9.LIVER ABSCESS

This is a lecture note for 5th-semester MBBS students. Lecture notes on hepatology, liver disease, and liver abscess. Introduction to a liver abscess, pyogenic liver abscess, causes, approach and management of liver abscess.

1. Hepatology lectures for
5
th
Sem;MBBS
Pratap Sagar Tiwari
MBBS,MD (Medicine),DM (Hepatology)

2. LIVER ABSCESS
PYOGENIC
HYDATID
AMOEBIC
INTRA-PERITONEAL ABSCESS
VISCERAL ABSCESS
LIVER ABSCESS
Note: Hydatiddisease is a parasitic infestation by a
tapeworm of the genusEchinococcus.
Infected hydatid are included in liver abscess, for further info; learn hydatid cystic disease
FUNGAL

3. INTRODUCTION: LIVER ABSCESS
•Aliverabscessisaspace-occupyingsuppurativelesionintheliverresulting
fromtheinvasionofmicroorganismsenteringdirectlyfromaninjury,through
thebloodvessels,orthroughthebileducts.(Schiff)
•Thethreemajorformsofliverabscess,classifiedbyetiology,areasfollows:
1.Pyogenicabscess,whichismostoftenpolymicrobial,accountsfor80%of
hepaticabscesscasesintheUS.
2.AmebicabscessduetoEntamoebahistolyticaaccountsfor10%ofcases
[1]
3.Fungalabscess,mostoftenduetoCandidaspecies,accountsforfewer
than10%ofcases.
1.Othman N, Mohamed Z, YahyaMM, LeowVM, Lim BH, NoordinR. Entamoebahistolyticaantigenic protein detected in pus aspirates from patients with amoebic liver abscess. ExpParasitol. 2013 Aug. 134 (4):504-10.
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4. PYOGENIC LIVER ABSCESS
•There are four major ways in which pyogenic organisms invade the liver.
First,theymaytravelthoughtheportalveinfromregionsdrainedbyit.
Eg;Suppurativeappendicitis,pyelophlebitis,Ulcerationofthestomachorboweland
diseaseoftherectum,spleenandpancreas
Second,bloodborneinfections:transmittedthoughhepaticartery.
Eg;Osteomyelitis,acuteinfectionsofupperrespiratorytractorpyemiafromany
sourcelikecholnagitis
Third:directextensionfromacontiguousinfection.
Eg;Subphrenicabscess,empyemagallbladder,nephritic/perinephricabscess.Infection
ofcysticlesionsortumorsofliver.
Lastly:trauma,postprocedures
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5. INTRODUCTION: LIVER ABSCESS
Source
Biliary Source multiple and of small size and involve both lobes of the liver
Septic emboli from the PV solitary and tend to be more common in the right lobe of liver
Contiguous source solitary and localized to one lobe only
Approximately60-75%aresolitaryandtheyaremainlylocatedintheRT
lobeasaresultofthestreamingpatternofPBF,secondarytothefactthattherightlobeissuppliedpredominantlyby
theSMVandbecausemostofthehepaticvolumeisintheRTlobe.
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6. RISK FACTORS FOR DEVELOPMENT OF HA
Diabetes mellitus
Immunocompromised state
Liver Cirrhosis
Use of PPI
Advanced age
Male Gender
DMispresentinupto40%ofcasesandismorecommonlya/wabscessesduetoKlebsiellapneumoniae[6,7].
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7. Microbiology
Gram-tiveAerobic Bacteria 50-70%Gram+tiveAerobic Bacteria 25%
Escherichia coli
Klebsiellapneumoniae
Enterobacterspp.
Pseudomonas spp.
Proteus spp.
Enterococcus spp.
Streptococcus pyogenes
Staphylococcus aureus
Streptococcus millerigroup
Anaerobic Bacteria 40-50%
Bacteroidesspp.
Fusobacterium spp.
Others
Candida spp.
Mycobacterium
tuberculosis
Sleisenger
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8. CLINICAL FEATURES
Pre antibiotic era
Spiking fevers
Pain RUQ
Shock
Acute presentation
Present Context
Low grade fever
Anorexia
Weight loss
Dull pain abdomen
Sub-Acute presentation
Only 10% of pts will have the “characteristic” symptom triad of fever, jaundice, and right
upper quadrant (RUQ) tenderness. (Zakim/Boyer)
Whenanabscessissituatednearthedomeoftheliver,painmaybereferredtothertshoulder,ora
coughresultingfromdiaphragmaticirritationoratelectasismaybepresent.
In1928penicillin,thefirsttrueantibiotic,wasdiscoveredbyAlexanderFleming,ProfessorofBacteriologyatSt.Mary'sHospitalinLondon
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9. PHYSICAL EXAMINATION
Fever
PHTNmayfollowrecoveryifthePVhasbeenthrombosed.
Ascitesisrare
Intheabsenceofcholangitis,jaundiceispresentonlylateinthecourseoftheillness.
Splenomegalyisunusual,exceptwithachronicabscess.Hepatomegaly
Liver tenderness
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10. •Liver imaging : USG, CT LIVER
•Needle aspiration under ultrasound guidance confirms the diagnosis
and provides pus for culture.
•A leucocytosisis frequently found, ↑ plasma ALP activity, ↓serum
albumin.
•Chest X-ray: raised right diaphragm and lung collapse, or an effusion
at the base of the right lung.
•Blood cultures: positive in 50–80%.
INVESTIGATION

