Liver abscess. Briefly explained including new techniques of management

Liver abscess. Briefly explained including new techniques of management

1. Liver abscess Presented by: Dr. Umer Hamid Wani

2. CONTENTS S urface & S urgical Anatomy of Liver Introduction & history of Liver abscesses Types Etiology Pathogenesis Clinical manifestations Diagnosis Treatment Complications Conclusion

3. surface anatomy of liver

4. Peritoneal & Visceral Relations Of Liver

5. A confined pocket of pus that collects in tissues, organs or spaces inside the body. When an area in the body becomes infected, the body's immune system sends white blood cells to fight the infection. These cells collect and combine with the damaged tissue and germs, creating liquid called pus. An abscess is characterised by a painful, swollen lump that's filled with pus.

6. A liver abscess is defined as a pus-filled mass in the liver that can develop from injury to the liver or an intra abdominal infection disseminated from the portal circulation.

7. The first description of a hepatic abscess is credited to Hippocrates in the year 4000 BC . Ochsner’s classic 1938 paper described this disease as one that occurred in young males with pylephlebitis , usually due to appendicitis, and resulting in liver abscess however, despite the more aggressive approach to treatment, the mortality remained at 60-80%. In 1953, McFadzean and associates in Hong Kong advocated closed aspiration and antibiotics for treatment of solitary pyogenic liver abscess however, this treatment did not gain widespread acceptance until imaging advancements in the 1980s allowed for precise localization and a percutaneous approach to treatment.

8. PYOGENIC LIVER ABSCESS Epidemiology Incidence is 3.6 per 100,000 population(earlier). 15 cases per 100,000 admissions today(aggressive management approach to hepatobiliary and pancreatic cancers as well as major improvements in diagnostic imaging) Risk of developing liver abscesses increases with advanced age/older than 65 Men>>>Fem(apprx.60-70%) Diabetes mellitus(48% of the patients at the time of diagnosis) Hepatobiliary neoplasms , pancreas and colorectal cancer(CRC), ethanol abuse, chronic immunosuppression, chronic kidney disease, previous liver transplantation, and benign biliary disease are also associated with increased risk of developing liver abscesses.

9. Pathophysiology Ascending cholangitis / biliary infection.(f) Hematogenous venous dissemination Hematogenous arterial infection Direct trauma Extension from a contiguous septic process In 20% to 30% of the cases, no underlying source of infection can be identified. These abscesses are described as cryptogenic

10. 1. Biliary sepsis 35%; commonest route. a. Empyema gallbladder. b. Cholangitis . c. After biliary tract surgery. d. Instrumentation. e. Stone disease, Caroli’s disease, biliary ascariasis , biliary enteric anastomosis . 2. Portal vein sepsis : a. Appendicitis. b. Diverticulitis. c. Inflammatory bowel disease, pancreatitis, perforation, PID, colorectal carcinoma. d. Omphalitis in newborn 3. Distant infections (through hepatic artery): a. Pneumonia. b. Upper UTI. c. Endocarditis , osteomyelitis , bacteraemia . ETIOLOGY

11. Abscess cultures are positive for growth in the majority of cases (80%-97%), whereas blood cultures are positive in only 50% to 60% of cases. Escherichia coli, Klebsiella species, enterococci , and Pseudomonas species are the most common aerobic organisms cultured, whereas Bacteroides species, anaerobic streptococci, and Fusobacterium species are the most common anaerobes.

12. Clinical Presentation Pain in the right hypochondrium—60%. High fever, with rigors—90%. Weight loss. Jaundice-20%. Intercostal tenderness. Tender, soft liver-60%. Features of toxicity. Constitutional symptoms like malaise, lethargy, vomiting

13. Laboratory Evaluation Leukocytosis is present in 70% to 90%, an elevated alkaline phosphatase in 80%, and an elevated bilirubin and transaminases in 50% to 67% of patients. Anemia, hypoalbuminemia , and prolonged prothrombin time are seen in 60% to 75% of patients

