Liver abscess

Etiology
Types of Liver Abscess
Diagnostic Evaluation
Medical Mngt
Nursing Management
Research based data

1. Liver Abscess Presented by: Anjali Arora M.Sc. Nursing -1 ST Year College Of Nursing Institute Of Liver and Biliary Sciences

2. Case -1 A 29 year old Indian man reported a 4-day history of RUQ abdominal pain. fever, chills and fatigue. Laboratory tests Leukocytosis- 14040 cells/mm 3 T otal bilirubin- 1.6 mg/dl, ALT- 100 U/L, AST- 69 U/L. Chest X-ray - right hemidiaphragm. USG- 10 cm diameter lesion in the right lobe of the liver. CT scan - 10 cm hypodense lesion

3. Case-2 A 76 year old presented with a 5-day history of spiking fever and chills with past medical history of cholecystectomy. Laboratory tests C Reactive Protein 31 mg/dl S.creatinine-1.8 mg/dl A lkaline phosphatase (823 U/L) T otal bilirubin- 2.12mg/dl, ALT- 110 U/L, AST- 139 U/L. Chest X-ray - right hemidiaphragm. USG- 3 cm diameter lesion in the right lobe of the liver. CT scan - 3 cm hypodense lesion

4. Anatomy of liver

5. Introduction Hepatic abscess (HA) is a localized process of encapsulated suppurative material. Although rare but it is associated with morbidity and mortality figures of 2-12%.

6. Introduction Liver abscess usually develops in association with one of the following three conditions: • Bacterial cholangitis , which results from obstruction of the bile ducts by stone or stricture • Portal vein bacteraemia , which may develop following bowel inflammation or organ perforation • Amebiasis (infection with amoeba)

7. Abscess may be define as a collection of pus (dead cells and neutrophils) that has accumulated within a tissue

8. Definition Liver abscess is a localized collection of necrotic inflammatory pus-filled mass in the liver. OR A liver abscess is a localized collection of pus and or organisms within the parenchyma of the liver.

9. Historical facts Liver abscess has long been recognized since the age of Hippocrates (400 BC). In 1883, Koch described the amoebae as a cause of liver abscess, and the first published review was in 1936 by Bright. In 1938, Ochsner and Debakey published the largest series of pyogenic and amebic liver abscesses in the literature.

10. Epidemiology Liver – organ most subject to the development of abscesses 13% of total intraabdominal abscesses 48% of all visceral abscess Mortality - 5-30% of cases Equal Male to female ratio. Males have poorer prognosis Male > female 3 : 1 More in right lobe, superior aspect Increased incidence in Diabetes Mellitus

11. Liver abscess A liver abscess is a collection of pus in the liver caused by bacteria, fungi, or parasites. It may occur as a single lesion or as multiple lesions of different sizes. The abscess may contain thick, bad smelling pus or reddish-brown anchovy paste-like fluid with no odor. 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.

12. Liver Abscess Left lobe receives blood from – Inferior mesenteric – Splenic veins Right lobe receives blood from – Superior mesenteric – Portal veins

13. Risk factors Age: Advanced age, particularly in people older than 70 years. Health: Having a long-term disease, (cancer, diabetes, tuberculosis) or splenectomy, a weak immune system, AIDS. Taking Drugs: Such as steroids, chemotherapy. Lifestyle: Drinking too much alcohol, too often. Living in over crowding area, poor sanitation Nutrition: Being malnourished (having poor nutrition). Activity: Traveling to places where amebiasis is common. Eating foods and drinking liquids that are sold in the street may further increase risk.

14. Liver abscess usually develops in association with one of the following three conditions: • Bacterial cholangitis • Portal vein bacteraemia • Amebiasis. Others: 1 .Infected hepatic cyst 2 .Metastatic liver tumours 3 .Diverticulitis Etiology

15. Pathophysiology

16. Pathophysiology

17. Classification CLASSIFICATION

18. Classification CLASSIFICATION

19. Classification CLASSIFICATION

20. Classification CLASSIFICATION

21. Classification CLASSIFICATION

22. Pyogenic liver abscess

23. Pyogenic Liver Abscess Pyogenic liver abscess is most often polymicrobial, accounts for 80% of hepatic abscess cases in the United States. A pyogenic liver abscess is a type of liver abscess caused by bacteria, can be single or multiple. The cluster sign is characteristic of the PHA, consisting of several lesions grouping to form a single multiloculated cavity.

24. Pyogenic Liver Abscess

25. Pyogenic Liver Abscess CLUSTER SIGN

26. Amoebic liver abscess

27. Amoebic liver abscess Amoebic liver abscess due to Entamoeba histolytica accounts for 10% of cases. E. histolytica causes amoebic colitis and dysentery but liver abscess is the most common extra-intestinal manifestation of infection Route of entry via oro -fecal route by ingestion of contaminated food or water. Amoebae invade intestinal mucosa and can gain access to the portal venous system.