11. USG
PLA (A) Initial US showing debris inside the abscess cavity. (B) Liquefied pus inside the abscess. (SCHIFF)
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12. CT SCANS: PLA
PLAintheRLshowingahypointenserimwhichissecondary
toperipheralinflammation.
Ref:SCHIFF
CT scan shows a low attenuation defect in the
right lobe of the liver. Note gas in bile ducts (arrow).
Ref: Sherlock.
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13. CT SCAN: PLA: CLUSTER SIGN
(a)Arterial phase CECT shows a hypoattenuatinglesion consisting of smaller aggregating cystic
lesions, known as the “cluster” sign.
(b) Portal venous phase CT depicts enhancement of the irregular septa within the abscess.
Source: https://radiologykey.com/focal-hepatic-infections/
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14. GENERAL APPROACH
Suspicious?
USG/CT
Send blood & Aspirate Culture
Send Serum IgG/IgM Elisa for
Entamoeba
Start Empirical Antibiotics
Adjust antibiotics as per C & S
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15. MODALITIES OF MANAGEMENT
1.Management withAntibiotics
2.USG guided Aspiration: percutaneous needle aspiration
3.Drainage:
➢CT or US-guided percutaneous catheter drainage
➢Surgical drainage
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Forasolitaryabscess<5cmindiameter,confirmedbyaspirateandwithavailableantimicrobial
sensitivity,resolutioncanbeachievedwithantibioticsalone.

16. EMPIRICAL ANTIBIOTIC REGIME
•Antibiotictherapychoicesinvolvecombiningbroadspectrum
antibiotics:
➢Third-generationcephalosporinplusclindamycinormetronidazole.
➢Broadspectrumpenicillinplusaminoglycosides.
➢Second-generationcephalosporinplusaminoglycosides.
Schiff
Treatmentshouldbestartedimmediatelyafterspecimenshavebeen
obtainedforculturewithoutwaitingfordefinitiveresults.
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17. COMPLICATIONS OF PYOGENIC LIVER ABSCESS
•Pleural or pericardial effusion
•Empyema
•Portal vein thrombosis =24 %
•Hepatic Vein thrombosis= 22 %
•Splenic vein thrombosis
•Rupture into the pericardium, thoracic and abdominal fistula formation, and sepsis.
•Metastatic septic endophthalmitisoccurs in as many as 10% of diabetic patients
with a liver abscess caused by Klebsiellapneumoniae.
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18. DIFFERENCES BETWEEN AMOEBIC AND PLA
Schiff
ALA are usually solitary and present in Rtlobe
near the diaphragm.
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19. END OF SLIDES
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