• <tr id="yyy80"></tr>
  • <sup id="yyy80"></sup>
  • <tfoot id="yyy80"><noscript id="yyy80"></noscript></tfoot>
  • 99热精品在线国产_美女午夜性视频免费_国产精品国产高清国产av_av欧美777_自拍偷自拍亚洲精品老妇_亚洲熟女精品中文字幕_www日本黄色视频网_国产精品野战在线观看 ?

    Patients with culture negative pyogenic liver abscess have the same outcomes compared to those with Klebsiella pneumoniae pyogenic liver abscess

    2016-11-14 12:18:30VishalShelatQiaoWangClementLKChiaZhongkaiWangJeeKeemLowandWinstonWLWoon

    Vishal G Shelat, Qiao Wang, Clement LK Chia, Zhongkai Wang,Jee Keem Low and Winston WL Woon

    Singapore, Singapore

    Patients with culture negative pyogenic liver abscess have the same outcomes compared to those with Klebsiella pneumoniae pyogenic liver abscess

    Vishal G Shelat, Qiao Wang, Clement LK Chia, Zhongkai Wang,Jee Keem Low and Winston WL Woon

    Singapore, Singapore

    BACKGROUND: Etiologic organism is not frequently isolated despite multiple blood and fluid cultures during management of pyogenic liver abscess (PLA). Such culture negative pyogenic liver abscess (CNPLA) is routinely managed by antibiotics targeted to Klebsiella pneumoniae. In this study, we evaluated the outcomes of such clinical practice.

    METHODS: All the patients with CNPLA and Klebsiella pneumoniae PLA (KPPLA) admitted from January 2003 to December 2011 were included in the study. A retrospective review of medical records was performed and demographic, clinical and outcome data were collected.

    RESULTS: A total of 528 patients were treated as CNPLA or KPPLA over the study period. CNPLA presented more commonly with abdominal pain (P=0.024). KPPLA was more common in older age (P=0.029) and was associated with thrombocytopenia (P=0.001), elevated creatinine (P=0.002), bilirubin(P=0.001), alanine aminotransferase (P=0.006) and C-reactive protein level (P=0.036). CNPLA patients tend to have anemia(P=0.015) and smaller abscess (P=0.008). There was no difference in hospital stay (15.7 vs 16.8 days) or mortality (14.0% vs 11.0%). No patients required surgical drainage after initiation of medical therapy.

    CONCLUSION: Despite demographic and clinical differences between CNPLA and KPPLA, overall outcomes are not different.

    (Hepatobiliary Pancreat Dis Int 2016;15:504-511)

    culture negative;

    Klebsiella pneumoniae;

    pyogenic liver abscess

    Introduction

    Pyogenic liver abscess (PLA) is a potentially lifethreatening infection with mortality rate ranging from 4%-30%.[1-3]The pathogens for this condition are detected by culture of blood and/or pus drained from the abscess. Among all pathogens found in PLA,Klebsiella pneumoniae is the commonest and the features of Klebsiella pneumoniae PLA (KPPLA) have been widely described, particularly from Southeast Asian countries.[4-7]Absence of routine widespread application of advanced microbial detection techniques,[8,9]noncompliance to sepsis guidelines[10]and absence of routine testing for fungal infections result in inability to identify the etiologic microorganism. Such culture negative pyogenic liver abscess (CNPLA) deserves a special recognition as the selection of antibiotic is not standardized. The incidence of CNPLA varies from 15%-80%[11-13]and despite being commonly encountered, it has not received the same attention as KPPLA.[14]It is a common practice to empirically treat CNPLA patients with the same antibiotics which are commonly used for KPPLA patients. It remains unclear if this approach is safe. Furthermore,CNPLA is more common when an attempt to obtain pus culture by aspiration or drainage has not been done. It is evident that outcomes of patients whose PLA is nottreated by drainage are inferior compared to drainage.[15]Also, routinely patients with positive blood cultures are treated with minimum 10-14 days of intravenous antibiotics and it is possible that CNPLA patients are undertreated. We conducted this study to evaluate if CNPLA results in adverse outcomes comparable to KPPLA.

    Methods

    Patients

    A diagnosis of PLA was established based on clinical presentation and imaging. Patients with age <18 years,amoebic liver abscess, infected liver cyst, infected hydatid cyst, ruptured liver abscess requiring an urgent surgical intervention and culture positive for any bacteria other than Klebsiella pneumoniae were excluded. Constitutional symptom was defined collectively for vague presenting complains of weakness, fatigue, fever and feeling unwell. All patients with PLA had at least one set of blood culture taken prior to the initiation of empirical broad spectrum intravenous antibiotics. Patients underwent percutaneous drainage (or aspiration) of PLA when any of the following criteria was met: (1) size of PLA >4 cm, solitary or dominant; (2) presence of hemodynamic instability or need for inotropic support on admission;(3) gas within the abscess cavity regardless of size and(4) failure of antibiotic therapy for PLA <4 cm. Drain fluid was routinely sent for microbiology testing. Drains were flushed with 10 mL saline to prevent blockages and accurate logs were maintained for the quality and quantity of effluents. A contrast dye study via the drain was routinely obtained when the drain output was <10 mL/24 h for at least two days. The percutaneous drains were removed upon resolution of sepsis as evidenced by stable vital parameters, total white blood cell count and/ or C-reactive protein (CRP) levels down trending and<10 mL/24 h drain aspirates for at least two consecutive days.

