今日の臨床サポート

肝膿瘍

著者: 中村造 東京医科大学病院 感染制御部 感染症科

監修: 上原由紀 聖路加国際病院 臨床検査科/感染症科

著者校正/監修レビュー済:2020/10/01
患者向け説明資料

概要・推奨   

  1. 細菌性肝膿瘍では発熱が多くみられるが、非特異的な症状が不明熱と診断されていることも多い。また血液検査でもWBC上昇、肝機能障害などがみられることが多い。非特異的所見にとどまるが、治療の一助となるため、血液検査を行うことが推奨される(推奨度2)。
  1. 肝膿瘍の治療において、起因菌同定は重要である。血液培養と並行して膿瘍穿刺液の細菌検査を行うことにより検出感度を上昇させることができるため、細菌学的検査を行うことは強く推奨される(推奨度2)。
  1. 重症化していない(左葉でない、多発していない、細菌性と合併しない)アメーバ性肝膿瘍は内科的治療のみで治療が可能と考えられており、ドレナージはおそらく推奨されない(推奨度3)。
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  1. 最も検出頻度の高いKlebsiella pnemumoniaeによる肝膿瘍に対して、起因菌判明後に嫌気性菌用抗菌薬を使用する必要は低い可能性がある(推奨度3)。
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
中村造 : 特に申告事項無し[2021年]
監修:上原由紀 : 特に申告事項無し[2021年]

改訂のポイント:
  1. 定期レビューを行った(変更なし)。

病態、疫学、診察

疾患情報  
ポイント:
  1. 肝膿瘍は、大きく細菌性とアメーバ性の2種類に分けられる。発熱、倦怠感、食欲不振、吐気・嘔吐、体重減少など非特異的症状が2週~1カ月ほど持続し、発熱のフォーカスがはっきりしていない、いわゆる不明熱の形で発症することが多い。
  1. 不明熱と認識した場合は、肝膿瘍を鑑別診断に含め、腹部エコー、腹部造影CTで膿瘍を確認し、診断に至る。
  1. Klebsiella pnemumoniaeによる肝膿瘍では、台湾を中心に大腸癌との関連性を指摘する報告もある。
  1. アメーバ性では、男性同性間性的接触、肛門性交がリスクとなる。
  1. 赤痢アメーバによる感染の場合は感染症法5類感染症であり、7日以内に届出をする必要がある。
 
疫学:
  1. 肝腫瘍は10万入院患者当たり10~20人程度とされる。
 
起因菌:
  1. ポイント:
  1. 起因菌は基礎疾患によりさまざまである。
  1. 単独感染の場合と混合感染の場合があり、起因菌は以下のように細菌性、真菌性、原虫性に分類される。
 
肝膿瘍の起因菌

Identity of organisms recovered from patients with pyogenic liver abscesses.

出典

img1:  Pyogenic liver abscess: recent trends in etiology and mortality.
 
 Clin Infect Dis. 2004 Dec 1;39(11):1654-・・・
 
肝膿瘍の起因菌数

Number of bacterial isolates recovered per case in patients with pyogenic liver abscesses.

出典

img1:  Pyogenic liver abscess: recent trends in etiology and mortality.
 
 Clin Infect Dis. 2004 Dec 1;39(11):1654-・・・
 
  1. 細菌:
  1. 混合感染の場合はE.coliなどの腸内細菌科とBacteroides属などの嫌気性菌が起因菌となる。
  1. 単独感染の場合はKlebsiella属または、緑色連鎖球菌が起因菌となる。
  1. 近年、台湾を中心に市中感染の起因菌として病原性が強いK.pneumoniaeの症例が増加しており注目されている。髄膜炎や眼内炎など播種性病変を認めることがある。
  1. 原虫:
  1. Entamoeba histolyticaが病原微生物となる。
  1. 真菌:
  1. Candida spp.が起因菌となる。真菌性では、胆管病変や腹膜病変に関連しているというよりも血行性播種が原因であることがほとんどであり、カンジダによる中心静脈留置カテーテル関連血流感染症などの転移病巣として発症する。
問診・診察のポイント  
  1. 発熱、倦怠感、食欲不振、吐気・嘔吐、体重減少など非特異的症状が2週~1カ月ほど持続していることを確認する。

