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Imaging-Guided Percutaneous Needle Aspiration or Catheter Drainage of Neonatal Liver Abscesses: 14-Year Experience

¹ Division of Image Guided Therapy, Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, 555 University Ave., Toronto, ON M5G 1X8, Canada.
² Present address: Diagnostic Radiology, St. Mary's Hospital, The Catholic University of Korea, Seoul, 150-713, South Korea.
³ Division of Neonatology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada.

Received July 18, 2007; accepted after revision September 24, 2007.

 
Address correspondence to B. L. Connolly (bairbre.connolly{at}sickkids.ca).

Abstract

Top Abstract Introduction Materials and Methods Results Discussion References

 
OBJECTIVE. The purpose of our study was to review the clinical aspects and long-term outcomes of imaging-guided percutaneous aspiration or drainage of liver abscesses in neonates.

MATERIALS AND METHODS. We retrospectively reviewed the clinical and imaging records of eight neonates with liver abscesses referred for imaging-guided percutaneous aspiration or drainage, including one autopsy-proven case in whom the percutaneous aspiration or drainage was not performed. Clinical and imaging features, complications, and long-term follow-up results were assessed.

RESULTS. Eight neonates with liver abscesses were referred for imaging-guided percutaneous aspiration or drainage (five males, three females; age range, 7–100 days; weight, 610–3,400 g). Six were born prematurely (24–29 weeks of gestation). Six had a history of umbilical catheterization. All were clinically septic. All neonates received long-term IV antibiotics. Five neonates had solitary multiloculated abscesses (right lobe [n = 3], straddling both lobes [n = 2]), and three had solitary uniloculated abscesses (right lobe [n = 1] and left lobe [n = 2]). Imaging-guided drainage catheter insertion (n = 4), aspiration (n = 2), and aspiration followed by drainage catheter insertion (n = 1) were performed in seven neonates within 1 day after referral. Coagulase-negative Staphylococcus (4/8) was the most common organism isolated from blood and pus. There were no procedure-related complications. Catheter repositioning was required in one. Serial sonography (mean, 12.5 months) and clinical follow-up (mean, 20.7 months) showed complete clinical remission in seven cases. Three healed with calcification in the previous abscess site. Long-standing left portal vein thrombosis was seen in two cases.

CONCLUSION. Neonatal liver abscess is associated with good long-term outcome and minimal complications when imaging-guided percutaneous aspiration or drainage is performed in conjunction with long-term antibiotic coverage.

Keywords: drainage • interventional radiology • liver abscess • newborn • percutaneous aspiration

Introduction

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Neonatal liver abscess is a rare clinical entity, with potentially serious clinical sequelae and, in the past, a high mortality [1–3]. Hematogenous spread of infection, umbilical venous catheterization, abdominal surgery, and systemic sepsis and immune deficiencies have been recognized as underlying risk factors. In adults, imaging-guided percutaneous aspiration or drainage of liver abscess is a well-accepted treatment [4, 5]. There have been few reported cases [6–12] of abscess drainage in pediatrics, and, to our knowledge, there are no focused case series about imaging-guided percutaneous aspiration or drainage of neonatal liver abscesses with long-term follow-up. We report our experience of treating neonatal liver abscesses with imaging-guided percutaneous aspiration or drainage in combination with long-term antibiotic treatment and evaluate its safety and long-term follow-up.

View larger version (119K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A —24-day-old male neonate with percutaneous aspiration or drainage of postoperative hepatic abscess. Klebsiella pneumoniae and Enterococcus faecalis were sources. Under sonographic guidance, 20-gauge needle (arrow) was inserted through anterior–inferior right lobe of liver into abscess.

View larger version (122K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B —24-day-old male neonate with percutaneous aspiration or drainage of postoperative hepatic abscess. Klebsiella pneumoniae and Enterococcus faecalis were sources. Contrast material injection through pigtail catheter shows pigtail within abscess in two planes, frontal (B) and lateral (C).