    Groups and treatment

    The specimens obtained were processed for Gram stain, bacterial cultures (aerobic and anaerobic) and tests for antibiotic susceptibility [organism identification was performed using a mix of Microbact? 12A (Oxoid, UK),VITEK 2 system (bioMe'rieux), and the Bruker Biotyper(version 2.0) matrix-assisted laser desorption/ionization time-of-flight (MALDI-TOF) mass spectrometry system;susceptibility testing was performed using the VITEK 2 system (bioMe'rieux) and Kirby-Bauer method]. Antibiotic therapy was subsequently tailored to culture and sensitivity results. In KPPLA patients, either blood or pus culture was positive for Klebsiella penumoniae. CNPLA was defined when no organism was evident on any blood or pus samples. PLA patients were initially taken empirical broad spectrum intravenous antibiotics, usually a combination of a third generation cephalosporin, such as ceftriaxone 1 g intravenous 8 hourly, along with metronidazole 500 mg intravenous 8 hourly. Total duration of antibiotic therapy varied according to the clinical and radiological response. Patient monitoring and blood investigations were done based on individual surgeons' preference. All the patients underwent a repeat radiologic imaging at 2-3 weeks interval to evaluate radiological response. Antibiotic therapy was switched from intravenous to oral based on clinical response and discontinued when there was a near complete to complete radiological resolution of abscess. Patients with positive blood culture were routinely treated with minimum 10-14 days of intravenous antibiotics before converting to oral. All patients with persistent sepsis were evaluated according to surviving sepsis guidelines with repeat imaging and culture directed escalation of antibiotic treatment. It is a local practice to escalate antibiotic treatment to either piperacillin-tazobactam 4.5 g intravenous 8 hourly or carbapenems in septic CNPLA patients who do not respond to first line treatment. In patients with negative cultures, metronidazole was discontinued at the time of switching intravenous antibiotics to oral amoxicillin clavulanate. The medical records of all patients were studied for demographic profile, co-morbidities, clinical features, laboratory and radiologic investigations, imaging characteristics of abscesses, treatment, hospital stay,and mortality. All the cut-off values of laboratory investigations were based on our hospital laboratory records except for CRP where an arbitrary cut-off value of 100 mg/L was determined. Total duration of antibiotic treatment was determined by adding the intravenous and oral days of all types of antibiotics prescribed. Mortality was defined as death due to any cause during hospitalization or within 30 days of diagnosis of PLA.

    Statistical analysis

    Data was analyzed using commercial statistical software (SPSS for Windows, version 14.0, Chicago, IL, USA). All continuous data were expressed as mean±standard deviation (SD) and analyzed by independent samples t-test. All categorical variables were described as percentage and compared by either Chi-square or Fisher's exact test based on the feature of the data. Multivariate analysis for mortality was processed by logistic regression using stepwise forward method, all factors analyzed in the single factor study were included as inputs. A P value of<0.05 was considered statistically significant.

    Results

    Baseline characteristics

    During January 2003 and December 2011, 635 patients were treated for PLA at Tan Tock Seng Hospital in Singapore. Fig. 1 demonstrates the patient selection. 528 patients were treated for CNPLA (264 patients) or KPPLA (264 patients). This equal number is purely coincidental. The mean age of patients was 60.7 years (range 15-99) and 322 (61.0%) patients were male. 191 (36.2%)patients had history of hepato-pancreatico-biliary diseases, in which, the majority was gallstones (74.3%). Table 1 shows the baseline characteristics of patients with CNPLA and KPPLA. KPPLA patients had blood or pus culture done for a median of 4 times (range 2-13) and CNPLA patients had blood or pus culture taken for a median of 4 times (range 2-15).

    Clinical presentation and investigations

    Clinical features, biochemical results and imagingfeatures are shown in Table 2. Fever and constitutional symptoms were the most common clinical manifestations in both groups but significantly more in KPPLA patients (85.2% vs 68.6%, P=0.001, and 83.0% vs 68.9%,P=0.001, respectively). Abdominal pain was more common in CNPLA group (53.0% vs 43.2%, P=0.024). KPPLA patients showed evidence of organ dysfunction withmore patients having thrombocytopenia (platelet <150 × 109/L) (35.6% vs 15.5%, P=0.001), elevated creatinine(>130 μmoI/L) (32.2% vs 20.1%, P=0.002), elevated bilirubin (>22 μmol/L) (56.1% vs 41.7%, P=0.001), raised aspartate aminotransferase (AST) (>34 IU/L) (76.9% vs 67.8%, P=0.025) and raised alanine aminotransferase (ALT) (>44 IU/L) (65.2% vs 53.0%, P=0.006) level. High CRP level was also more common in KPPLA group(68.9% vs 60.2%, P=0.036). CNPLA patients tend to have anemia (17.0% vs 9.8%, P=0.015) and smaller abscesses(5.4 vs 6.2 cm, P=0.008). There was equal distribution of multiple lesions (29.9% vs 30.3%, P=0.992).

    Fig. 1. Flowchart of patient selection.

    Table 1. Baseline characteristics of patients with CNPLA and KPPLA

    Table 2. Clinical presentation and investigations of CNPLA and KPPLA patients

    Table 3. Management and clinical outcomes of CNPLA and KPPLA patients (n, %)

    Management and clinical outcomes

    KPPLA patients required percutaneous drainag (63.6% vs 34.8%, P=0.001) more frequently. No patients required surgical drainage after initiation of medical therapy. There was no difference in hospital stay (15.7 vs 16.8 days, P=0.397). Overall 30-day mortality of CNPLA and KPPLA patients(14.0% vs 11.0%, P=0.292) was similar. Mortality in patients with percutaneous drainage was 8.7% and 9.5%(P=0.825) and of those who were treated with antibiotics alone was 16.9% and 13.5% (P=0.474) for CNPLA and KPPLA groups, respectively (Table 3).

    CNPLA patients outcomes

    Those patients who had the abscess drained in the CNPLA group, were younger (P=0.05) with larger abscess (7.4 vs 4.2 cm, P<0.001) and fever (78.3% vs 63.4%,P=0.013) as common presenting complain. CNPLA patients treated with drainage also had deranged (>12 × 09/L or <4×109/L) white blood cells (71.7% vs 57.0%,P=0.018) and elevated gamma-glutamyl transferase(GGT) levels (89.1% vs 76.7%, P=0.014) compared to CNPLA patients treated with antibiotic alone. Mortality was lower in patients treated with drainage but not significant (8.7% vs 16.9%, P=0.069) (Table 4). The multivariate analysis showed that old age, absence of fever,elevated blood urea and coagulopathy as evidenced by elevated international normalized ratio (INR) predicted mortality in CNPLA patients (Table 5).