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文献 

著者: Joseph Rahimian, Tina Wilson, Valerie Oram, Robert S Holzman
雑誌名: Clin Infect Dis. 2004 Dec 1;39(11):1654-9. doi: 10.1086/425616. Epub 2004 Nov 9.
Abstract/Text BACKGROUND: Pyogenic liver abscess, a potentially life-threatening disease, has undergone significant changes in epidemiology, management, and mortality over the past several decades.
METHODS: We reviewed the data for patients admitted to Bellevue Hospital and New York University Downtown Hospital (New York, New York) over a 10-year period.
RESULTS: Of 79 cases reviewed, 43% occurred in patients with underlying biliary disease. The most common symptoms were fever, chills, and right upper quadrant pain or tenderness. The most common laboratory abnormalities were an elevated white blood cell count (in 68% of cases), temperature >or=38.1 degrees C (90%), a low albumin level (70.2%), and an elevated alkaline phosphatase level (67%). Seventy percent of the abscesses were in the right lobe, and 77% were solitary. Klebsiella pneumoniae was identified in 41% of cases in which a pathogen was recovered. Eighteen (50%) of 36 Asian patients had K. pneumoniae isolated, in contrast to 6 (27.3%) of 22 non-Asian patients (not statistically significant). Fifty-six percent of cases involved treatment with percutaneous drainage. Although prior reports noted mortality of 11%-31%, we observed only 2 deaths (mortality, 2.5%).
CONCLUSIONS: The data suggest that K. pneumoniae has become the predominant etiology of pyogenic liver abscess and that mortality from this disease has decreased substantially.

PMID 15578367  Clin Infect Dis. 2004 Dec 1;39(11):1654-9. doi: 10.1086・・・
著者: Roy F Chemaly, Gerri S Hall, Thomas F Keys, Gary W Procop
雑誌名: Diagn Microbiol Infect Dis. 2003 Aug;46(4):245-8.
Abstract/Text Although rare, pyogenic liver abscesses are potentially fatal. We evaluated the predictive value of Gram stain of liver abscess aspirates and temporally associated blood cultures. Gram stains detected bacteria in 79% of the liver abscesses tested. The sensitivity and specificity of Gram stain of the liver abscesses were 90% and 100% for Gram-positive cocci (GPC) and 52% and 94% for Gram-negative bacilli (GNB). The sensitivities of the blood cultures for any GPC and GNB present in the liver abscess were 30% and 39%, respectively. Although, Gram stains and blood cultures offer incomplete detection of the microbial contents of pyogenic liver abscesses, both tests should always accompany liver abscess cultures.

PMID 12944014  Diagn Microbiol Infect Dis. 2003 Aug;46(4):245-8.
著者: Hyun Ah Kim, Doo Ryeon Chung, Joon-Sup Yeom, Hyun Kyun Ki, Hae Suk Cheong, Jun Seong Son, Jin Seo Lee, Soo-Youn Moon, Seung Soon Lee, Jeong-A Lee, Kyung-Hwa Park, Seung-Ji Kang, Sook-In Jung, Shin-Woo Kim, Hyun Ha Chang, Seong Yeol Ryu, Ki Tae Kwon, Chisook Moon, Yu Mi Wi, Sang Taek Heo, Mi Kyong Joung, Cheol-In Kang, Kyong Ran Peck, Jae-Hoon Song
雑誌名: Diagn Microbiol Infect Dis. 2015 Jan;81(1):60-5. doi: 10.1016/j.diagmicrobio.2014.10.002. Epub 2014 Oct 13.
Abstract/Text Although most Klebsiella pneumoniae liver abscesses have been reported to be monomicrobial, clinical outcomes have not been compared between antimicrobial therapy with and without anti-anaerobic coverage. A propensity score-matched cohort study was conducted using the 731 cases of K. pneumoniae liver abscess. Clinical outcomes were compared between a group discontinuing anti-anaerobic agents after K. pneumoniae identification and a group continuing. A total of 170 cases were matched at a 1:1 ratio using their propensity to discontinue anti-anaerobic agents. The McNemar's test showed no difference in mortality rates (1.8% for discontinuation versus 2.3% for continuation; P = 1.00) or relapse (1.8% versus 2.9%; P = 0.73) between groups. Early discontinuation of anti-anaerobic agents had no association with treatment failure by means of the generalized estimating equation model (odds ratio 0.48; P = 0.14) and the Kaplan-Meier method (P = 0.85) in matched groups. Early discontinuation of anti-anaerobic agents does not affect the clinical outcomes of patients with K. pneumoniae liver abscess.