View larger version (123K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1C —24-day-old male neonate with percutaneous aspiration or drainage of postoperative hepatic abscess. Klebsiella pneumoniae and Enterococcus faecalis were sources. Contrast material injection through pigtail catheter shows pigtail within abscess in two planes, frontal (B) and lateral (C).

Top Abstract Introduction Materials and Methods Results Discussion References

Procedure Characteristics
After we obtained informed consent, the procedures were performed under general anesthesia (n = 1) or with sedation (n = 6) by the neonatal ICU (NICU) transport team. The majority of neonates were already intubated and ventilated in the NICU, so the NICU transport team sedated the neonates with agents such as morphine or fentanyl, frequently in combination with a muscle relaxant such as pancuronium.

All percutaneous aspiration or drainage procedures were performed in these neonates with sonographic guidance (HDI 5000 or 3000 US, Philips Medical Systems) using 5-12–MHz linear transducer, with or without fluoroscopy in combination. A freehand technique with a 20- to 22-gauge Chiba needle (Inrad) or Angiocath (Becton Dickinson) was used (Fig. 1A). After successful puncture, a sample of fluid was aspirated and sent for bacterial culture and sensitivity. The decision to aspirate only or place a drain was made depending on the size of the collection and its capacity to accommodate a pigtail as well as the viscosity of the contents and the ability to drain through a tube.

Near complete evacuation of pus from the abscess cavity was attempted for each abscess undergoing aspiration only. For drainage procedures, minimal contrast injection confirmed the position of the needle within the collection. A 0.018-inch guidewire was then inserted into the abscess collection. The needle was removed, and the track was dilated. A 5-French catheter was placed directly over the 0.018-inch guidewire, or the guidewire was upsized to a 0.035-inch guidewire, and a 6-French catheter was placed. The pigtail was formed within the abscess and its position confirmed with contrast administration, usually in more than one plane (Figs. 1B and 1C). The choice of needle size and catheter caliber was at the discretion of the interventional radiologist and was tailored to the location and nature of the abscess and neonates' body size. Catheters were irrigated with a small volume of saline to maintain patency (approximately 2–3 mL once or twice a day) until clinical and sonographic improvement was seen. Catheter removal with track embolization using a gelatin sponge torpedo was performed in one case. In the remaining cases, the drain was removed without track embolization.

Clinical and radiologic characteristics, complic ations, and long-term follow-up results were assessed. Complete clinical remission was defined as those neonates who were symptom free with a stable residual lesion or no focal liver lesions detected on serial sonographic follow-up. Successful percutaneous aspiration or drainage was defined as those neonates who were symptom free without the need for a drainage procedure or surgery within 1 month and with no major procedure-related complication.

Results

Top Abstract Introduction Materials and Methods Results Discussion References

 
Table 1 shows patient characteristics, predisposing factors, and outcomes of the eight cases of neonatal liver abscesses. Six neonates were premature with gestational ages between 24 and 29 weeks. All neonates received long-term (> 3 weeks) IV antibiotics before and after percutaneous aspiration or drainage; the antibiotics were modified according to antibiotic sensitivities of the pus aspirates (n = 7). The duration of antibiotic treatment was 3 weeks–6 months (mean, 11 weeks).

All neonates were clinically ill at admission; the predominant features were sepsis (n = 8), abnormal liver function test (n = 5), abdominal distention (n = 5), and hepatomegaly (n = 4). The duration of symptoms varied from 2 to 16 days (mean, 7.6 days) before referral for drainage. Six of the eight neonates had a history of umbilical catheterization (catheter-indwell time range, 5–16 days; mean, 10.3 days). Five neonates had typical solitary multiloculated abscesses (three in the right lobe and two straddling both lobes), and three had solitary uniloculated abscesses (one in the right lobe and two in the left lobe). There were irregular internal septa with debris within all of the five multiloculated abscesses. There was a mixed echogenic center with a well-defined hypoechoic rim in two cases of uniloculated abscess and one case revealed a poorly defined margin.