    Table 4. Demographic, clinical, radiological profile and outcomes of CNPLA patients treated with and without percutaneous drainage

    Discussion

    CNPLA is common but poorly studied and under reported. In this study involving 264 patients with CNPLA,we are the first to demonstrate that empirical treatment of CNPLA according to KPPLA is an acceptable clinical practice. This study also confirms that CNPLA patients with percutaneous drainage have better outcomes com-pared to those treated with antibiotics alone. This is the first study to report variables that predict mortality in CNPLA patients by performing a multivariate analysis on a large population.

    Table 5. Univariate and multivariate analysis of CNPLA patients for mortality

    Antibiotic treatment is a minimum universal requirement of all PLA patients. Ideally antibiotic therapy should be targeted to the culprit microorganism. In PLA patients, blood culture is the prime source for microbial identification. Chemaly et al[16]have found that the sensitivities of the blood cultures for any Gram-positive cocci and Gram-negative bacilli present in PLA were 30% and 39% respectively, which means that PLA pathogens are usually underrepresented in blood cultures. Hence alternative means of microbial identification are important. Percutaneous aspiration or drainage provides pus which serves dual purpose of microbial isolation and therapeutic abscess drainage. Patients who have PLA aspiration or drainage will have pus available for bacteriology testing and hence will have opportunity of microbial isolation and targeted therapy. In our previous experience of managing 741 patients with PLA, only 60.1% (220/366)had positive pus cultures.[17]This is likely because antibiotics are almost always prescribed prior to drainage. Recently, advanced microbial detection techniques like polymerase chain reaction (PCR) have been employed not only to enhance the diagnostic yield but also to facilitate early bacteriological diagnosis.[18]Microorganism detection rate of PCR along with routine culture meth-ods was significantly better compared to each modality alone.[18]Higher incidence of CNPLA in patients treated without percutaneous drainage is confirmed in our study. Also, in clinical practice, more sick patients are managed aggressively with repeated testing for bacteriology. This can enhance the bacterial yield in such patients. This is confirmed in our experience where more sick patients belong to KPPLA group. It is our routine practice to treat CNPLA patients empirically according to the treatment of the commonest pathogen i.e. Klebsiella pneumoniae. It is challenging that some patients may fail to respond to treatment, especially in the absence of bacteriology results. This could increase treatment failures and adverse outcomes in CNPLA patients. It is hence important to evaluate if local practice of empirical treatment of CNPLA patients according to KPPLA algorithm is acceptable. Fig. 2 shows the dilemma associated with CNPLA.

    Fig. 2. Dilemma of culture negative pyogenic liver abscess.

    CNPLA patients universally receive empirical antibiotics and selectively receive percutaneous aspiration/ drainage. Khan et al[14]have reported that predictive factors for aspiration of liver abscess included age ≥55 years,size of abscess ≥5 cm, involvement of both lobes of the liver, and duration of symptoms ≥7 days. Considerable success rate of needle aspiration of PLA, even in multiple abscesses, was reported in different series.[19]However,up to 40% of PLA patients require repeated aspiration sessions.[20]Percutaneous drainage is a safe intervention which is tolerated well by patients and thick pus can be drained more efficiently.[21,22]We do not perform percutaneous aspiration but offer percutaneous drainage in selected patients based on abscess size, sepsis severity,presence of gas in abscess cavity and failure of antibiotic treatment. A 4-cm size cut-off is widely recommended for acute colonic diverticular abscess and recently a new classification system is proposed based on this size criterion.[23]We have previously published 4 cm cut-off for consideration of percutaneous drainage of PLA.[24]Our results showed that KPPLA patients present with severe sepsis and larger abscess size compared to CNPLA patients. However due to retrospective nature of our study,the cause and effect relationship cannot be established as it is possible that more sick patients underwent aggressive management with repeated tests for bacteriology increasing the microbial isolation. Also patients with larger abscess size underwent more frequent percutaneous drainage providing additional source of microbial isolation and increasing yield. We do not consider large size as an indication of surgery and have reported that percutaneous drainage is safe and sufficient even in ≥10 cm PLA.[25]In our study, almost twice the number of patients received percutaneous drainage in the KPPLA group. Despite the lower proportion of patients undergoing percutaneous drainage in CNPLA group,the overall mortality was similar to KPPLA group. In a subgroup of patients treated with antibiotic alone, there was no difference in mortality among the two groups. Similarly in a subgroup of patients treated with drainage, there was no difference in mortality among the two groups either. However a subgroup analysis of CNPLA patients demonstrated that, in patients treated with antibiotics alone, mortality was higher compared to CNPLA patients treated with drainage. This may suggest a more liberal policy of drainage for therapeutic efficacy rather than simple aspiration for improving the microbial yield. Moreover, these results also suggest that a retroactive strategy of percutaneous drainage in cases of failure of antibiotic treatment could be a missed opportunity to improve outcomes by early drainage. Some reports show that Klebsiella pneumoniae is more likely to appear as single abscess[26]and uni-lobular involvements[27]than non-Klebsiella pneumoniae liver abscess, but this was not confirmed in our study and hence the outcomes are not determined by number and focality of PLA location. Prospective study is required to confirm these findings.

    KPPLA is reported to have a mortality rate of 4%-12%[4-7]and there is limited data for CNPLA. Khan et al[14]reported 2.3% mortality rate in a series of 966 patients including 661 (68%) of patients with amoebic etiology. In our series, the overall mortality rate was 11.0% and 14.0% for KPPLA and CNPLA groups, respectively. Khan's study predominantly included young patients (71% were <55 years), only 17.5% incidence of diabetes and none patient with PLA having cholangitis. Advanced age, presence of sepsis, underlying malignancy,poor physiological state and co-morbidities, are predictors of mortality in PLA.[2,11,28-30]In our study, various factors had been analyzed to reveal the risk of mortality for patients with CNPLA. Multivariate analysis revealedold age, fever, coagulopathy and elevated urea predict mortality in CNPLA patients. These results emphasize the fact that elderly patients who are unable to mount a febrile response to sepsis are vulnerable and high index of suspicion with prompt diagnosis and management are recommended. Elevated urea has been shown to be a predictor of poor outcomes including mortality in patients with acute pancreatitis, acute cholecystitis and perforated peptic ulcer.[31-33]Blood urea nitrogen is a surrogate marker of intravascular volume status and provides valuable feedback with regards to fluid resuscitation. Coagulopthy is a marker of organ dysfunction in severe sepsis and has been shown to be associated with mortality in PLA.[34]It is possible that percutaneous drainage is delayed until the coagulopathy is artificially corrected. In a study of 103 elderly patients with acute cholecystitis,we have shown that early percutaneous cholecystostomy improves outcomes.[35]While this large single institution study provides novel information on under reported and poorly studied disease of CNPLA, it is limited by retrospective nature.

