Liver abscess
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This presentation gives general overview of liver abscess.
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Liver abscess
- 1. Liver Abscess Muhammad Haris Janjua Resident, Surgical unit I SIMS/Services Hospital, Lahore.
- 2. Classification • Pyogenic abscess, – polymicrobial, • Amoebic liver abscess – Entamoeba histolytica • Fungal abscess – Candida species
- 4. • More common in Right lobe WHY?
- 5. • Left lobe receives blood from – Inferior mesenteric – Splenic veins • Right lobe receives blood from – Superior mesenteric – Portal veins • Streaming effect in portal circulation is causative.
- 6. • The most common infecting agents are gram- negative bacteria; – Escherichia coli • Other common organisms include – Streptococcus faecalis, – Klebsiella, and – Proteus vulgaris. • In patients with endocarditis and infected indwelling catheters, – Staphylococcus and – Streptococcus species are common
- 7. Presentation
- 8. Common presentation • Fever (either continuous or spiking) • Chills • Right upper quadrant pain • Tender hepatomegaly • Anorexia • Malaise • Diarrhea in present in 1/3 patients with amoebic liver abscess
- 9. Differential diagnosis • Acute Gastritis • Bacterial Pneumonia • Biliary Disease • Cholecystitis • Hepatocellular Carcinoma • Hydatid Cysts • Parapneumonic Pleural Effusions and Empyema Thoracis
- 10. Diagnosis • Lab tests • Most common – Neutrophilic leucocytosis – Elevated ESR – Elevated AP levels • elevations of transaminase and bilirubin levels are variable
- 11. • Blood cultures are positive in roughly 50% of cases. • Culture of abscess fluid should be the goal in establishing microbiologic diagnosis • ELISA should be performed – to detect E histolytica in patients either from endemic areas or who have traveled to endemic areas. • Indirect Haemagglutinin assays (IHA) is the most sensitive test (90%).
- 12. Imaging studies
- 14. Principals of Management of Pyogenic liver abscess • Drain the pus • Institute appropriate antibiotics, and • Deal with any underlying source of infection, Percutaneous drainage combined with antibiotics has become the first line and mainstay of treatment for most PLAs
- 15. Drainage Options • Percutaneous – Needle aspiration – Catheter drainage • Surgical drainage – Open – Laproscopic
- 16. Percutaneous needle aspiration • Under CT or USG guidance, needle aspiration of cavity material can be performed. • Needle aspiration enables – rapid recovery of material for microbiologic and pathologic evaluation. • Large percentage requires second or third aspirations to achieve success
- 17. Percutaneous catheter drainage • Percutaneous drainage has become the standard of care. • Should be the first intervention considered for – Small cysts. – The pus is too thick to be aspirated – The wall is thick and non-collapsible – The PLA is multi-loculated
- 18. • Advantages include – reduced costs, recovery time, – it eliminates the need for general anesthesia – This also allows for gradual, controlled drainage.
- 19. Percutaneous catheter drainage • A catheter is placed under ultrasonographic or CT guidance via the Seldinger or trocar techniques. • The catheter is flushed daily until output is less than 10 mL/day or cavity collapse is documented by serial CT.
- 20. • Contraindications to catheter drainage include • coagulopathy; • a difficult access path to the cavity; • peritonitis; and/or • a complicated, multiloculated, thick- walled abscess with viscous pus.
- 21. Antibiotic therapy • Antibiotic therapy should cover gram negative organisms and anaerobes • First line antibiotics are – Penicillin's, aminoglycosides and metronidazole or – Cephalosporin and metronidazole • Can be changed after Culture report
- 22. • IV antibiotic therapy should be continued for at least 8 weeks • Some studies suggest antibiotics should be administered parenterally for 2 weeks • Then appropriate oral agents may be used for a further 6 weeks
- 23. Surgical drainage • Indications of surgical drainage include – Failure of non operative treatment – Intraperitoneal rupture – the presence of a complicated, multiloculated, thick-walled abscess with viscous pus – treatment of underlying intra-abdominal processes, • peritonitis; • existence of a known abdominal surgical pathology (eg, diverticular abscess)
- 24. Approaches Open • A transperitoneal approach – allows for abscess drainage and – abdominal exploration to identify previously undetected abscesses and the location of an etiologic source • Transpleural approach – For high posterior lesions, – easier access to the abscess, – the identification of multiple lesions or a concurrent intra-abdominal pathology is lost
- 25. Laparoscopic approach • Used in select cases • Experienced and well equipped setups
- 26. Management of amoebic liver abscess Medical • Metronidazole 750 mg three times a day for 7 to 10 days is the treatment of choice • successful in 95% of cases.
- 27. • Aspiration of the abscess rarely is needed –with large abscesses, –Those who appear to be superinfected. –Large abscess having impending rupture / compression sign –Thin rim of liver tissue around the abscess (<10 mm) –Sero-negative abscesses –Failure in the improvement following non- invasive treatment after 4 to 5 days
- 28. • Abscesses of the left lobe of the liver at risk for rupture into the pericardium should be treated with aspiration and drainage.
- 29. Open drainage • Rupture of amoebic abscess in adjacent viscera is indication of open drainage
- 30. • The amebic abscess has • Necrotic central portion that contains a thick, reddish brown, pus-like material. • This material has been likened to anchovy paste or chocolate sauce.
- 32. Treatment of intestinal carriage • Luminal amebicidal agent • Paromomycin – 25-30 mg/kg/d orally for 7 days in three divided doses – Iodoquinol – Diloxanide furoate
- 33. Long-Term Monitoring • Weekly serial computed tomography (CT) or ultrasound examinations to document adequate drainage of the abscess cavity. • Maintain drains until the output is less than 10 mL/day • Monitor fever curves. – Persistent fever after 2 weeks of therapy may indicate the need for more aggressive drainage
- 34. • For patients with an underlying malignancy, definitive treatment, such as surgical removal of the mass, should be pursued if at all possible. • Patients on prolonged parenteral antibiotics monitoring of RFTs and TLC may be needed.
- 35. Complications of liver abscess – Sepsis – Empyema resulting from contiguous spread or intrapleural rupture of abscess – Rupture of abscess with resulting peritonitis – Endophthalmitis when an abscess is associated with K pneumoniae bacteremia.