LIVER ABSCESS

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LIVER ABSCESS

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• 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.

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• Pyogenic abscess
• Amoebic abscess

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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

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Origin causes

• Biliary tract
• Underlying biliary diseases is the most
  common cause
• a) Septic cholangitis
• b) Biliary stenting
• c) Sclerosing cholangitis
• d) Cholangio carcinoma

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• 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

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• 3) Hepatic artery
• a) Bacterial endocarditis
• 4) Trauma
• a) Penetrating wound
• b) Blunt trauma

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• 5) Direct
• a) Perforated peptic ulcer
• b) Subphrenic abscess
• c) Adjacent abscess- Perinephric
  abscess

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• 6) Miscellaneous
• Obscure in 5 cases
• Other unusual causes
• a) Cysts- Including Polycystic liver
  disease)
• b) Intrahepatic malignancy
• c) Hydatid cyst

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Bacteriology

• Majority derived from GI tract in gt75 cases
• Aerobic
• a) E.coli most common cause
• b)Klebsiella pneumoniae
• c)Others Pseudomonas aerogenosa,
  Morganella morganii, Serratia marsecens, etc.

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• Anaerobic
• a) Bacteroides fragilis (most common)
• b) Others Fusobacterium spp.,
  anaerobic Streptococci, Clostridium spp.,
  Actinomyces spp.

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• Based on size distribution of focal sites
• a) Macroscopic abscess
• b) Microscopic abscess

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Macroscopic Microscopic
Single Restricted to one lobe Present subacutely with symptoms of several days to weeks duration Require primary drainage Multiple b) Widely distributed throughout the hepatic parenchyma c) Manifest acutely over a few days d) Require primary medical treatment with surgery
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Clinical features

• Symptoms
• Fever
• Abdominal pain
• Chills
• Anorexia
• Weight loss
• Nausea, Vomiting
• Right shoulder pain / irritable cough

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• Signs
• Hepatomegaly
• Tenderness
• Rebound tenderness
• Jaundice (late)

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Histology

• Portal zone infection surrounding hepatocytes,
  infiltrated with polymorph

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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)

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• 3) Chest X-Ray
• a) Elevation of right hemidiaphragm
• b) Right basilar infiltrate
• 4) USG
• Differentiate as a round or oval area-
  hypoechoic fluid filled area
• 5) CT Scan
• Cluster sign- seen when multiple small
  abscess aggregate, which suggests beginning of
  coalescence to single abscess

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• 6) MRI
• Raised lesion with sharp borders
• 7) Aspiration of material
• Diagnostic Therapeutic

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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

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• 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

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Amoebic Abscess

• Commonest extra-intestinal presentation of
  amoebiasis
• Common in alcoholics
• Caused by Entamoeba histolytica
• Entry by faeco-oral route

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Pathology

• Amoeba multiply-block in intrahepatic portal
  radicles-focal infarction of liver cells-
• proteolytic enzymes released- destiny liver
  parenchyma

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• 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

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Histology

• Necrotic area containing degenerated liver cells,
  leucocytes, RBCs, connective tissue strands,
  debris amoeba

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Clinical features

• Symptoms
• High grade fever with rigor
• Weight loss
• Upper quadrant pain ( Initially dull
  aching, later on stabbing)
• Jaundice (not common)

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• Signs
• Hepatomegaly (tender)
• Consolidation in right lower zone of
  lungs
• Pleurisy

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Complications

• 1) Rupture into lung/pleura
• a) Empyema
• b) Hepatobronchial fistula
• c) Pulmonary abscess
• d) Pneumonitis
• e) Pleural effusion

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• 2) Rupture into pericardium
• 3) Intraperitoneal rupture
• 4) Rupture into portal vein (rare)
• 5) Secondary infection

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Investigations

• Routine
• Leucocytosis
• Anemia
• 2) Liver function test
• Increased Alkaline Phosphatase
• Increased Transaminase
• 3) Stool examination cysts/ trophozoites

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• 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

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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

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• 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

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• Thank You