    In conclusion, KPPLA and CNPLA have several demographic and clinical differences. CNPLA patients are less likely to present with severe sepsis and renal dysfunction. CNPLA patients are also more likely to have a smaller abscess size which is less likely to be drained. There is an increased mortality in CNPLA patients who did not receive percutaneous drainage. The overall outcomes of CNPLA patients are equivalent to KPPLA patients and hence it is justified to treat CNPLA patients with empirical antibiotics targeted to Klebsiella pneumoniae.

    Contributors: SVG proposed the study. WQ and CCLK performed the research and wrote the first draft. WQ collected and analyzed the data. All authors contributed to the design and interpretation of the study and to further drafts. SVG and WQ contributed equally to this study. SVG is the guarantor.

    Funding: None.

    Ethical approval: This study was approved by Institutional Review Board of Tan Tock Seng Hospital.

    Competing interest: No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.

    1 Alvarez Pérez JA, González JJ, Baldonedo RF, Sanz L, Carre?o G, Junco A, et al. Clinical course, treatment, and multivariate analysis of risk factors for pyogenic liver abscess. Am J Surg 2001;181:177-186.

    2 Lee KT, Wong SR, Sheen PC. Pyogenic liver abscess: an audit of 10 years' experience and analysis of risk factors. Dig Surg 2001;18:459-466.

    3 Ruiz-Hernández JJ, León-Mazorra M, Conde-Martel A, Marchena-Gómez J, Hemmersbach-Miller M, Betancor-León P. Pyogenic liver abscesses: mortality-related factors. Eur J Gastroenterol Hepatol 2007;19:853-858.

    4 Cerwenka H. Pyogenic liver abscess: differences in etiology and treatment in Southeast Asia and Central Europe. World J Gastroenterol 2010;16:2458-2462.

    5 Pang TC, Fung T, Samra J, Hugh TJ, Smith RC. Pyogenic liver abscess: an audit of 10 years' experience. World J Gastroenterol 2011;17:1622-1630.

    6 Chan DS, Archuleta S, Llorin RM, Lye DC, Fisher D. Standardized outpatient management of Klebsiella pneumoniae liver abscesses. Int J Infect Dis 2013;17:e185-188.

    7 Lederman ER, Crum NF. Pyogenic liver abscess with a focus on Klebsiella pneumoniae as a primary pathogen: an emerging disease with unique clinical characteristics. Am J Gastroenterol 2005;100:322-331.

    8 Liao CH, Huang YT, Chang CY, Hsu HS, Hsueh PR. Capsular serotypes and multilocus sequence types of bacteremic Klebsiella pneumoniae isolates associated with different types of infections. Eur J Clin Microbiol Infect Dis 2014;33:365-369.

    9 Orosz E, Perkátai K, Kapusinszky B, Farkas A, Kucsera I. Realtime PCR assay for rapid qualitative and quantitative detection of Entamoeba histolytica. Acta Microbiol Immunol Hung 2012;59:451-460.

    10 Berg GM, Vasquez DG, Hale LS, Nyberg SM, Moran DA. Evaluation of process variations in noncompliance in the implementation of evidence-based sepsis care. J Healthc Qual 2013;35:60-69.

    11 Meddings L, Myers RP, Hubbard J, Shaheen AA, Laupland KB,Dixon E, et al. A population-based study of pyogenic liver abscesses in the United States: incidence, mortality, and temporal trends. Am J Gastroenterol 2010;105:117-124.

    12 Zibari GB, Maguire S, Aultman DF, McMillan RW, McDonald JC. Pyogenic liver abscess. Surg Infect (Larchmt) 2000;1:15-21.

    13 Mangukiya DO, Darshan JR, Kanani VK, Gupta ST. A prospective series case study of pyogenic liver abscess: recent trands in etiology and management. Indian J Surg 2012;74:385-390.

    14 Khan R, Hamid S, Abid S, Jafri W, Abbas Z, Islam M, et al. Predictive factors for early aspiration in liver abscess. World J Gastroenterol 2008;14:2089-2093.

    15 Cheng HP, Siu LK, Chang FY. Extended-spectrum cephalosporin compared to cefazolin for treatment of Klebsiella pneumoniae-caused liver abscess. Antimicrob Agents Chemother 2003;47:2088-2092.

    16 Chemaly RF, Hall GS, Keys TF, Procop GW. Microbiology of liver abscesses and the predictive value of abscess gram stain and associated blood cultures. Diagn Microbiol Infect Dis 2003;46:245-248.

    17 Lo JZ, Leow JJ, Ng PL, Lee HQ, Mohd Noor NA, Low JK, et al. Predictors of therapy failure in a series of 741 adult pyogenic liver abscesses. J Hepatobiliary Pancreat Sci 2015;22:156-165.

    18 Pletz MW, Wellinghausen N, Welte T. Will polymerase chain reaction (PCR)-based diagnostics improve outcome in septic patients? A clinical view. Intensive Care Med 2011;37:1069-1076.

    19 Giorgio A, de Stefano G, Di Sarno A, Liorre G, Ferraioli G. Percutaneous needle aspiration of multiple pyogenic abscesses of the liver: 13-year single-center experience. AJR Am J Roentgenol 2006;187:1585-1590.

    20 Zerem E, Hadzic A. Sonographically guided percutaneous catheter drainage versus needle aspiration in the managementof pyogenic liver abscess. AJR Am J Roentgenol 2007;189:138-142.

    21 Liao WI, Tsai SH, Yu CY, Huang GS, Lin YY, Hsu CW, et al. Pyogenic liver abscess treated by percutaneous catheter drainage: MDCT measurement for treatment outcome. Eur J Radiol 2012;81:609-615.

    22 Yu SC, Ho SS, Lau WY, Yeung DT, Yuen EH, Lee PS, et al. Treatment of pyogenic liver abscess: prospective randomized comparison of catheter drainage and needle aspiration. Hepatology 2004;39:932-938.