Copyright © 2015 Elsevier Inc. All rights reserved.
PMID 25459498  Diagn Microbiol Infect Dis. 2015 Jan;81(1):60-5. doi: 1・・・
著者: Jayant Kumar Ghosh, Sundeep Kumar Goyal, Manas Kumar Behera, Manish Kumar Tripathi, Vinod Kumar Dixit, Ashok Kumar Jain, Ramchandra Shukla
雑誌名: Trop Gastroenterol. 2015 Oct-Dec;36(4):251-5.
Abstract/Text BACKGROUND: Amebic liver abscess (ALA) is a common and serious problem in our country. There are only a few controlled trials on the efficacy and advantages of combination therapy with percutaneous needle aspiration and pharmacotherapy, over pharmacotherapy alone for amebic liver abscess.
MATERIAL AND METHODS: This study was conducted to compare the efficacy of two different treatment modalities i.e. drug treatment alone vs. drug treatment and aspiration of abscess cavity in patients with small (up to 5 cm) and large (5 cm to 10 cm) size ALA. This is one of the largest single center, prospective, randomized studies comparing the efficacy of aspiration in ALA.
RESULTS: (i) Mean body temperature, liver tenderness, total leukocyte count (TLC), serum alanine aminotransferase (ALT) and liver span were significantly decreased in the aspiration group on days 8 and 15 as compared to non-aspiration group especially in large abscess (5 cm to 10 cm). (ii) Abscess cavity maximum diameter decreased significantly in aspiration group on days 8 and 15, and 1 month & 3 months in large abscess (5cm to 10 cm).
CONCLUSIONS: (i) Needle aspiration along with metronidazole hastens clinical improvement especially in large (5 cm up to 10 cm) cavities in patients with ALA. (ii) Aspiration is safe and no major complications occurred. (iii) Hence, combination therapy should be the first choice especially in large ALA (5 cm to 10 cm).

PMID 27509703  Trop Gastroenterol. 2015 Oct-Dec;36(4):251-5.
著者: C L Rajak, S Gupta, S Jain, Y Chawla, M Gulati, S Suri
雑誌名: AJR Am J Roentgenol. 1998 Apr;170(4):1035-9. doi: 10.2214/ajr.170.4.9530055.
Abstract/Text OBJECTIVE: This study was designed to determine and compare the efficacy of sonographically guided percutaneous needle aspiration and percutaneous catheter drainage in the treatment of liver abscesses.
SUBJECTS AND METHODS: In a randomized study, 50 patients (38 males and 12 females; age range, 2-72 years; average age, 35 years) with liver abscesses (amebic, 20; pyogenic, 11; indeterminate, 19) underwent either percutaneous needle aspiration (n = 25) or catheter drainage (n = 25) along with appropriate antimicrobial therapy. In patients assigned to the needle aspiration group, an 18-gauge needle was used to aspirate the abscess cavity. Repeated aspiration was attempted only once in each patient not responding to the first aspiration; nonresponse to the second aspiration was considered failure of treatment, and these patients were given catheter drainage (however, these patients were not included in the catheter drainage group). For catheter drainage, 8- to 12-French catheters were introduced into the abscess cavity using the Seldinger technique. In patients with multiple abscesses (seven in aspiration group and five in catheter group), all the abscesses except those smaller than 3 cm were subjected to percutaneous treatment. Patients were followed up to assess the outcome of the percutaneous treatment, length of hospital stay, and development of any complications. Sonography was performed every third day during hospitalization. After discharge of the patient, periodic clinical and sonographic examinations were done until total resolution of abscesses was achieved.
RESULTS: Although percutaneous needle aspiration was successful in only 15 (60%) of the 25 patients after one (n = 11) or two (n = 4) aspirations, catheter drainage was curative in all 25 patients (100%) (p < .05). Among the successfully treated patients, the average time for clinical improvement and the mean hospital stay were similar in the two treatment groups. Although the average time needed for a 50% reduction in the size of the abscess cavity was significantly (p < .05) greater in the aspiration group than in the catheter group (11 days versus 5 days), the average time taken for total resolution of abscess was the same (15 weeks) in both groups. No major complications were encountered. No relapse was documented on clinical and sonographic examination during follow-up, which ranged from 8 to 37 weeks.
CONCLUSION: Our results show that percutaneous catheter drainage is more effective than needle aspiration in the treatment of liver abscesses. Needle aspiration, if limited to two attempts, has a high failure rate.

