LIVER ABSCESS

By :Hamad Emad Hamad

Dhuhayr

OBJECTIVES

Anatomy of liver Classification Etiology and patho-physiology Management

ANATOMY OF LIVER

CLASSIFICATIONPYOGENIC

Gram Positive Gram-negative Anaerobic

Staph aureus,Strepto pyogenes,Strepto milleri,strepto faecalis

E coli,Klebsiella,Proteus Bacteroids,Clostridium,Actinomyces

AMOEBIC

CANDIDA

TB (rare)

PATHO PHYSIOLOGY

Liver largest portion of reticuloendothelial system so continuous exposure to bacteria from enteric tract

Due to high level of reticuloendothelial tissue, non-viral infections are uncommon

RISK FACTORS

PYOGENIC DM Cancer Liver Transplant

ENTAMOEBA Pregnancy Steroids Cancer Endemic area travel (short or long term)

PYOGENIC LIVER ABSCESS

EPIDEMIOLOGY

MALE > FEMALE3 : 1

MORE IN RIGHT LOBE, SUPERIOR ASPECT INCREASED INCIDENCE IN DIABETES

MELLITIS

PATHO PHYSIOLOGY OF PYOGENIC ABCESS PYOGENIC:

Peritonitis To liver via portal circulation

Direct Spread Biliary infections(ascending cholingitis

Hematogenous Seeding Bacteremia, septecemia(unusual)

Adjacent infections Sub phrenic abscess, Cholecystitis

Sites: R lobe most common Blood supply

…PATHO PHYSIOLOGY

Mostly multiple abscesses/sometimes single 40 % monomicrobial 40 % polymicrobial 20 % negative culture

SIGN AND SYMPTOMS

Rigors high swinging temp(90 %) Tender palpable liver(50 %) Jaundice 1/3 Charcot’s triad Or non-specific malaise over month

INVESTIGATIONS

NON SPECIFIC total lymphocyte count: increase leukocytosis Increase ESR Increase alk phosphate(mild)(67-90%)

SPECIFIC USG DIAGNOSTIC ASPIRATION & CULTURE SENSITIVITY CT scan

ULTRASOUND OF PYOGENIC ABSCESS

CT SCAN

TREATMENT

MEDICAL BROAD SPECTRUM ANTIBIOTICS

triple regime(penicillin , amino glycoside and Metronidazole)

cephalosporin and Metronidazole SPECIFIC

ACCORDING TO CULTURE SENSITIVITY i/v fluids to prevent hepatorenal syndrome ANALGESICS & ANTIPYRATICS Urgent drainage

CONTINUED

INVASIVE TO DRAIN OR NOT TO DRAIN:

<5cm, single abscess- needle aspiration or catheter

>5cm- catheter Also: Surgery, ERCP

URGENT DRAINAGE USG GUIDED, AND PIG TAIL CATHETER OPEN

ERCP IN CASE OF OBSTRUCTION

AMOEBIC LIVER ABSCESS

AMOEBIC ABSCESS

Epidemiology M > F 7:1 10 % world population 40-50 million amoeba infections/year worldwide Age Extremes Endemic Areas most susceptible Country of origin or Travel

GEOGRAPHIC DISTRIBUTION

ETIOLOGY AND PATHOPHYSIOLOGY

Entemoeba histolytica

MODE OF TRANSMISSION Large intestine (history of dysentery) Travel to liver most common superior aspect near

diaphragm through portal vein Where proliferates to produce cytolytic enzymes Destroy liver tissues Abscess which is sterile(anchovy paste or

chocolate sauce Amoeba may be found in abscess wall

SIGN AND SYMPTOMS

Fever Pain RHC Dysentery Tenderness

INVESTIGATIONS

NON SPECIPIC Increase TLC Increase LFT’s Most common biochemical abnormality(alk phosphate)

SPECIFIC USG CT SCAN IMAGE GUIDED ASPIRATION ANCHOVY SAUCE

LIKE CULTURE AND SENSTIVITY Fluorescent antibody test for Entamoeba(can be

positive even after clinical cure) If serology is negative , amoebiasis is uncertain

USG OF AMEBIC ABSCESS-NOTE PERIPHERAL LOCATION, ROUNDED SHAPE, POOR RIM WITH INTERNAL ECHOES

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CT SHOWING SUPERFICIAL ABSCESS

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CT SCAN OF AMEBIC ABSCESS (A). THE LESION IS PERIPHERALLY LOCATED AND ROUND. RIM IS NONENHANCING BUT SHOWS PERIPHERAL EDEMA (BLACK ARROWS). NOTE THE EXTENSION INTO THE INTERCOSTAL SPACE (WHITE ARROWS).

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TREATMENT

NON INVASIVE Metronidazole 400-800 mg TDS …….7 to 10 days

INVASIVE Ultrasound guided aspiration Surgery

Amoeba: drainage not usually required Exceptions:

Verge of rupture Abx not working Imminent need to exclude other dx Large abscess

COMPARISON

PROGNOSIS & NATURAL HISTORY

• Mortality 2-12%• Often due to co morbidities, not

necessarily abscess itself

SUMMARY

If untreated LA is potentially fatal. Must be diagnosed & treated promptly Investigations-LFT,USG and CT SEROLOGY-corner stone to differentiate Pyogenic liver abscess-Antibiotics plus

drainage Causative pathology should also be treated

ALA-most cases treated with amebicidal agents alone with drainage procedures reserved for resistant or complicated cases

Luminal amebicides should also be given When there is high index of suspicion for LA

Rx should not be withheld until diagnosis is confirmed

REFERRENCES

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