28. Amoebic liver abscess Causes a 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 It affects the right lobe in 80%. This type is common in overcrowded areas with poor sanitation and in alcoholics.

29. S urgical piece of hepatectomy by PHA Well circumscribed cavity , with uneven contours , with dark material (“anchovy paste”) content. 

30. Parasitic liver abscess

31. Parasitic Liver abscess Parasitic protozoa: Entamoeba histolytica (10%). Parasitic helminths: Hepatic abscess is rarely associated with it. Mode of transmission: Ingestion of cysts.

32. Parasitic Liver abscess Pathology: Two-stage life cycle. The trophozoite (ameba stage) is motile. The cyst stage is nonmotile. Trophozoites are found in the intestinal and extraintestinal lesions. Cysts predominate in the stools, with some trophozoites present.

33. Fungal liver abscess

34. Fungal liver abscess Fungal abscess , most often due to Candida species, accounts for less than 10% of cases. Fungal abscesses is a less common type, primarily due to Candida albicans and occur in individuals with : Prolonged exposure to antimicrobials Hematologic malignancies Solid-organ transplants Congenital and acquired immunodeficiency.

35. Classification CLASSIFICATION

36. Liver Abscess Based on the duration of symptoms Acute (Less than a month) Chronic (Greater than a month)

37. Classification CLASSIFICATION

38. Liver Abscess Based on Associated conditions Primary Liver Abscess: if patient was previously healthy Secondary Liver Abscess: When associated with any systemic diseases or risk factors that could compromise the immune system such as HIV, infection, Neoplasm etc.

39. Route of Infection Biliary tract Hematogenous (via hepatic artery) Cryptogenic abscesses Blunt or penetrating trauma Direct infiltration and penetrating injuries tend to cause a large abscess

40. Clinical Manifestations Fever (either continuous or spiking) ,(PUO in Amoebic Abscess) Chills Right upper quadrant pain Pleuritic chest pain Anorexia Malaise Diarrhoea is present in 1/3 patients with amoebic liver abscess Clay- colored stools

41. Clinical Manifestations Abdominal pain Weight loss Nausea, Vomiting Right shoulder pain Cough and Dyspnoea ( due to hepatic friction rub associated with diaphragmatic irritation or inflammation of Glisson capsule) Hepatomegaly Tenderness Rebound tenderness Jaundice (late)

42. https://youtu.be/LHqqvrm2j6g

43. Basilar rales (crackles) https://youtu.be/LHqqvrm2j6g

44. Assessment History Collection Physical Examination

45. Diagnostic evaluation NON SPECIPIC Increase TLC - Leucocytosis Increase LFT’s SPECIFIC USG CT SCAN Image guided Aspiration Culture and sensitivity Fluorescent antibody test for Entamoeba(can be positive even after clinical cure) ELISA should be performed – to detect E histolytica Indirect Haemagglutinin assays (IHA)

46. Imaging studies

47. Diagnostic evaluation CBC Increased WBC, usually Neutrophilic Leukocytosis . Raised erythrocyte sedimentation rate (ESR). Mild normochromic normocytic anaemia. Liver function studies Hypoalbuminemia Elevation of alkaline phosphatase Elevations of transaminase and bilirubin levels (variable)

48. Diagnostic evaluation Blood cultures are positive in roughly 50% of cases. Stool Analysis : Stools can contain cysts or trophozoites of E. histolytica. Serology should be carried out if E. histolytica is suspected. Culture of abscess fluid should be the goal in establishing microbiologic diagnosis. Usually done through Percutaneous needle aspiration (under CT or Ultrasound Guidance)

49. Diagnostic evaluation Chest X-Ray: May show raised right hemi-diaphragm on. Ultrasonography Can show abscess and also allow guided percutaneous aspiration and drainage and biliary tree examination. A Doppler ultrasound study may be done to check for blood flow in your liver. CT scanning Can show the abscess , allow guided aspiration and drainage and show other intra-abdominal abscesses or a possible cause such as diverticular disease, appendicitis, etc. It is good for the detection of small abscesses. MRI

50. Diagnostic evaluation Microscopic stool examinations for trophozoites and cysts are performed in 3 to 6 stool samples for concentration and specificity and are positive in 25% cases. WHO recommends that intestinal amoebiasis should be diagnosed with specific stool E. histolytica testing (such as cultures, serology, antigen testing, and Enzyme immunoassay, hemagglutination tests or PCR) rather than microscopy for ova and cysts.

