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

A BSTRACT 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. 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. 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. 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. 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.