    23 Sartelli M, Moore FA, Ansaloni L, Di Saverio S, Coccolini F,Griffiths EA, et al. A proposal for a CT driven classification of left colon acute diverticulitis. World J Emerg Surg 2015;10:3.

    24 Shelat VG, Chia CL, Yeo CS, Qiao W, Woon W, Junnarkar SP. Pyogenic liver abscess: does Escherichia coli cause more adverse outcomes than Klebsiella pneumoniae? World J Surg 2015;39:2535-2542.

    25 Ahmed S, Chia CL, Junnarkar SP, Woon W, Shelat VG. Percutaneous drainage for giant pyogenic liver abscess--is it safe and sufficient? Am J Surg 2016;211:95-101.

    26 Yang CC, Yen CH, Ho MW, Wang JH. Comparison of pyogenic liver abscess caused by non-Klebsiella pneumoniae and Klebsiella pneumoniae. J Microbiol Immunol Infect 2004;37:176-184.

    27 Alsaif HS, Venkatesh SK, Chan DS, Archuleta S. CT appearance of pyogenic liver abscesses caused by Klebsiella pneumoniae. Radiology 2011;260:129-138.

    28 Alkofer B, Dufay C, Parienti JJ, Lepennec V, Dargere S, Chiche L. Are pyogenic liver abscesses still a surgical concern? A Western experience. HPB Surg 2012;2012:316013.

    29 Chen SC, Huang CC, Tsai SJ, Yen CH, Lin DB, Wang PH, et al. Severity of disease as main predictor for mortality in patients with pyogenic liver abscess. Am J Surg 2009;198:164-172.

    30 Lok KH, Li KF, Li KK, Szeto ML. Pyogenic liver abscess:clinical profile, microbiological characteristics, and management in a Hong Kong hospital. J Microbiol Immunol Infect 2008;41:483-490.

    31 Wu BU, Johannes RS, Sun X, Conwell DL, Banks PA. Early changes in blood urea nitrogen predict mortality in acute pancreatitis. Gastroenterology 2009;137:129-135.

    32 Ransohoff DF, Miller GL, Forsythe SB, Hermann RE. Outcome of acute cholecystitis in patients with diabetes mellitus. Ann Intern Med 1987;106:829-832.

    33 Menekse E, Kocer B, Topcu R, Olmez A, Tez M, Kayaalp C. A practical scoring system to predict mortality in patients with perforated peptic ulcer. World J Emerg Surg 2015;10:7.

    34 Chu KM, Fan ST, Lai EC, Lo CM, Wong J. Pyogenic liver abscess. An audit of experience over the past decade. Arch Surg 1996;131:148-152.

    35 Yeo CS, Tay VW, Low JK, Woon WW, Punamiya SJ, Shelat VG. Outcomes of percutaneous cholecystostomy and predictors of eventual cholecystectomy. J Hepatobiliary Pancreat Sci 2016;23:65-73.

    Accepted after revision May 12, 2016

    Strive not to be a success, but rather to be of value.

    —Albert Einstein

    December 2, 2105

    Author Affiliations: Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore (Shelat VG, Low JK and Woon WWL);Ministry of Health Holdings Pte Ltd., Singapore 099253, Singapore(Wang Q, Chia CLK and Wang Z)

    Vishal G Shelat, FRCS, FEBS, Consultant, Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433,Singapore (Tel: +65-635-77807; Fax: +65-635-77809; Email: vgshelat@ gmail.com)

    ? 2016, Hepatobiliary Pancreat Dis Int. All rights reserved.

    10.1016/S1499-3872(16)60127-3

    Published online August 25, 2016.

