Imaging-based Stratification and Management of Pediatric Liver Abscess with Rupture: Experience from a Tertiary Care Center

ABSTRACT

Background:

Liver abscess in the pediatric age group is an uncommon but serious condition. Extension or rupture of a liver abscess may result in intrathoracic or intra-abdominal contamination and has traditionally been considered an indication for surgical intervention. With advances in imaging, antibiotics, and minimally invasive techniques, management strategies have evolved toward selective nonoperative approaches.

Aim:

This study aims to evaluate clinical presentation, radiological patterns, management strategies, and outcomes of pediatric liver abscess with true rupture, using imaging-based anatomical stratification.

Materials and Methods:

This prospective observational study was conducted between August 2022 and August 2024 at a tertiary care pediatric surgery unit. Children with radiologically confirmed liver abscesses demonstrating either contained extension or true rupture were included. Contrast-enhanced computed tomography was used to classify patients based on capsular integrity and extent of spillage. Management strategies included antibiotics, selective image-guided drainage, and surgery for strict indications. Nutritional status and serum albumin levels were assessed at admission and during follow-up.

Results:

A total of 94 children out of 349 patients with liver abscess extension or rupture were included. Contained subcapsular extension beneath an intact liver capsule constituted 52% of cases and was successfully managed with intravenous antibiotics alone. True rupture, defined by capsular breach with free spillage, accounted for the remaining cases, including thoracic rupture (18%), subdiaphragmatic rupture (16%), and free intraperitoneal rupture (14%). Minimally invasive drainage was required selectively. An exploratory laparotomy was performed in 2 children (2.1%) who developed generalized peritonitis. No mortality was observed.

Conclusion:

Contained subcapsular extension of pediatric liver abscess can be safely managed conservatively. Rupture requires careful imaging-based stratification, selective minimally invasive drainage, and timely surgical intervention when indicated. Surgery remains essential in children with generalized peritonitis or failed nonoperative management.

INTRODUCTION

Liver abscess in children is an uncommon condition caused by pyogenic, amebic, or, less frequently, fungal infections.[1,2,3] While most uncomplicated abscesses respond well to antibiotics with or without drainage, extension or rupture of the abscess represents a potentially serious complication.[2,4] Clinical presentation is often nonspecific, and differentiation from other acute abdominal or thoracic conditions may be challenging.[1,3]

With the widespread availability of ultrasonography and contrast-enhanced computed tomography (CECT), accurate delineation of abscess anatomy has become possible.[2,5] Importantly, a distinction must be made between contained subcapsular extension beneath an intact liver capsule and true rupture, which implies capsular breach with free spillage into the peritoneal or pleural cavity.[2,6]

This study evaluates pediatric liver abscesses with contained minor leaks and true rupture and analyzes management outcomes using an anatomy-driven approach.

MATERIALS AND METHODS

This prospective observational study was conducted in the Department of Pediatric Surgery at ABVIMS and Dr. Ram Manohar Lohia Hospital, New Delhi, between August 2022 and August 2024, after institutional ethics committee approval. Children younger than 12 years with radiologically confirmed liver abscesses demonstrating either contained subcapsular extension or true rupture were included. Radiological evaluation was performed using ultrasonography followed by CECT for detailed characterization. Contained subcapsular extension was defined as abscess extension beneath an intact hepatic capsule without extracapsular spillage, whereas true rupture was defined as capsular breach with extension of abscess contents into the peritoneal, subdiaphragmatic, or pleural cavity. Clinical presentation, laboratory parameters, abscess size, imaging findings, management strategies, and outcomes were recorded. Surgical intervention was reserved for generalized peritonitis or failure of nonoperative management. Data were analyzed using descriptive statistics.

RESULTS

The mean age of the cohort was 6.9 years, with the majority of children between 6 and 10 years. There was a slight male predominance (57.4%). Fever and abdominal pain were the most common presenting symptoms, whereas vomiting (39%) and respiratory distress (15.9%) were less frequent. Right upper quadrant tenderness was the most frequent clinical sign.

Liver abscesses were categorized as >6 cm (mean volume 319.9 cc) and <6 cm (mean volume 154.1 cc). Among ruptured abscesses, the patterns included subcapsular extension with minor leak (52%), thoracic rupture (18%), subdiaphragmatic rupture (16%), and free intraperitoneal rupture (14%) [Table 1].

Table 1.

Pattern of extension and rupture

Category	n	Management
Contained subcapsular extension with minor leak (%)	52	Antibiotics
Thoracic rupture (%)	18	ICD/conservative
Subdiaphragmatic rupture (%)	16	Aspiration
Free intraperitoneal rupture (%)	14	Conservative/surgery

ICD: Intercostal drainage

Baseline investigations included complete blood count, liver function tests, inflammatory markers, and serum albumin. Hypoalbuminemia was defined as serum albumin <3.5 g/dL, with clinically significant hypoalbuminemia defined as 2.5–3 mg/dL and severe hypoalbuminemia <2.5 mg/dL.

All patients received empirical intravenous antibiotics consisting of a third-generation cephalosporin with metronidazole. In cases of severe sepsis or inadequate response, antibiotics were escalated to piperacillin–tazobactam or carbapenems. The mean duration of intravenous antibiotics was 7 ± 4 days, followed by oral antibiotics for 14 ± 7 days.

Drainage of the primary abscess cavity was not based on size alone. Image-guided aspiration or intercostal drainage (ICD) was performed in patients with persistent sepsis, large symptomatic collections, or thoracic involvement, while clinically stable children with contained disease were managed conservatively.