Imaging-guided percutaneous aspiration or drainage was successfully performed promptly within 1 day of referral after consultation with the referring neonatologist in seven neonates. Seven of the eight neonates were already intubated and ventilated, so their sedation or anesthesia was managed by the neonatal transport team. Radiologic features and results of percutaneous aspiration or drainage are shown in Table 2. In one neonate (case 7), a decision was made to treat with antibiotics alone without percutaneous aspiration or drainage because of high-risk comorbidities (extreme-low-birth weight, sepsis, and coagulopathy) and because the neonate was initially improving clinically on anti biotics. Two aspiration procedures were performed at the bedside in the NICU with use of sonographic guidance alone because the neonates (cases 3 and 8) were too unstable to be transported to IGT. The remaining procedures (six procedures in five neonates) were performed in the IGT department.

One neonate (case 6) had hepatomegaly with a solitary well-circumscribed avascular solid liver mass with a mixed echogenic center, the appearance of which remained unchanged over a period of 2 months. Initially, it was thought to be a benign nodule rather than a solitary abscess. Despite an initially stable course, the baby became septicemic (Staphylococcus aureus) and failed to respond to antibiotics alone. Aspiration of the mass at that stage confirmed an abscess. One neonate (case 8) with an umbilical venous catheter for 10 days (Figs. 2A and 2B) had a rupture of a bilobed intrahepatic collection into the peritoneum, with free communication of fluid between the liver collection and the adjacent peritoneal collection (Figs. 2C and 2D). In the NICU, he underwent emergency drainage of the peritoneal collection, which concomitantly decompressed the liver cavity because of the wide communication with the peritoneum. The peritoneal fluid resembled total parenteral nutrition. The baby improved clinically after treatment with percutaneous drainage and antibiotics. The residual hepatic cavity became walled off and isolated, and it gradually resorbed and calcified over time. Further percutaneous aspiration or drainage of the liver lesion was not performed because the baby was then clinically stable.

View larger version (119K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2A —11-day-old male neonate with probable (culture-negative) liver abscess or hepatic parenchymal injury secondary to umbilical venous catheter infusate. Initial supine abdominal radiograph shows umbilical venous catheter tip (arrow) projected over liver.

View larger version (126K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2B —11-day-old male neonate with probable (culture-negative) liver abscess or hepatic parenchymal injury secondary to umbilical venous catheter infusate. Left lateral decubitus abdominal radiograph shows isolated mottled air shadow (arrows) in region of liver.

View larger version (155K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2C —11-day-old male neonate with probable (culture-negative) liver abscess or hepatic parenchymal injury secondary to umbilical venous catheter infusate. Sonograms show multicystic septated intrahepatic fluid (arrows, C) suggesting liver abscess and hepatic parenchymal injury and necrosis with or without infection and perihepatic multiseptated fluid (arrow, D) suggesting rupture of hepatic abscess or infected total parenteral nutrition into peritoneum.

View larger version (141K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2D —11-day-old male neonate with probable (culture-negative) liver abscess or hepatic parenchymal injury secondary to umbilical venous catheter infusate. Sonograms show multicystic septated intrahepatic fluid (arrows, C) suggesting liver abscess and hepatic parenchymal injury and necrosis with or without infection and perihepatic multiseptated fluid (arrow, D) suggesting rupture of hepatic abscess or infected total parenteral nutrition into peritoneum.

