Liver Abscess

liver abscess

1. Liver Abscess Prepared by: P rerit Devkota 2nd year Resident Department of EM/GP PAHS Moderator : Dr. Samyukta K.C

2. LIVER ABSCESS C ollection of purulent material in liver parenchyma forming a cavity M ost common type of visceral abscess Uncommon 3.6/100000 populations UK/US 15/100000 Asia Prevalence stable,detection improved ,mortality improved C an be: B acterial (pyogenic) P arasitic (amoebic) F ungal Amoebic liver abscess – worldwide P yogenic liver abscess – USA

3. P yogenic Liver Abscess

4. P yogenic Liver Abscess L iver abscess due to bacteria Incidence : 2.3/100000 populations Male : female = 1.5:1 R isk factors: DM U nderlying hepatobiliary or pancreatic disease L iver transplant R egular use of PPI Male gender C olorectal Ca. ---- K. P neumoniae --- Liver abscess

5. Pathogenesis Liver – recieves portal venous bacterial load regularly – clears up – beyond capacity – abscess Asia – gall stones and cholangitis West – malignant obstruction

6. Pathogenesis Portal vein : diverticulitis, appendicitis, pancreatitis, inflammatory bowel disease, pelvic inflammatory disease, perforated viscus , and omphalitis in the newborn Hepatic artery: systemic infection ( endocarditis , pneumonia, osteomyelitis ) – bacteremia Penetrating/blunt trauma: Intrahepatic hematoma/necrosis – infection – abscess

7. Microbiology and Pathology Right lobe – 75% 50% - solitary Polymicrobial – 40% ( pyelophlebitis / cholangitis ) or monomicrobial (systemic infections) Gram negative and anarobes : 40 -60 % Escherichia coli , Klebsiella pneumoniae , Staphylococcus aureus , Enterococcus Pseudomonas, Proteus, Enterobacter,Peptostreptococcus Fungal and mycobacterial – rare in immunocompromised Blood culture : 50 – 60% positive

8. Clinical features Classical presentation : fever with chills, jaundice and RUQ pain with tenderness on palpation C omplications: A bscess rupture – peritoneal or pleural or pericardial space S epsis / septic shock Klebsiella - endogenous endophthalmitis (3% ) in diabetics

9. Examination Fever and RUQ tenderness Jaundice – 25% , chest findings - 25% Hepatomegaly – 50% Ruptured abscess – signs of peritonitis and shock

10. D iagnosis L iver lesion on imaging (USG/CT/MRI) + Purulent material on Aspiration + I solation of organism from pus(gram stain,AFB stain,c/s,serology ,PCR)

11. Investigations CBC LFT Albumin and PT/INR CXR (50%) – elevated right hemidiaphragm , right pleural effusion, or atelectasis Abdomina X-ray : air-fluid levels or portal venous gas

12. Imaging USG Vs. CECT – 85% vs.95% sensetivity

13. Differential Diagnosis H epatitis L iver tumors R ight lower lobe pneumonia A cute cholangitis A cute cholecystitis H ydatid cyst G all Stone

14. Treatment M edical and S urgical M edical : E mperic Atbx : S tarted before pus culture or other reports S hould cover Streptococci,E.coli,Anarobes,E.histolytica C eftriaxone + Metronidazole , Ampicillin+Metronidazole+Gentamycin, floroquinolone+Metronidazole I f Staphylococcus – Vancomycin D uration : 4-6 weeks : if incomplete drainage when surgically intervened 2-4 weeks : if completely drained

15. Surgical Treatment PNA or PCD USG or CT guided ERCP drainage – if infection continues through biliary tree S ingle abscess </= 5cm ----- PNA or PCD – 7 days S ingle unilocular >5 cm ---- PCD > PNA – 7 days M ultiple or multiloculated abscess PCD > PNA

16. Open Surgery Indications : I nadequate response to PCD or PNA Abscess with viscious content that blocks catheter Infected hepatic malignant neoplasm, hepatolithiasis , or intrahepatic biliary stricture

17. Follow up

18. P rognosis M ortality : 2 – 12 % N eed for open surgical intervention A ssociated with malignancy A naerobic infection

19. Any Questions???

20. A moebic Liver Abscess

21. A moebic Liver Abscess C aused by protozoa - E.histolytica h/o travel and dysentry or diarrhoea Age : 20 – 40 yrs M:F = 10:1 Menstruating women and IDA – low incidence Alcohol consumption and immunocompromised state – high risk

22. Pathogenesis

23. Pathology Anchovy sauce pus Odourless Liquefactive necrosis Glisson capsule is resistant to hydrolysis by amoeba

24. Clinical features

25. Investigations CBC LFT PT/INR – elevated Indirect hemagglutination test (90%)– circulating antibodies Past Vs. Active infection PCR – pus X- ray,USG,CT

26. T reatment U ncomplicated : Medical therapy M etronidazole/Tinidazole/Nitazoxanide – 7 – 10 days P aramomycin (20-30 mg/kg/day) / DF – 7 - 10 days P regnant lady : Metronidazole / Chloroquine (6oo mg – 2 days then 300 mg 3 weeks) C omplicated : PCD/PNA Left lobe abscess L ack of clinical response of medical therapy for 5 days - UpToDate 2020

27. Prognosis Poor prognosis elevated serum bilirubin level (>3.5 mg/ dL ), encephalopathy, hypoalbuminemia (<2.0 g/ dL ), multiple abscess cavities, abscess volume larger than 500 mL M ortality <1%

28. T ake Home Mess a ges L iver abscess is one of the common cause for RUQ pain in our world – amoebic liver abscess being most common C an be diagnosed clinically aided by radiological investigation M ostly involves right lobe in 20 – 40 yrs usually male population with E.coli being most common organism <5 mm – can be managed medically , if >5 mm : better to go for percutaneous drainage (PCD/PNA) ; PCD being superior to PNA for early clinical improvement, less duration of hospital stay and earlier reduction in 50% reduction of abscess size

29. R eferences Sabiston textbook of surgery, 20 th edition UpToDate 2020 Kulhari M, Mandia R. Prospective randomized comparative study of pigtail catheter drainage versus percutaneous needle aspiration in treatment of liver abscess. ANZ Journal of Surgery. 2018;89(3):E81-E86.

30. Any Queries???

31. T hank you!!