51. CXR USG The radiographic general rule of liver abscess: Bacterial and fungal abscesses are often Multiple Amoebic abscesses are often single

52. X-Ray features Gas within the abscess cavity, Gas in biliary tree ( pneumobilia ) or Gas beneath the diaphragm (elevating the diaphragm) right pleural effusion

53. USG features Intrahepatic abscesses larger than 2 cm Hypoechoic round or oval lesions (still with some internal echoes however), and irregularly shaped well defined borders Limitation in abscesses located in the dome of the liver and liquefied necrotic area does not enhance

54. USG features for Amoebic abscess Round or oval shaped lesion Absence of prominent abscess wall Hypoechogenicity Contiguity with diaphragm

55. USG features for candida abscess USG features Wheel within a wheel Bull’s eye Uniformly hypoechoic Echogenic BULL’S EYE

56. USG of amebic abscess Note : P eripheral location, rounded shape, poor rim with internal echoes

57. CT features CT scan is superior in detecting abscess (es) as small as 0.5 cm and reveals the abscess as: Lobar involvement Solid appearance (mimicking a hepatic tumour ) Contain gas in 20% of lesions Association with thrombophlebitis Contrast-enhanced CT scan demonstrates a large, lobulated,well -defined cystic mass in the right hepatic lobe. Double ring /double target sign

58. CT Scan

59. CT scan of amebic abscess Note: The lesion is peripherally located and round. Rim is non enhancing but shows peripheral edema (black arrows). Note the extension into the intercostal space (white arrows).

60. Faint rim enhancement and perilesional edema ( CLUSTER SIGN)

61. CT SCAN (Candidiasis) MRI (Candidiasis)

62. MRI

63. Imaging difference in amoebic and bacterial liver abscess

64. Management

65. Princip le s of Managemen t 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

66. Management   Intervention in hepatic abscess consists of: (1) P ercutaneous drainage of the abscess with antimicrobial therapy, (2) Surgical drainage of large abscess with post operative antimicrobial therapy (3) Antimicrobial therapy without drainage for a few months. Abscesses resulting from amoebic infestation (such as by Entamoeba histolytica) call for treatment with metronidazole (Flagyl) or chloroquine phosphate instead of broad-spectrum antibiotics.

67. Medical Management   A ntibiotic therapy Continuous supportive care Open surgical drainage may be required. P ercutaneous drainage are ineffective.

68. 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

69. 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

70. Empirical antibiotic Regimen

71. Management Pain Management : Alleviation or reduction in pain Nutrition Management: Assisting with or providing a balanced dietary intake of foods and fluids. Infection Protection: Infection Control, Prevention and early detection of infection in a patient at risk.

72. Pyogenic liver abscess Broad spectrum antibiotics should be started before waiting for culture results. Usually start treatment with tri-therapy included the use of penicillin, amino-glycoside and metronidazole. A third-generation cephalosporin can be considered in the elderly or if renal function is impaired. Antibiotic therapy can be modified once culture results are available. Treatment may be needed for up to 12 weeks and should be g uided by the clinical picture and radiological monitoring.

73. Amoebic liver abscess Metronidazole is the treatment of choice. Most patients show a response to treatment within 72-96 hours . Diloxanide furoate should be prescribed for 10 days to eliminate intestinal amoebae after the abscess has been successfully treated. Antifungal agents such as amphotericin B are used if fungal abscess is suspected.

74. Algorithm Intestinal obstruction

75. Drainage Options Percutaneous Needle aspiration Catheter drainage Surgical drainage Open Laparoscopic

76. 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

77. 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

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

79. 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.

80. Surgical drainage Indications 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)

81. 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

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

83. Surgical Management Surgical therapy is necessary for multiple macroscopic or multiloculated abscesses, or those in the left lobe, after percutaneous drainage failure. H epatectomy ( Hemi/Segmental Resection)

84. Complication of Liver abscess Rupture and peritonitis Rupture into lung Bronchopleural fistula Subphrenic abscess Retroperitoneal abscess Cardiac tamponade Septicaemia Encephalopathy liver failure Liver cysts

85. Nursing Management

86. As sessment History Physical examination Assess any pre-existing illness

87. Nursing Diagnosis Ineffective breathing pattern  related to restriction of thoracic excursion as evidenced by dyspnoea . Acute Pain related to tissue as evidenced by facial expressions and verbalization . Impaired thermoregulatory pattern related to inflammation as evidenced by Fever.

88. Nursing Diagnosis Impaired fluid and electrolytes related to in-situ drainage as evidenced by dehydration Impaired skin integrity  related to pruritus from jaundice and edema. Activity intolerance  related to  fatigue , lethargy, and malaise.

89. Nursing Diagnosis Imbalanced nutrition : less than body requirements  related to anorexia as evidenced by less intake of food. Risk for infection related to open wound R isk for injury  related to altered  clotting  mechanisms and altered level of consciousness.