Intravenous human albumin (20%) was administered at 1 g/kg/day for 3–5 days in children with serum albumin ≤2.5 g/dL, particularly in the presence of edema or third-space fluid collections. Serum albumin was reassessed after infusion.

Imaging demonstrated a size-dependent clinical gradient. Abscesses <5 cm predominantly manifested as contained subcapsular extension and were managed with needle aspiration. Lesions 5–6 cm often required repeated aspirations, while abscesses >6 cm showed increasing rates of subdiaphragmatic and intraperitoneal rupture with escalation to catheter drainage and thoracic procedures.

A progressive decline in serum albumin was observed with increasing abscess diameter (2.8 ± 0.2 g/dL in <5 cm vs. 2.2 ± 0.2 g/dL in > 8 cm), demonstrating a significant negative trend (analysis of variance P = 0.002) [Table 2]. Hypoalbuminemia was present in 97.8% (n = 92) of patients. Although malnutrition overlapped with hypoalbuminemia, the two did not completely coincide.

Table 2.

Increasing abscess size correlates with hypoalbuminemia and escalation of intervention (n=94)

Abscess size (cm)	n (%)	Serum albumin (g/dL), mean±SD	Clinical profile and intervention pattern
<5	22 (23.8)	2.8±0.2	Predominantly subcapsular extension; managed with needle aspiration
5.1–6	46 (48.6)	2.6±0.4	Subcapsular extension common; the majority required repeated aspiration; few pigtail insertions
6.1–7	17 (18.1)	2.4±0.2	Increasing subdiaphragmatic rupture; shift toward pigtail drainage
7.1–8	8 (8.6)	2.4±0.4	Intraperitoneal/thoracic rupture more frequent; pigtail±ICD
>8	1 (1.0)	2.2±0.2	Advanced disease; invasive intervention, including laparotomy

Trend analysis: Serum albumin declined significantly with increasing abscess size (ANOVA P=0.002) ↓. SD: Standard deviation, ICD: Intercostal drainage

Fluid culture was obtained in 25 patients (8 ICD, 15 aspirations, and 2 laparotomies). Culture positivity was 84% (n = 21), with Klebsiella pneumonia being the most commonly isolated organism.

Overall, 92 of 94 patients (97.8%) were successfully managed without operative intervention. An exploratory laparotomy was required in two patients with generalized peritonitis. No mortality was observed. Clinical assessment and ultrasonography were performed at 4 and 8 weeks to document resolution. Clinical resolution was achieved in 80% of cases at 8 weeks, while the remaining patients were followed at 4-weekly intervals until resolution.

DISCUSSION

Compared with protocol-based cohorts in which lesion size primarily guided intervention thresholds, our findings demonstrate that detailed imaging-defined rupture patterns provide an additional layer of risk stratification. Previous tertiary-center studies have reported high success rates with percutaneous aspiration or catheter drainage in pediatric liver abscess; however, many of these series grouped contained subcapsular extension together with true rupture, potentially overestimating the severity of rupture-associated disease. By distinguishing these entities radiologically, our data suggest that a substantial proportion of lesions behave as anatomically contained disease and can be managed successfully with minimally invasive strategies.[8,9,10,11]

In contrast to earlier series that focused predominantly on procedural outcomes, the present study integrates biochemical severity with imaging morphology. The observed decline in serum albumin with increasing abscess size supports previous reports identifying hypoalbuminemia as a marker of complicated liver abscess and systemic inflammatory response.[7,12,13] However, our findings suggest that serum albumin may reflect overall inflammatory burden and nutritional status rather than acting as an independent determinant of rupture. Incorporating biochemical parameters alongside imaging morphology may therefore improve early risk stratification and triage, particularly in resource-limited settings where rapid decision-making is essential.

Consistent with contemporary pediatric cohorts, the majority of children in our study were successfully managed without operative intervention, reaffirming the effectiveness of a step-up management strategy beginning with antibiotics and progressing to image-guided drainage when required.[9,11,14] Advances in imaging, percutaneous techniques, and targeted antibiotic therapy have substantially reduced the need for surgical intervention in pediatric liver abscesses over the past two decades.[10,14]

Nevertheless, our experience highlights that surgery remains indispensable in selected cases, particularly in children presenting with generalized peritonitis, persistent sepsis despite antibiotics and drainage, or clinical deterioration following rupture. In such situations, exploratory laparotomy may reveal capsular breach with purulent intraperitoneal contamination requiring lavage and drainage. Favorable outcomes following timely surgery emphasize that operative management continues to play a critical salvage role within an imaging-guided, stepwise treatment strategy, ensuring balanced integration of conservative, minimally invasive, and surgical approaches in pediatric liver abscess care.[10,14,15]

Collectively, these comparisons suggest that imaging-based rupture stratification represents a refinement of existing management algorithms rather than a departure from established protocol-driven care, enabling more accurate risk assessment and optimized intervention selection in pediatric liver abscess.

CONCLUSION

An imaging-based stratification model demonstrates that abscess size and rupture pattern predict both biochemical severity and escalation of intervention in pediatric liver abscess. A contained subcapsular extension can be managed conservatively with aspiration or catheter drainage, whereas true rupture requires selective minimally invasive or surgical intervention. The observed decline in albumin with increasing abscess size supports its role as a severity marker when interpreted alongside imaging findings. By differentiating contained extension from true rupture, our study refines existing protocol-based approaches and provides a clinically relevant framework for stepwise management in tertiary care settings.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.