Serial sonography (range, 3 weeks–33 months; mean, 12.5 months) and clinical follow-up (range, 2 months–9 years; mean, 20.7 months) showed complete clinical remission in seven cases, all of whom were discharged well. Three cases developed chronic partially calcified foci in the previous abscess site without interval change (Figs. 3A and 3B). Long-standing left portal vein thrombosis was seen in two cases (Figs. 4A, 4B, 4C). The autopsy-proven case (case 7) with known Staphylococcus capitis sepsis and an echogenic hepatic mass was treated with antibiotics only for 3 weeks. After stopping antibiotics for 2 days, the baby's condition deteriorated acutely, and despite restarting antibiotics, the baby died. Postmortem study showed a 2 x 3 cm abscess growing coagulase-negative Staphylococcus with nodules on the surface of the right pleura growing the same organism.

View larger version (152K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3A —12-day-old male neonate with solitary multiloculated abscess. Coagulase-negative Staphylococcus and Enterobacter cloacae were sources. Initial sonogram shows large, septated hypoechoic lesion.

View larger version (131K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3B —12-day-old male neonate with solitary multiloculated abscess. Coagulase-negative Staphylococcus and Enterobacter cloacae were sources. Follow-up sonogram shows foci of dystrophic calcifications (arrow) at previous abscess site.

View larger version (147K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4A —17-day-old female neonate with history of umbilical venous catheter. (Coagulase-negative Staphylococcus and gram-positive cocci were sources.) Sonogram shows well-defined mixed echogenic lesion (arrow).

View larger version (127K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4B —17-day-old female neonate with history of umbilical venous catheter. (Coagulase-negative Staphylococcus and gram-positive cocci were sources.) Late follow-up sonograms show thrombi that are calcified in umbilical vein extending to left portal vein (arrows).

View larger version (127K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4C —17-day-old female neonate with history of umbilical venous catheter. (Coagulase-negative Staphylococcus and gram-positive cocci were sources.) Late follow-up sonograms show thrombi that are calcified in umbilical vein extending to left portal vein (arrows).

Top Abstract Introduction Materials and Methods Results Discussion References

The cause of neonatal liver abscesses differs significantly from those in the older child or adult. Systemic sepsis and direct contiguous infection are frequent risk factors. Many reports have determined that umbilical catheterization, long-term parenteral nutrition, prematurity, and necrotizing enterocolitis that requires the patient to have surgery are also risk factors [1, 3]. Furthermore, the premature infant with low birth weight has a greater risk of liver abscess because of the decreased adherence and chemotaxis of the neutrophils [22].

The causative agent of neonatal pyogenic liver abscess is variable. Although S. aureus and gram-negative enteric bacteria are the most common pathogens isolated from a neonatal liver abscess, any organism can potentially cause an abscess [1, 15]. Even though amebiasis is endemic in tropical areas with poor sanitation, amebic liver abscess in neonates is extremely uncommon. Some developed countries have experienced amebic abscesses due to immigration [23, 24].

In our series, all cases were clinically septic and had at least one or more well-known risk factors as described. Two cases were associated with abdominal bowel resection related to necrotizing enterocolitis and five with umbilical venous catheter insertion and one failed umbilical venous catheter attempt. This suggests an association between liver abscess and catheter infections, either by direct effect (from the umbilical catheter or the infusate) or hematogenously (bloodstream infections being the most common nosocomial infection in the NICU) [13, 20, 22, 25]. This association is supported in that the most common organism cultured was coagulase-negative Staphylococcus epidermidis.

The majority of neonatal liver abscesses are small and multiple and are managed conservatively using only long-term antibiotics because multiple tiny foci are not suitable for surgical drainage or imaging-guided percutaneous aspiration or drainage. Solitary types, which comprise 30% of reported neonatal liver abscesses [1], can be effectively managed by percutaneous aspiration or drainage. Unfortunately, we do not know the definite incidence of diffuse or multifocal microabscesses in our institution. Whether pyogenic liver abscesses are solitary or multiple, antibiotic treatment is crucial, even with drainage of the abscess [17, 26].

Imaging-guided percutaneous aspiration or drainage using sonographic guidance was first reported in 1974 in adults and now has been applied in children [6–12]. Tan et al. [22] reported a series of six cases, three of whom were solitary abscesses that were treated by open drainage in two and antibiotics alone in one with good results. The remaining three cases of multiple microabscesses, on the other hand, were medically managed. The authors recommended a treatment approach to neonatal pyogenic liver abscesses in premature infants on the basis of experience available from the literature and their own series.