    久久久精品94久久精品| 一区福利在线观看| 在线精品无人区一区二区三| av在线观看视频网站免费| 亚洲一级一片aⅴ在线观看| 欧美精品av麻豆av| 日韩中文字幕欧美一区二区 | 中文字幕亚洲精品专区| 欧美人与善性xxx| 最新的欧美精品一区二区| 高清av免费在线| 91精品伊人久久大香线蕉| 蜜桃国产av成人99| 亚洲,欧美,日韩| 午夜日本视频在线| 国产亚洲欧美精品永久| 下体分泌物呈黄色| 欧美变态另类bdsm刘玥| 国产极品天堂在线| 一边亲一边摸免费视频| 黄色视频在线播放观看不卡| 久久精品aⅴ一区二区三区四区 | 免费在线观看视频国产中文字幕亚洲 | 丝袜美腿诱惑在线| 少妇的丰满在线观看| 亚洲综合精品二区| 亚洲三级黄色毛片| 美女大奶头黄色视频| xxx大片免费视频| 国语对白做爰xxxⅹ性视频网站| 免费黄网站久久成人精品| 熟女av电影| 男女边摸边吃奶| 日韩av免费高清视频| av不卡在线播放| 国产亚洲精品第一综合不卡| 久久精品国产亚洲av高清一级| 日韩三级伦理在线观看| 老司机影院成人| 在线观看一区二区三区激情| 欧美精品一区二区大全| 久久ye,这里只有精品| 侵犯人妻中文字幕一二三四区| 成年女人在线观看亚洲视频| 免费高清在线观看视频在线观看| 啦啦啦中文免费视频观看日本| 亚洲成人一二三区av| 免费在线观看完整版高清| 这个男人来自地球电影免费观看 | 日韩大片免费观看网站| 欧美亚洲 丝袜 人妻 在线| 伊人亚洲综合成人网| 91午夜精品亚洲一区二区三区| 欧美日韩视频精品一区| 成年女人毛片免费观看观看9 | 午夜激情av网站| 999久久久国产精品视频| 精品一品国产午夜福利视频| 亚洲国产日韩一区二区| 男女免费视频国产| 69精品国产乱码久久久| 日韩av免费高清视频| 中国国产av一级| 美女国产高潮福利片在线看| 欧美97在线视频| 制服丝袜香蕉在线| 伦理电影免费视频| 久久久久久久国产电影| 人人妻人人澡人人爽人人夜夜| 久久久精品国产亚洲av高清涩受| 我要看黄色一级片免费的| 十八禁高潮呻吟视频| 国产有黄有色有爽视频| 午夜久久久在线观看| 下体分泌物呈黄色| 80岁老熟妇乱子伦牲交| 午夜av观看不卡| 久久久久久久精品精品| 国产无遮挡羞羞视频在线观看| 中文乱码字字幕精品一区二区三区| 99国产综合亚洲精品| 成人免费观看视频高清| 1024视频免费在线观看| 日韩三级伦理在线观看| 国产成人a∨麻豆精品| 国产一级毛片在线| 高清欧美精品videossex| 一级黄片播放器| 中文字幕亚洲精品专区| 国产淫语在线视频| 两个人免费观看高清视频| 高清视频免费观看一区二区| 精品人妻偷拍中文字幕| 日日撸夜夜添| 久久久久久久久免费视频了| 久久久久网色| 男人舔女人的私密视频| 1024香蕉在线观看| 久久国产精品大桥未久av| 亚洲美女黄色视频免费看| 亚洲欧美色中文字幕在线| 欧美日韩精品网址| 一级,二级,三级黄色视频| 国产有黄有色有爽视频| 丝袜人妻中文字幕| 亚洲天堂av无毛| 又大又黄又爽视频免费| www.熟女人妻精品国产| 热re99久久国产66热| 一二三四在线观看免费中文在| 欧美成人精品欧美一级黄| 久久婷婷青草| 人体艺术视频欧美日本| freevideosex欧美| 国产欧美日韩综合在线一区二区| 国产一区亚洲一区在线观看| 国精品久久久久久国模美| 性色avwww在线观看| 丰满饥渴人妻一区二区三| 涩涩av久久男人的天堂| 老熟女久久久| 久久婷婷青草| 国产男女超爽视频在线观看| av在线观看视频网站免费| 日本wwww免费看| 亚洲欧美成人综合另类久久久| 成年女人毛片免费观看观看9 | 高清黄色对白视频在线免费看| 久久99一区二区三区| 欧美精品一区二区免费开放| 亚洲成国产人片在线观看| 日韩大片免费观看网站| 青青草视频在线视频观看| 男男h啪啪无遮挡| 啦啦啦视频在线资源免费观看| 女性被躁到高潮视频| 涩涩av久久男人的天堂| 天天躁狠狠躁夜夜躁狠狠躁| 日韩欧美一区视频在线观看| 亚洲,欧美,日韩| 波野结衣二区三区在线| 国产极品天堂在线| 一级片'在线观看视频| 一级片'在线观看视频| 又黄又粗又硬又大视频| 国产乱人偷精品视频| 久久久久国产网址| 丝袜美腿诱惑在线| 老鸭窝网址在线观看| 国产一区二区三区av在线| 十分钟在线观看高清视频www| 午夜福利网站1000一区二区三区| 日本午夜av视频| 久久ye,这里只有精品| 一本大道久久a久久精品| 纯流量卡能插随身wifi吗| 不卡视频在线观看欧美| 色94色欧美一区二区| 久久久久久久久久久免费av| 亚洲精品视频女| 制服诱惑二区| 欧美少妇被猛烈插入视频| 亚洲欧美一区二区三区久久| 超碰97精品在线观看| 午夜影院在线不卡| 国产xxxxx性猛交| 国产在线免费精品| 亚洲精品自拍成人| 菩萨蛮人人尽说江南好唐韦庄| 午夜免费鲁丝| 国产精品久久久久久久久免| 女性生殖器流出的白浆| 国产成人免费观看mmmm| 亚洲av免费高清在线观看| 日韩精品免费视频一区二区三区| 免费大片黄手机在线观看| 天天躁夜夜躁狠狠久久av| 欧美人与性动交α欧美精品济南到 | 国产精品国产三级专区第一集| 最新中文字幕久久久久| 久久影院123| 黄网站色视频无遮挡免费观看| 亚洲精品久久成人aⅴ小说| 叶爱在线成人免费视频播放| 国产一区二区在线观看av| 久久午夜福利片| 国产亚洲av片在线观看秒播厂| 日韩电影二区| 精品国产露脸久久av麻豆| 亚洲av成人精品一二三区| 在线观看美女被高潮喷水网站| 国产成人aa在线观看| 天天躁夜夜躁狠狠躁躁| 亚洲欧美成人精品一区二区| 老汉色av国产亚洲站长工具| 伊人亚洲综合成人网| 桃花免费在线播放| 亚洲精品久久午夜乱码| 亚洲欧美精品综合一区二区三区 | 制服丝袜香蕉在线| 国产欧美日韩综合在线一区二区| 免费久久久久久久精品成人欧美视频| 