PMID 9530055  AJR Am J Roentgenol. 1998 Apr;170(4):1035-9. doi: 10.22・・・
著者: Simon C H Yu, Simon S M Ho, Wan Y Lau, Deacons T K Yeung, Edmund H Y Yuen, Paul S F Lee, Constantine Metreweli
雑誌名: Hepatology. 2004 Apr;39(4):932-8. doi: 10.1002/hep.20133.
Abstract/Text This study aims to compare the therapeutic effectiveness of continuous catheter drainage versus intermittent needle aspiration in the percutaneous treatment of pyogenic liver abscesses. Over a 5-year period, 64 consecutive patients with pyogenic liver abscess were treated with intravenous antibiotics (ampicillin, cefuroxime, and metronidazole) and randomized into two percutaneous treatment groups: continuous catheter drainage (with an 8F multi-sidehole pigtail catheter); and intermittent needle aspiration (18G disposable trocar needle). There was no statistically significant difference between the two groups regarding patient demographics, underlying coexisting disease, abscess size, abscess number, number of loculation of abscess, the presenting clinical symptoms such as fever, abdominal pain, and pretreatment liver function test. Although not statistically significant, the duration of intravenous antibiotics treatment before percutaneous treatment was longer with the catheter group, and the change of antibiotics after the sensitivity test was more frequent with the needle group. The needle group was associated with a higher treatment success rate, a shorter duration of hospital stay, and a lower mortality rate, although this did not reach statistical significance. In conclusion, this study suggests that intermittent needle aspiration is probably as effective as continuous catheter drainage for the treatment of pyogenic liver abscess, although further proof with a large-scale study is necessary. Due to the additional advantages of procedure simplicity, patient comfort, and reduced price, needle aspiration deserves to be considered as a first-line drainage approach.

PMID 15057896  Hepatology. 2004 Apr;39(4):932-8. doi: 10.1002/hep.2013・・・
著者: Norberto C Chavez-Tapia, Jorge Hernandez-Calleros, Felix I Tellez-Avila, Aldo Torre, Misael Uribe
雑誌名: Cochrane Database Syst Rev. 2009 Jan 21;(1):CD004886. doi: 10.1002/14651858.CD004886.pub2. Epub 2009 Jan 21.
Abstract/Text BACKGROUND: Metronidazole is the standard of care for uncomplicated amoebic liver abscesses (considering that complicated liver abscesses are those localized in left lobe, multiple, and/or pyogenic abscesses). However, a subset of patients with amoebic liver abscesses remain symptomatic, with a significant risk of rupture of the abscess into the peritoneum. The role of image-guided percutaneous therapeutic aspiration in these patients remains controversial.
OBJECTIVES: To assess the beneficial and harmful effects of image-guided percutaneous procedure plus metronidazole versus metronidazole alone in patients with uncomplicated amoebic liver abscess.
SEARCH STRATEGY: We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials in The Cochrane Library (Issue 2, 2007), MEDLINE (1966 to November 2007), EMBASE (1988 to September 2007), and Science Citation Index Expanded (1945 to September 2007).
SELECTION CRITERIA: Randomised or quasi-randomised trials comparing an image-guided percutaneous procedure plus metronidazole versus metronidazole alone in patients with uncomplicated amoebic liver abscess.
DATA COLLECTION AND ANALYSIS: Inclusion criteria, trial quality assessment, and data extraction were done in duplicate. We calculated relative risks (RR) and mean differences, and checked for heterogeneity by visual inspection of forest plots and chi-squared and I(2) tests.
MAIN RESULTS: Seven low quality randomised trials were included. All studies included a total of 310 patients, but due to selective outcome reporting bias, less patients could be included in our analyses. Pooled analysis of three homogenous trials showed that needle aspiration did not significantly increase the proportion of patients with fever resolution (RR 0.60, 95% confidence interval (CI) 0.22 to 1.61). Sensitivity analysis according to trial quality preserved these findings. Trials that evaluated resolution of abdominal pain, days to resolution of fever, pain, resolution of abscess cavities, reduction in liver size, and duration of hospitalisation were heterogeneous. The benefits in the number of days to resolution of pain (MD -1.59, 95%CI -2.73 to -0.42), number of days to resolution of abdominal tenderness (MD -1.70, 95%CI -2.86 to -0.54), and duration of hospitalisation (MD -1.31, 95%CI -2.05 to -0.57) were observed in the needle aspiration group only.
AUTHORS' CONCLUSIONS: Therapeutic aspiration in addition to metronidazole to hasten clinical or radiologic resolution of uncomplicated amoebic liver abscesses cannot be supported or refuted by the present evidence. The trials lack methodological rigour and adequate sample size to conclude on the presence of effectiveness of adjunctive image-guided aspiration plus metronidazole versus metronidazole alone. Further randomised trials are necessary.

PMID 19160244  Cochrane Database Syst Rev. 2009 Jan 21;(1):CD004886. d・・・

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