90. Planning Have adequate relief from the underlying health problem Have satisfactory pain management Cope with the body image changes Make satisfying lifestyle adjustment 

91. Nursing Considerations

92. Intervention Health Promotion Acute Care Pre-operative care Post operative care Ambulatory care Special considerations

93. Health Promotion Prompt treatment of abdominal and other infections. Educating and exercising proper sanitary measures Avoiding fecal contamination of food and water Boiling is the only effective means of eradicating cyst in water. Travelers should avoid drinking local water including ice cubes frequently used for cocktails Eat a variety of healthy foods. Do not drink alcohol.

94. Nursing Management The nursing management depends on the patient's physical status and the medical management that is indicated. For patients who undergo evacuation and drainage of an abscess, monitoring of the drainage and skin care are imperative. Vital signs are monitored to detect changes in the patient's physical status. Deterioration in vital signs or the onset of new symptoms such as increasing pain, which may indicate rupture or extension of the abscess, is reported promptly. The nurse administers IV antibiotic therapy as prescribed.

95. Nursing Management The white blood cell count and other laboratory test results are monitored closely for changes consistent with worsening infection. The nurse prepares the patient for discharge by providing instruction about symptom management, signs and symptoms that should be reported to the physician, management of drainage, and the importance of taking antibiotics as prescribed. Encourage movement, coughing, and deep breathing to prevent or limit pulmonary complications related to hepatic abscess. Increase the client's fluid in take and provide skin care in the event of hyperpyrexia. Dispose of faeces carefully, and wash your hands to prevent transmission of amoebic infestations.

96. Video https://media.springernature.com/original/springer-static/image/chp%3A10.1007%2F978-1-4614-6123-4_22/MediaObjects/217224_1_En_22_Fig2_HTML.gif https://www.youtube.com/watch?v=Zcbra9s2Mpk https://www.youtube.com/watch?v=fWSxYxDL_qI

97. Evaluation Accept and Integrate changes into lifestyle Have no evidence of open skin breakdown Have reduction or absence of pain Become mobile within limitations.

98. Documentation Guidelines Condition of the surgical site Control of initial postoperative pain by Pain Medication Presence of any complication

99. Discharge guidelines The clinical and radiographic progress of the patient should guide the length of therapy. Intravenous medication should be administered for 14 days, and then replaced with oral medications to complete a 4-6 week course following adequate drainage. Multiple abscesses require up to 12 weeks of therapy. A 10-day course of Diloxanide furoate should be given at the completion of metronidazole to destroy any amoebae in the gut.

100. Follow up Patients prolonged parenteral medications may continue after discharge. Monitoring of vital organ functions and complete blood count will be needed. Imaging studies Long-Term Monitoring Weekly serial computed tomography (CT) or ultrasound examinations to document adequate drainage 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.

101. Prognosis With better diagnostic techniques and early treatment Prognosis is good as abscess resolves completely within 8 months to 2 years. Co-morbidities could alter the prognosis. Recurrence is common if pathogen(s)-causing abscess are not completely eradicated. With treatment , (despite co-morbidities) mortality is less than 15%. But without treatment, the mortality rate approaches 100%. The most common causes of death include sepsis, multi-organ failure and hepatic failure. Also mortality has increased significantly with laparotomy

102. Summary

103. Conclusion Liver abscesses are of significant relevance , which is related to the high morbidity and mortality figures which they can cause if not detected and treated in time.  If left untreated, these lesions are invariably fatal.

104. References Abbas, M. T.; Khan, F. Y.; Muhsin, S. A.; Al- Dehwe , B.; Abukamar , M. & Elzouki , A. N. Epidemiology, clinical features and outcome of liver abscess: a single reference center experience in Qatar. Oman Med. J., 29(4):260-3, 2014. Akhondi , H. & Sabih , D. E. Liver Abscess. StatPearls website. Treasure Island (FL), StatPearls Publishing, 2019. Alam , F.; Salam, M. A.; Hassan, P.; Mahmood, I.; Kabir, M. & Haque, R. Amebic liver abscess in Northern Region of Bangladesh: sociodemographic determinants and clinical outcomes. BMC Res. Notes, 7:625, 2014. Alghofaily , K. A.; Saeedan , M. B.; Aljohani , I. M.; Alrasheed , M.; McWilliams, S.; Aldosary , A. & Neimatallah , M. Hepatic hydatid disease complications: review of imaging findings and clinical implications. Abdom . Radiol . (N. Y.), 42(1):199-210, 2017. Anesi , J. A.; & Gluckman , S. Amebic liver abscess. Clin. Liver Dis. (Hoboken), 6(2):41-3, 2015. [ Links ] Barosa , R.; Pinto, J.; Caldeira , A. & Pereira, E. Modern role of clinical ultrasound in liver abscess and echinococcosis. J. Med. Ultrason . (2001), 44(3):239-45, 2017.

105. Thank you