liver abscess

liver disease

1. LIVER ABSCESS By : Hamad Emad Hamad Dhuhayr

2. Objectives Anatomy of liver Classification Etiology and patho-physiology Management

3. Anatomy of liver

4. Classification PYOGENIC Gram Positive Gram-negative Anaerobic Staph aureus,Strepto pyogenes,Strepto milleri,strepto faecalis E coli,Klebsiella,Proteus Bacteroids,Clostridium,Actinomyces AMOEBIC CANDIDA TB (rare)

5. Patho physiology Liver largest portion of reticuloendothelial system so continuous exposure to bacteria from enteric tract Due to high level of reticuloendothelial tissue, non-viral infections are uncommon

6. Risk Factors PYOGENIC DM Cancer Liver Transplant ENTAMOEBA Pregnancy Steroids Cancer Endemic area travel (short or long term)

7. PYOGENIC LIVER ABSCESS

8. EPIDEMIOLOGY MALE > FEMALE 3 : 1 MORE IN RIGHT LOBE, SUPERIOR ASPECT INCREASED INCIDENCE IN DIABETES MELLITIS

9. Patho physiology of PYOGENIC ABCESS PYOGENIC: Peritonitis To liver via portal circulation Direct Spread Biliary infections(ascending cholingitis Hematogenous Seeding Bacteremia, septecemia(unusual) Adjacent infections Sub phrenic abscess, Cholecystitis Sites : R lobe most common Blood supply

10. …Patho physiology Mostly multiple abscesses/sometimes single 40 % monomicrobial 40 % polymicrobial 20 % negative culture

11. Sign and symptoms Rigors high swinging temp(90 %) Tender palpable liver(50 %) Jaundice 1/3 Charcot’s triad Or non-specific malaise over month

12. investigations NON SPECIFIC total lymphocyte count : increase leukocytosis Increase ESR Increase alk phosphate(mild)(67-90%) SPECIFIC USG DIAGNOSTIC ASPIRATION & CULTURE SENSITIVITY CT scan

13. ULTRASOUND of pyogenic abscess

14. CT SCAN

15. Treatment MEDICAL BROAD SPECTRUM ANTIBIOTICS triple regime(penicillin , amino glycoside and Metronidazole) cephalosporin and Metronidazole SPECIFIC ACCORDING TO CULTURE SENSITIVITY i/v fluids to prevent hepatorenal syndrome ANALGESICS & ANTIPYRATICS Urgent drainage

16. CONTINUED INVASIVE TO DRAIN OR NOT TO DRAIN: <5cm, single abscess- needle aspiration or catheter >5cm- catheter Also: Surgery, ERCP URGENT DRAINAGE USG GUIDED, AND PIG TAIL CATHETER OPEN ERCP IN CASE OF OBSTRUCTION

17. AMOEBIC LIVER ABSCESS

18. Amoebic abscess Epidemiology M > F 7:1 10 % world population 40-50 million amoeba infections/year worldwide Age Extremes Endemic Areas most susceptible Country of origin or Travel

19. GEOGRAPHIC DISTRIBUTION

20. ETIOLOGY AND PATHOPHYSIOLOGY Entemoeba histolytica

21. Mode of transmission Large intestine (history of dysentery) Travel to liver most common superior aspect near diaphragm through portal vein Where proliferates to produce cytolytic enzymes Destroy liver tissues Abscess which is sterile(anchovy paste or chocolate sauce Amoeba may be found in abscess wall

22. SIGN AND SYMPTOMS Fever Pain RHC Dysentery Tenderness

23. INVESTIGATIONS NON SPECIPIC Increase TLC Increase LFT’s Most common biochemical abnormality(alk phosphate) SPECIFIC USG CT SCAN IMAGE GUIDED ASPIRATION ANCHOVY SAUCE LIKE CULTURE AND SENSTIVITY Fluorescent antibody test for Entamoeba(can be positive even after clinical cure) If serology is negative , amoebiasis is uncertain

24. USG of amebic abscess-Note peripheral location, rounded shape, poor rim with internal echoes pgmedicalworld.com

25. CT showing superficial abscess pgmedicalworld.com

26. CT scan of amebic abscess (A). The lesion is peripherally located and round. Rim is nonenhancing but shows peripheral edema (black arrows). Note the extension into the intercostal space (white arrows). pgmedicalworld.com

27. treatment NON INVASIVE Metronidazole 400-800 mg TDS …….7 to 10 days INVASIVE Ultrasound guided aspiration Surgery Amoeba: drainage not usually required Exceptions: Verge of rupture Abx not working Imminent need to exclude other dx Large abscess

28. Comparison

29. PROGNOSIS & NATURAL HISTORY Mortality 2-12% Often due to co morbidities, not necessarily abscess itself

30. SUMMARY If untreated LA is potentially fatal. Must be diagnosed & treated promptly Investigations-LFT,USG and CT SEROLOGY-corner stone to differentiate Pyogenic liver abscess -Antibiotics plus drainage Causative pathology should also be treated

31. ALA-most cases treated with amebicidal agents alone with drainage procedures reserved for resistant or complicated cases Luminal amebicides should also be given When there is high index of suspicion for LA Rx should not be withheld until diagnosis is confirmed

32. Referrences Baily and love

33. Thank you