Liver abscess

liver abscess

1. Identification of liver specimen Size- largest organ Reddish brown Rubbery to touch Anatomical right & left lobes Covered by: Glisson’s capsule & visceral peritonium Ligaments: right and left triangular, falciform & lesser omentum Uncovered area- Bare Area Gall bladder, IVC, hilum etc.

2. Identification of liver specimen.. Cut surface/partial hepatectomy : Reddish brown/ tan pink/fleshy parenchyma Capsular surface smooth Multiple cut bile ducts: Variable sizes Bile stained

3. Amoebic liver abscess

4. Pyogenic liver abscess

5. Liver abscess Space occupying lesions (SOL) Collection of: Pyogenic material- frank pus “Anchovy sauce” pus Greenish pus Number of SOL: Solitary Multiple

6. Liver abscess What types of liver abscess you know? Commonly 2 types: Amoebic Pyogenic Others : Tubercular fungal

7. Liver abscess What causes amoebic liver abscess? Parasite: Entamoeba Hystolytica What causes pyogenic liver abscess? Bacteria: E . coli & Streptoccocus milleri —commonest Other enteric organism- Klebsiella, Proteus vulgaris, Streptococcus fecalis , Pseudomonas Mixed growth Opportunistic Staphyloccoci

8. Liver abscess Aetiology of amoebic liver abscess? Endemic to Entamoeba Histolytica - tropical countries Indian subcontinent & Africa 4. Diabetes Mellitus 2. Chronic alcohol intake 5. Immunosuppressed state 3. Liver cirrhosis 6. Reproductive age females

9. Liver abscess Aetiology of pyogenic liver abscess? 1. Biliary sepsis: a. Empyema gallbladder. b. Cholangitis. c. After biliary tract surgery. d. Instrumentation. 4. Super added infections: a. Amoebic liver abscess. b. Hydatid cyst. 2. Portal vein sepsis : a. Appendicitis . b. Diverticulitis . c. any severe abdominal sepsis . 5. Cryptogenic liver abscess—No identified primary i nfection. ( m.c.c .) 3. Distant infections: a. Pneumonia. b. Upper U.T.I. c. Endocarditis. 6. Trauma- becoming common cause 7. Diabetics

10. Liver abscess What is the clinical presentation? Amebic abscess- more common in males Symptoms: Pain- right upper abdomen (throbbing) Fever, with rigors with malaise Occasionally jaundice May be associated dysentery Weakness Decreased appetite/ loss of weight If complicated- difficulty breathing, fainting etc.

11. Liver abscess What signs can be found? Signs: Tenderness-right hypochondrium Intercostal tenderness- right Hepatomegaly: smooth, soft Icterus Signs of complications: Peritonitis, pleural effusion, ascitis , bronchopleural fistula etc Signs of sepsis

12. Liver abscess What are the complications of liver abscess? Pleural effusion- right sided Ascites Jaundice Rupture- brochopleural fistula/ empyema ( m.c. ) peritonitis Retroperitonial abscess Subphrenic abscess Cardiac temponade Into intestines & skin (amoebic cutis)

13. Liver abscess What are other complications of liver abscess? Superinfection of amoebic abscess Budd Chiary syndrome Liver failure / Hepatic encephalopathy Septicemia, later shock Death

14. Liver abscess How does amoebic liver abscess develop? Mature cyst ( faeces ) Contaminate food & water Ingestion of cyst Pass through stomach undamaged Cyst wall lysis occurs by trypsin (alkaline medium) Excystation Release of quadrinucleate amoebae Metacyst trophozoites formed Habitat in crypts of caecum commonly, often in sigmoid colon as to form trophozoites .

15. Liver abscess How diagnosis is made? Ultrasound abdomen is diagnostic Space occupying lesion Altered echogenecity (anechoic, hypoechoic ) Site, size, number & nature Associated complications CECT abdomen CXR- raised right hemidiaphragm , effusion, soft tissue shadow

16. Liver abscess How do you investigate a patient with history suggestive of liver abscess? Blood tests- CBC: may show low Hb , raised TLC LFT: altered bilirubin, liver enzymes, albumin Prothombin Time/INR: can be raised USG abdomen CXR CECT – chest & abdomen

17. Liver abscess How do you investigate a patient with history suggestive of liver abscess? Amoebic serology: ELISA/ Indirect haemagglutination / gel diffusion tests/ counter immuno -electrophoresis USG guided spirated Pus: culture & sensitivity Colonscopy / sigmoidoscopy : amoebic typhilitis / active ulcers- showing trophozoites

18. Liver abscess What is the treatment? Drugs: Amoebic abscess: Metronidazole- Tab. 800mg TDS/ Inj. 750mg i.v. TDS x 10d Or Tinidazole , Secnidazole , Ornidazole ( nitroimidazoles ) To control/ prevent secondary infection- cefotaxime , ciprofloxacin, amoxycillin Cyst eradicators/ luminal amoebicides - Diloxanate furoate , iodoquinol , paromonycin Other drugs- dihydroemetine , chloroquine (tissue amoebicides )

19. Liver abscess What is the treatment? Drugs: Pyogenic liver abscess: Systemic antibiotics- Combination of third generation cephalosporin+ metronidazole USG guided drainage: Percutaneous aspiration (therapeutic) Percutaneous Indwelling catheter drainage Open drainage Treat primary cause in case of pyogenic abscess

20. Liver abscess When & how is percutaneous drainage of liver abscess done? Indication: Abscess not responding symptomatically to drugs Large abscess (>200cc, >10cm- RT) Any size in caudate lobe Seronegative abscess Abscess in pregnancy Diagnostic: in case of dilemma

21. Liver abscess When & how is percutaneous drainage of liver abscess done? Prerequisite: Clinical diagnosis Patient’s consent Normal coagulation profile Abscess accessible

22. Liver abscess When & how is percutaneous drainage of liver abscess done? Technique : Under real time USG guidance Wide bore needle with 10-50cc syringe Catheter tube: red rubber/ malecot , pigtail catheter Introduced through abdomen ( preferrably ) or intercostal space, under local anesthesia & sterility Pus sent: C/S, cytology, trophozoite detection

23. Liver abscess Is surgery even required? What are the indications? Non responsive (symptomatically) to percutaneous drainage i.e. failure Thick pus Multiloculated abscess Multiple abscess Complications- rupture What is the approach? Transperitonial

24. Liver abscess What follow up advice will you give? Abstain from alcohol intake Complete course of drugs Repeat LFT Repeat USG abdomen, if symptoms recur or do not resolve

25. Liver abscess What is the prognosis? Mortality in amoebic liver abscess is 4% & rises with rupture esp. pericardia (30 %) Poor prognostic factors Rupture Diabetes Serum bilirubi n >3.5 mg% Cirrhosis Serum albumin <2.0 g/dl Multiple abscesses Liver failure,, anaemia Volume of abscess >500 ml

26. Thank you! Doubts?

27. Quiz