大片免费播放器 马上看| 高清欧美精品videossex| 超碰97精品在线观看| 久久久久国产网址| 国产精品无大码| 午夜av观看不卡| 国产一区二区 视频在线| 中文乱码字字幕精品一区二区三区| 欧美精品高潮呻吟av久久| 大陆偷拍与自拍| 少妇被粗大猛烈的视频| 久久久久久久久免费视频了| 国产精品久久久久成人av| 久久精品久久久久久久性| 亚洲国产毛片av蜜桃av| 伦理电影大哥的女人| 亚洲av国产av综合av卡| 亚洲精品国产一区二区精华液| 久久精品久久精品一区二区三区| 久久国产亚洲av麻豆专区| 国语对白做爰xxxⅹ性视频网站| 亚洲国产成人一精品久久久| 日韩,欧美,国产一区二区三区| 日产精品乱码卡一卡2卡三| 精品第一国产精品| 婷婷成人精品国产| 不卡视频在线观看欧美| 观看av在线不卡| 久久 成人 亚洲| 免费黄网站久久成人精品| 久久国产精品大桥未久av| 亚洲一级一片aⅴ在线观看| 在现免费观看毛片| 人妻 亚洲 视频| 麻豆av在线久日| 国产一区二区 视频在线| 日韩 亚洲 欧美在线| 自线自在国产av| 80岁老熟妇乱子伦牲交| 国产成人精品久久二区二区91 | 18禁国产床啪视频网站| 视频在线观看一区二区三区| 可以免费在线观看a视频的电影网站 | 男女国产视频网站| 国产成人a∨麻豆精品| 亚洲国产精品国产精品| 亚洲人成77777在线视频| 在线看a的网站| 日韩av免费高清视频| 欧美日韩av久久| 新久久久久国产一级毛片| 人体艺术视频欧美日本| 亚洲欧洲国产日韩| 黄色怎么调成土黄色| 夜夜骑夜夜射夜夜干| 成年av动漫网址| 老司机影院毛片| 一区在线观看完整版| videossex国产| 欧美97在线视频| 中文天堂在线官网| 又大又黄又爽视频免费| 嫩草影院入口| 欧美精品高潮呻吟av久久| 亚洲av日韩在线播放| 多毛熟女@视频| 国产日韩欧美视频二区| 18+在线观看网站| 美女主播在线视频| 久久午夜福利片| 在线观看一区二区三区激情| 母亲3免费完整高清在线观看 | 麻豆精品久久久久久蜜桃| 九草在线视频观看| 一本色道久久久久久精品综合| 久久久久精品性色| 欧美+日韩+精品| 一级,二级,三级黄色视频| 欧美另类一区| 午夜福利乱码中文字幕| 欧美精品国产亚洲| 亚洲欧美色中文字幕在线| 国产精品一国产av| 亚洲国产色片| 香蕉丝袜av| 日日爽夜夜爽网站| 久久久久国产网址| 久久97久久精品| 1024香蕉在线观看| 亚洲精品国产色婷婷电影| 久久国产精品男人的天堂亚洲| 精品国产乱码久久久久久小说| 一边摸一边做爽爽视频免费| 一级片免费观看大全| 免费在线观看视频国产中文字幕亚洲 | 国产成人精品婷婷| 国产在线一区二区三区精| 日本午夜av视频| 精品少妇一区二区三区视频日本电影 | 深夜精品福利| 国产一区二区 视频在线| 午夜福利乱码中文字幕| 一边亲一边摸免费视频| 国产免费又黄又爽又色| 一本色道久久久久久精品综合| 18禁观看日本| 哪个播放器可以免费观看大片| 国产黄色视频一区二区在线观看| 天天操日日干夜夜撸| 午夜91福利影院| 欧美激情极品国产一区二区三区| 亚洲精品av麻豆狂野| 亚洲精品一二三| 亚洲精品国产一区二区精华液| 免费黄频网站在线观看国产| 亚洲av男天堂| 国产野战对白在线观看| 美女国产视频在线观看| 在线亚洲精品国产二区图片欧美| 日本色播在线视频| 97精品久久久久久久久久精品| 不卡视频在线观看欧美| www.熟女人妻精品国产| 亚洲视频免费观看视频| 日本wwww免费看| 黄色视频在线播放观看不卡| 久久久亚洲精品成人影院| 中文乱码字字幕精品一区二区三区| 精品国产乱码久久久久久男人| 亚洲成人手机| 国产成人精品在线电影| 午夜91福利影院| 90打野战视频偷拍视频| 免费观看无遮挡的男女| 久久久久久久久久久免费av| 午夜日韩欧美国产| 叶爱在线成人免费视频播放| 又黄又粗又硬又大视频| 最近最新中文字幕大全免费视频 | 高清不卡的av网站| 国产白丝娇喘喷水9色精品| 一区二区三区四区激情视频| 伦理电影大哥的女人| 一级毛片黄色毛片免费观看视频| 一本大道久久a久久精品| 99精国产麻豆久久婷婷| 中文字幕精品免费在线观看视频| 中文字幕人妻丝袜制服| 欧美国产精品va在线观看不卡| 美女脱内裤让男人舔精品视频| 9191精品国产免费久久| 精品国产乱码久久久久久男人| 午夜91福利影院| 夫妻性生交免费视频一级片| 亚洲成人手机| 香蕉丝袜av| 最近手机中文字幕大全| 黄频高清免费视频| 成年人午夜在线观看视频| 亚洲第一区二区三区不卡| 久久 成人 亚洲| av有码第一页| 久久午夜福利片| 国产高清不卡午夜福利| 一区二区三区乱码不卡18| 午夜福利在线免费观看网站| 欧美日韩国产mv在线观看视频| 国产免费现黄频在线看| 国产在视频线精品| 国产女主播在线喷水免费视频网站| 中文乱码字字幕精品一区二区三区| 在线看a的网站| www日本在线高清视频| 免费女性裸体啪啪无遮挡网站| 欧美人与性动交α欧美软件| 黑丝袜美女国产一区| 亚洲婷婷狠狠爱综合网| av.