Transcript LIVER ABSCESS

LIVER ABSCESS
 Occurs when bacteria/protozoa
destroy hepatic tissue, produces a
cavity which fills up with infective
organisms, liquefied cells &
leucocytes. Necrotic tissue then falls
off the cavity from rest of the liver.
 Pyogenic abscess
 Amoebic abscess
Pyogenic abscess
 Male preponderance
 Average age – between 43 & 60 years
 Infective organisms invade liver
directly after liver wound or spread
from lungs, skin or other organs by
hepatic artery, portal vein, biliary
tract
Origin & causes
1) Biliary tract
Underlying biliary diseases is the
most common cause;
a) Septic cholangitis
b) Biliary stenting
c) Sclerosing cholangitis
d) Cholangio carcinoma
2) Portal vein
Portal pyaemia following pelvic /
GI infection that leads to Portal
Pylephlebitis or septic emboli
a) Appendicitis
b) Diverticulitis
c) Perforated ulcer
b) Pancreatitis
3) Hepatic artery
a) Bacterial endocarditis
4) Trauma
a) Penetrating wound
b) Blunt trauma
5) Direct
a) Perforated peptic ulcer
b) Subphrenic abscess
c) Adjacent abscess- Perinephric
abscess
6) Miscellaneous
Obscure in 5 % cases
Other unusual causes:
a) Cysts- Including Polycystic
liver disease)
b) Intrahepatic malignancy
c) Hydatid cyst
Bacteriology
 Majority derived from GI tract in
>75% cases
 Aerobic:
a) E.coli – most common cause
b)Klebsiella pneumoniae
c)Others: Pseudomonas
aerogenosa, Morganella morganii,
Serratia marsecens, etc.
 Anaerobic:
a) Bacteroides fragilis (most
common)
b) Others: Fusobacterium spp.,
anaerobic Streptococci, Clostridium
spp., Actinomyces spp.
 Based on size & distribution of focal
sites;
a) Macroscopic abscess
b) Microscopic abscess
Macroscopic
a) Single
b) Restricted to one
lobe
Microscopic
a) Multiple
b) Widely distributed
throughout the
hepatic
parenchyma
c) Present subacutely
with symptoms of c) Manifest acutely
over a few days
several days to
weeks’ duration
d) Require primary
d) Require primary
drainage
medical treatment
with surgery
Clinical features
 Symptoms:
Fever
Abdominal pain
Chills
Anorexia
Weight loss
Nausea, Vomiting
Right shoulder pain / irritable cough
 Signs:
Hepatomegaly
Tenderness
Rebound tenderness
Jaundice (late)
Histology
 Portal zone infection & surrounding
hepatocytes, infiltrated with
polymorph
Investigations
1) Routine:
a) Hb-anemia
b) WBC-luecocytosis
c) Blood culture – organisms present
2) Liver Function test:
a) Elevated serum alkaline
phosphatase (most reliable);
b) Elevated serum bilirubin (50%)
c) Elevated aminotransferases (48%)
d) Hypoalbuminemia (33%)
3) Chest X-Ray:
a) Elevation of right hemidiaphragm
b) Right basilar infiltrate
4) USG:
Differentiate as a round or oval areahypoechoic fluid filled area
5) CT Scan:
Cluster sign- seen when multiple small
abscess aggregate, which suggests
beginning of coalescence to single abscess
6) MRI:
Raised lesion with sharp borders
7) Aspiration of material:
Diagnostic & Therapeutic
Treatment
Start with empiric antibiotics:
Ampicillin
Metronidazole
Gentamicin
Specific antibiotics (Depending on cultures)
6-16 weeks
If persisting
Percutaneous drainage (under USG/CT
guidance)
Surgical Drainage
 Indications for surgical drainage:
a) Abscess with intra-abdominal
pathology requiring surgery
b) Ascitis
c) Multiple large abscesses
d) Abscess which cannot be
drained percutaneously
Amoebic Abscess
 Commonest extra-intestinal
presentation of amoebiasis
 Common in alcoholics
 Caused by Entamoeba histolytica
 Entry by faeco-oral route
Pathology
 Amoeba multiply-block in intrahepatic
portal radicles-focal infarction of liver
cellsproteolytic enzymes released- destiny
liver parenchyma
 Site: Right lobe of liver,
supraanteriorly, just below the
diaphragm
Large necrotic area which is
liquefied into thick reddish-brown pus
(Anchovy sauce pus) due to liquefied
necrosis, thrombosis of blood vessels,
lysis of liver cells
Histology
Necrotic area containing degenerated
liver cells, leucocytes, RBCs,
connective tissue strands, debris &
amoeba
Clinical features
 Symptoms:
High grade fever with rigor
Weight loss
Upper quadrant pain ( Initially
dull aching, later on stabbing)
Jaundice (not common)
 Signs:
Hepatomegaly (tender)
Consolidation in right lower
zone of lungs
Pleurisy
Complications
1) Rupture into lung/pleura
a) Empyema
b) Hepatobronchial fistula
c) Pulmonary abscess
d) Pneumonitis
e) Pleural effusion
2)
3)
4)
5)
Rupture into pericardium
Intraperitoneal rupture
Rupture into portal vein (rare)
Secondary infection
Investigations
1) Routine:
Leucocytosis
Anemia
2) Liver function test:
Increased Alkaline Phosphatase
Increased Transaminase
3) Stool examination: cysts/
trophozoites
4) Aspiration: Anchovy sauce pus
5) Chest X-Ray
Raised fixed diaphragm
Right lateral abscess
6) USG (most useful) : Round lesion
7) CT : Irregular edge
8) Serology: ELISA
Treatment
 Metronidazole 750mg orally/i.v. 3
daily x 4 days
If response, continue for 10
days; followed by luminal agents:
Iodoquinol 650mg 3 X 20
days
Paramomycin 500mg 3 X
10 days
If no response,
Dihydroemetine 1.5mg/Kg
i.m. 4 X 5 days
+
Chloroquine phosphate
600mg base/day orally 4 X 2 days,
then 300mg base/day orally 4 times
If no response to medical treatment:
Percutaneous drainage
Thank You