Liver abscess

This presentation gives general overview of 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

3. Pathophysiology

4. More common in R ight 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

13. 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

14. Drainage Options Percutaneous Needle aspiration Catheter drainage Surgical drainage Open Laproscopic

15. 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

16. Percutaneous catheter drainage Percutaneous drainage has become the standard of care. Should be the first intervention considered for S mall cysts. The pus is too thick to be aspirated The wall is thick and non-collapsible The PLA is multi- loculated

17. Advantages include reduced costs, recovery time, it eliminates the need for general anesthesia This also allows for gradual, controlled drainage .

18. 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.

19. 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.

20. 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

21. 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

22. 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)

23. 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

24. Laparoscopic approach Used in select cases Experienced and well equipped setups

25. 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 .

26. Aspiration of the abscess rarely is needed w ith 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

27. Abscesses of the left lobe of the liver at risk for rupture into the pericardium should be treated with aspiration and drainage .

28. Open drainage Rupture of amoebic abscess in adjacent viscera is indication of open drainage

29. 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.

30. Treatment of intestinal carriage Luminal amebicidal agent Paromomycin 25-30 mg/kg/d orally for 7 days in three divided doses Iodoquinol Diloxanide furoate

31. Long-Term Monitoring W eekly 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

32. 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.

33. 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.

34. Available at surgicalpresentations