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

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.