在线天堂| 热99国产精品久久久久久7| 日本免费在线观看一区| 老司机亚洲免费影院| 国产成人精品无人区| 国产精品嫩草影院av在线观看| 成年美女黄网站色视频大全免费| 曰老女人黄片| 亚洲av国产av综合av卡| 蜜桃国产av成人99| 搡女人真爽免费视频火全软件| 久久久久久人妻| 免费在线观看黄色视频的| 自线自在国产av| 99热网站在线观看| 亚洲三级黄色毛片| av天堂久久9| 人人妻人人爽人人添夜夜欢视频| 中文字幕av电影在线播放| 久久久国产精品麻豆| 王馨瑶露胸无遮挡在线观看| 国产成人精品久久久久久| 国产精品熟女久久久久浪| 人成视频在线观看免费观看| 少妇 在线观看| 91国产中文字幕| 女人被躁到高潮嗷嗷叫费观| 国产成人91sexporn| 丝袜喷水一区| 国产男女内射视频| 亚洲第一青青草原| 啦啦啦中文免费视频观看日本| 五月开心婷婷网| 精品国产国语对白av| 日本免费在线观看一区| 国产成人aa在线观看| 汤姆久久久久久久影院中文字幕| 婷婷色av中文字幕| 视频区图区小说| 亚洲av在线观看美女高潮| 日日撸夜夜添| 秋霞伦理黄片| 国产成人av激情在线播放| 老汉色av国产亚洲站长工具| 亚洲欧美一区二区三区久久| 纵有疾风起免费观看全集完整版| 国产精品国产三级国产专区5o| 欧美日韩视频精品一区| 国产乱人偷精品视频| 成年女人毛片免费观看观看9 | 人妻系列 视频| 亚洲天堂av无毛| 老熟女久久久| 一级片'在线观看视频| 热99久久久久精品小说推荐| 亚洲精品久久午夜乱码| 大陆偷拍与自拍| 女性被躁到高潮视频| 视频在线观看一区二区三区| 亚洲国产成人一精品久久久| 国产精品亚洲av一区麻豆 | 男的添女的下面高潮视频| 麻豆乱淫一区二区| 久久精品国产自在天天线| 精品人妻一区二区三区麻豆| 亚洲av.av天堂| 老熟女久久久| 国产亚洲欧美精品永久| 亚洲,欧美精品.| 高清不卡的av网站| 成年美女黄网站色视频大全免费| 秋霞在线观看毛片| 久久精品久久久久久噜噜老黄| 极品少妇高潮喷水抽搐| 国产精品 欧美亚洲| 亚洲男人天堂网一区| 久久韩国三级中文字幕| 最近最新中文字幕大全免费视频 | 男人爽女人下面视频在线观看| 国产黄色免费在线视频| 欧美成人精品欧美一级黄| 亚洲综合色惰| 午夜福利一区二区在线看| 日韩成人av中文字幕在线观看| 色94色欧美一区二区| 老司机亚洲免费影院| 国产极品天堂在线| 日韩制服丝袜自拍偷拍| 大片电影免费在线观看免费| 国产精品二区激情视频| 午夜福利影视在线免费观看| 这个男人来自地球电影免费观看 | 国产白丝娇喘喷水9色精品| 又黄又粗又硬又大视频| 超色免费av| www.自偷自拍.com| 日本猛色少妇xxxxx猛交久久| 人妻一区二区av| 亚洲国产欧美网| 人成视频在线观看免费观看| 美女视频免费永久观看网站| 日日撸夜夜添| 蜜桃在线观看..| 91精品伊人久久大香线蕉| 在线看a的网站| 性色av一级| 亚洲国产av新网站| 久久精品aⅴ一区二区三区四区 | 亚洲视频免费观看视频| 大片免费播放器 马上看| 男女下面插进去视频免费观看| 在线观看www视频免费| 精品国产一区二区久久| 日韩欧美一区视频在线观看| 免费观看无遮挡的男女| 国产女主播在线喷水免费视频网站| 在线观看www视频免费| 国产成人91sexporn| 久热这里只有精品99| 国精品久久久久久国模美| 制服丝袜香蕉在线| 婷婷色av中文字幕| 爱豆传媒免费全集在线观看| 国产成人一区二区在线| 夜夜骑夜夜射夜夜干| 免费高清在线观看视频在线观看| 亚洲精品一区蜜桃| 国产视频首页在线观看| 亚洲av电影在线进入| 亚洲国产色片| 日韩伦理黄色片| 日本欧美视频一区| 精品少妇久久久久久888优播| 日本免费在线观看一区| 啦啦啦啦在线视频资源| 七月丁香在线播放| 18+在线观看网站| 亚洲婷婷狠狠爱综合网| 午夜日本视频在线| 日日啪夜夜爽| 青春草亚洲视频在线观看| 久久精品人人爽人人爽视色| 曰老女人黄片| 免费播放大片免费观看视频在线观看| 在线观看免费视频网站a站| 国产av国产精品国产| 国产成人精品久久二区二区91 | 一级爰片在线观看| 午夜免费鲁丝| 满18在线观看网站| 欧美 日韩 精品 国产| 可以免费在线观看a视频的电影网站 | 色94色欧美一区二区| 国产黄色视频一区二区在线观看| 亚洲欧洲国产日韩| 国产精品国产av在线观看| 好男人视频免费观看在线| 亚洲精品自拍成人| 精品人妻一区二区三区麻豆| 精品第一国产精品| 成年美女黄网站色视频大全免费| 老汉色∧v一级毛片| 欧美精品国产亚洲| 精品酒店卫生间| 九色亚洲精品在线播放| 日韩制服骚丝袜av| 热99久久久久精品小说推荐| 天天躁日日躁夜夜躁夜夜| 这个男人来自地球电影免费观看 | 亚洲国产看品久久| 国产1区2区3区精品| 国产精品 国内视频| 久久精品国产亚洲av天美| 国产视频首页在线观看| 丝袜美腿诱惑在线| 婷婷成人精品国产| 日韩av免费高清视频| 日韩熟女老妇一区二区性免费视频| 九色亚洲精品在线播放| 日韩一卡2卡3卡4卡2021年| 久久亚洲国产成人精品v| 高清欧美精品videossex| 成人黄色视频免费在线看| 青春草视频在线免费观看| 一区二区三区四区激情视频| 天天躁夜夜躁狠狠久久av| 久久精品国产亚洲av天美| 国产高清国产精品国产三级| 美女脱内裤让男人舔精品视频| 久久精品久久久久久久性| 在线观看三级黄色| 伦理电影大哥的女人| 亚洲欧美日韩另类电影网站| 一本—道久久a久久精品蜜桃钙片| 精品少妇黑人巨大在线播放| 老司机影院成人| 日韩精品有码人妻一区| 蜜桃在线观看..| 欧美人与性动交α欧美软件| 日韩中字成人| 久久久精品免费免费高清| 咕卡用的链子| 街头女战士在线观看网站| 亚洲三级黄色毛片| 精品少妇内射三级| 国产黄频视频在线观看| 国产又爽黄色视频| 精品少妇内射三级| 国产精品成人在线| 国产xxxxx性猛交| 精品少妇久久久久久888优播| av网站免费在线观看视频| 999精品在线视频| 午夜久久久在线观看| 最近中文字幕2019免费版| 美女视频免费永久观看网站| 多毛熟女@视频| 在线天堂最新版资源| 飞空精品影院首页| 精品一区在线观看国产| 免费观看av网站的网址| 999久久久国产精品视频| 久久影院123| 日本免费在线观看一区| 国产精品蜜桃在线观看| 夫妻午夜视频| 国产av精品麻豆| 国产成人欧美| 精品一区在线观看国产| 成年美女黄网站色视频大全免费| 免费黄网站久久成人精品| 黑人欧美特级aaaaaa片| av网站免费在线观看视频| 老女人水多毛片| av国产精品久久久久影院| freevideosex欧美|