Liver abscess

Lecture on liver abscess for medical students on a disease endemic to Sarawak. Encompasses basic sciences, classifications, pathophysiology, principles and tips of management.

1. Liver abscess Chea Chan Hooi Surgeon Sibu Hospital

2. Content Epidemiology Etiology Microbiology Anatomy Clinical features Investigations Principles of management Pyogenic vs. amoebic

3. Epidemiology Male Endemic area, low socioeconomic area, agriculture, poor sanitation

4. Etiology Biliary tract (30%) Extrahepatic obstruction Choledocholithiasis Strictures Tumours (benign & malignant) Choledoenterostomy (sump syndrome) Choledochoduodenostomy & choledochojejunostomy Distal BD blocked by food particles Portal pyemia / pyelephlebitis (20%) Primary infection in abdominal cavity & seed/emboli into liver via portal vein Less common nowadays with early use of antibiotics & prompt proper source control Appendicitis still the most common source Hematogenous Via hepatic artery Bacterial endocarditis, urosepsis & IVDU Direct implantation Penetrating trauma Adjacent severe infection – e.g. gangrenous cholecystitis, Iatrogenic TACE, RFA, PEI Laparoscopic hepatobiliary surgery – commonly lap chole ERCP Cryptogenic Commonly in geriatric group, prolonged bed ridden & institutionalised Unclear pathophysiology

5. Microbiology Pyogenic Usually polymicrobial from enteric & biliary source Common organisms encountered E. coli 33 % K. pneumoniae 20 % Bacteroides spp 24 % Streptococcal spp 37 % Microaerophillic strep spp 12 % Amoebic Entamoeba histolytica Hydatid cysts get infected

6. Anatomy Right lobe 80% due to anatomical considerations Right lobe receives portal blood from both SMV & IMV Streaming effect of right PV (wider & straighter) Denser network of bile canaliculi More hepatic mass

7. Clinical features Abdominal pain Fever Chills & rigors Loss of appetite Weight loss Cough Pleuritic chest pain

8. Complications Rupture Peritoneal cavity Subphrenic or localised  percutaneous drainage Free rupture  Generalised peritonitis  emergency laparotomy Pleural space* Pleurisy, pleural effusion, empyema, bronchohepatic fistula Pericardial space* Rare but have been reported Beware if abscess is located adjacent to diaphragm & pericardium * subdiaphragmatic amoebic abscess Septic shock

9. Investigations Radiological USG The standard 1 st line for HPB imaging Poorly demarcated with variable appearance ( hypoechoic – hyperechoic ) Gas bubble may be seen Colour Doppler will demonstrate absence of central perfusion CT scan Differentiate from other pathology mimicking liver abscess HCC ( multicystic or infected) Necrotic liver mets Infected cysts Blood works FBC LFT RP PT/PTT ABG Blood C+S ESR/CRP Tumour markers

10. Principles of management Resuscitation Broad spectrum empirical antibiotics Sepsis control Percutaneous drainage Surgical drainage

11. Percutaneous drainage USG or CT guided Contraindication Location of abscess Irretractable coagulopathy Immunocompromised patients with diffuse microabscesses Ascites is a relative contraindication Might be difficult if <2 – 3 cm

12. Anchovy sauce drainage  amoebic

13. Failure No improvement within 72 hours Abscess persists despite adequate drainage Further options Insert another percutaneous drain Surgical drainage Complications Early Injury to liver (bleeding, biloma ), lung ( pneumo / haemothorax ), blood vessels (IVC, PV, HA) Intraperitoneal leakage causing generalised peritonitis Late Fistula

14. Surgery Indications Multi- septated Multiple abscesses Abscess cannot be drained percutaneously d/t location Failed antibiotic therapy Failed percutaneous drainage Coexisting biliary/intra-abdominal disease requiring surgery Ruptured intraperitoneally Large >5cm Approach Open Laparoscopic

15. TQ! Q&A?