Management of pyogenic liver abscesses - percutaneous or open drainage?

This pictorial essay aims to review the literature on the management of pyogenic liver abscess, focusing on the choice of drainage. Articles on the treatment of pyogenic liver abscess, accessed through a MEDLINE search using PubMed, were reviewed. A case series of the authors' experience with clinicopathological correlation is presented to highlight the indication and outcome of each modality of drainage. Intravenous antibiotic is the first line, and mainstay, of treatment. Drainage is necessary for large abscesses, equal to or larger than 5 cm in size, to facilitate resolution. While percutaneous drainage is appropriate as first-line surgical treatment in most cases, open surgical drainage is prudent in cases of rupture, multiloculation, associated biliary or intra-abdominal pathology. Percutaneous drainage may help to optimise clinical condition prior to surgery. Laparoscopic drainage is a feasible surgical option with promising results in the future. Liver resection is reserved for concomitant localised intrahepatic disease and tumour, after control of sepsis. The final verdict on the outcome of percutaneous versus open surgical drainage of pyogenic liver abscesses requires further studies in a controlled trial setting. Nevertheless, in current good clinical practices, the choice of therapy needs to be individualised according to patient's clinical status and abscess factors. They are complementary in the management of liver abscesses.