In our series of eight neonates, seven treated with percutaneous aspiration or drainage and long-term antibiotics (six of the liver collection and one of the peritoneal fluid adjacent to a ruptured liver collection) had good results. We had one autopsy-proven case. This patient did not undergo percutaneous aspiration or drainage because it was thought at the time (by both the clinician and the interventional radiologist) that the risks of the procedure in this severely premature coagulopathic baby outweighed the benefits. In another case, despite an initially stable course, the baby became unwell with S. aureus sepsis, despite antibiotics, and it was decided late in the treatment course to aspirate the mass to rule out an abscess. Although our numbers are small, experience with these latter two cases and the high mortality reported in the literature in the era before percutaneous aspiration or drainage caused us to believe that percutaneous aspiration or drainage should be seriously considered in solitary liver abscesses whenever possible, even in high-risk patients because antibiotic treatment alone may be insufficient and unsuccessful.

As is the case with abscess drainage in the pediatric population in general, the procedure can almost always be accomplished safely with adequate sedation and local anesthesia. In our case series, six neonates had percutaneous aspiration or drainage performed under deep sedation and one under general anesthesia. The authors recommend that good communication and collaboration between the interventional radiologist, the neonatologist, and the transport team is important to achieve safe percutaneous aspiration or drainage procedures and good long-term effect.

The clinical presentation of case 8 shares similar features with cases of umbilical venous catheter complications reported by Coley et al. [27]. All eight of their patients had hypotension and abdominal distention, as in our case. They commented that the most important factor of umbilical venous catheter–related hepatic parenchymal injury was improper positioning of the umbilical venous catheter. Hypertonicity of the infused fluid and a long duration of catheter placement were also significant contributing factors. Radiologists should be familiar with these clinical and radiologic findings to prevent fatal hemodynamic or infective sequelae after umbilical venous catheter insertion misplacement.

In both adult and pediatric populations, treatment for liver abscess remains controversial. Therapeutic options include antibiotic treatment only, antibiotic with aspiration with or without drainage, and open surgical drainage with or without percutaneous aspiration or drainage. Giorgio et al. [28] achieved good results with aspiration along with antibiotics without catheter drainage. In our study, we used aspiration only in two cases and catheter insertion only in four cases. The approach was tailored to the individual patient and was based on the size of the abscess and presence of liquefaction and septation, along with accessibility and clinical conditions. A similar study in adults by Ch Yu et al. [29] reported good results with repeated aspiration along with antibiotics; they reported two deaths from 64 cases because of uncontrolled sepsis. Irrespective of whether aspiration or drainage is used, it is important that evacuation of the purulent material from the abscess cavity be combined with appropriate sepsis control with long-term antibiotics guided by microbiologic findings.

There are several limitations of this study. Because of the small numbers of patients, it is not possible to standardize treatment methods or to perform any statistical analysis. The small number of subjects in this series is due to the rarity of this disease. However, this case series is one of the largest described to date. Although abscesses were followed at a minimum weekly using sonography, another limitation of our study is that there was not a standardized follow-up plan because of the retrospective nature of the review.

In conclusion, neonatal liver abscesses are associated with good long-term results and minimal complications if prompt imaging-guided aspiration and drainage is performed with long-term antibiotic coverage. In addition, a collaborative and multidisciplinary team approach with a neonatologist and an anesthesiologist is recommended to provide optimum management of these extremely small babies.

References

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This Article Abstract Figures Only Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Lee, S. H. Articles by Connolly, B. L. Search for Related Content PubMed PubMed Citation Articles by Lee, S. H. Articles by Connolly, B. L. Social Bookmarking                      What's this? Hotlight (NEW!) What's Hotlight?