma
- Inflammatory pseudotumors of the liver
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Guidelines
- Appropriateness criteria: right upper quadrant pain
- Appropriateness criteria: acute nonlocalized abdominal pain
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Patient information
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Videos
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Liver abscess

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic tests

1st tests to order

Tests to consider

Treatment algorithm

suspected pyogenic abscess

suspected amebic abscess

pyogenic abscess: following response to intravenous antibiotic therapy

amebic abscess: following response to nitroimidazole therapy

abscess recurrence

Contributors

Authors

Rachel P. Simmons, MD

Disclosures

Lawrence S. Friedman, MD

Disclosures

Peer reviewers

James Neuberger, BM, BCh

Disclosures

Nancy Reau, MD

Disclosures

References

Key articles

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials

Guidelines

Patient information

Videos

Log in or subscribe to access all of BMJ Best Practice

Log in or subscribe to access all of BMJ Best Practice

Log in to access all of BMJ Best Practice