14. Radiology Plain films such as chest radiographs are abnormal in 50% of patients. elevated right hemidiaphragm , a right pleural effusion, and/or right lower lobe atelectasis . air-fluid levels in the presence of gas-forming organisms, or portal venous gas if pylephlebitis is the source The upright chest X-ray showed right side pleural effusion, bilateral subphrenic free air (white arrows), and small air bubbles (black arrow) superimposing at upper liver area, which were suggestive of a GPLA with free air in the peritoneum

15. Ultrasonography Ultrasound will distinguish solid from cystic lesions and is 80% to 95% sensitive. reveals hypoechoic masses with irregularly shaped borders. Internal septations or cavity debris may be detected. It allows close evaluation of the biliary tree and simultaneous aspiration of the cavity Contrast-enhanced ultrasound Age: 75 years Gender: Female Presentation Fever and right flank pain. Patient Data contrast-enhanced ultrasound demonstrates enhancement of the wall and septa during arterial which diminished during the later phases

16. The typical findings in contrast-enhanced ultrasound were sub-segmental  hyperemia  and necrosis with a hyperemic margin in the arterial phase and a washout of liver tissue surrounding necrosis in the late phase Classifying different stages of pyogenic liver abscesses: On contrast-enhanced ultrasound (CEUS) Stage I defined by focal inflammation without necrosis Stage II by focal clusters of micro-abscesses appearing to coalesce Stage III by a single cavity with or without capsule Stage IV defined as numerous small abscesses scattered all over the liver

17. One  half completed

18. Computed tomography (CT) is more sensitive (95%-100%) than US in detecting hepatic abscesses. Computed tomography (CT) They appear as peripherally enhancing, centrally hypoattenuating lesions  . Occasionally they appear solid or contain gas (which is seen in ~20% of cases ). The gas may be in the form of bubbles or air-fluid levels . Segmental, wedge-shaped or circumferential perfusion abnormalities, with early enhancement, may be seen  

19. " double target sign " cluster sign "

20. Magnetic resonance (MR) is well established as a sensitive imaging method for detection of liver lesions. Some reports claim that it does not provide information of greater usefulness than US or CT.  the ‘cauliflower-like’ appearance of the hepatic abscess on MRI is suggestive of a developing pyogenic hepatic abscess . Magnetic Resonance Imaging

21. Signal characteristics include: T1 usually hypointense centrally heterogeneous maybe slightly hyperintense in fungal abscess T2 tends to have hyperintense signal perilesional oedema manifests as high signal intensity on T2-weighted images and can be identified in 35% of liver abscesses  

22. Differential diagnosis Biliary Disease Acute Cholecystitis Echinococcosis Hydatid Cyst Hepatic Cysts Hepatic Hemangiomas Hepatocellular Adenoma (Hepatic Adenoma) Hydatid Cysts Malaria Peritonitis and Abdominal Sepsis Typhoid Fever Hepatitis Pneumonia Pulmonary disease

23. Treatment Initial goals of therapy Aggressive fluid resuscitation Early (within 1 hour) administration of IV antibiotics Control of the source, Strict glycemic control Initial empirical therapy Initial broad-spectrum antibiotics against gram- ve rods & gram+ve cocci Community-acquired infections ampicillin / sulbactam ticarcillin / clavulanate piperacillin / tazobactam 3 rd or 4 th generation cephalosporin fluoroquinolone with or without metronidazole Conservative Percutaneous drainage Open (surgical) method The recommended duration of parenteral antibiotic therapy is 2-3 weeks

24. ESBL-producing Enterobacteriaceae , VRE, MRSA, & yeast coverage Fluconazole Echinocandin micafungin Carbapenems Daptomycin and linezolid

25. The indications for drainage of liver abscess together with medical management are: (1) left lobe liver abscess (2) abscess with thin rim of hepatic parenchyma (<10 mm) around it, (3) multiple liver abscesses, (4) impending rupture recognized on imaging, and (5) nonresponse to medical therapy after 3 to 5 days.

26. Percutaneous drainage Method • Ultrasound or CT-guided aspiration & drainage by using a pigtail catheter. • Irrigation of abscess cavity with saline. INDICATIONS • Superficial abscesses • Abscess with no intra-abdominal pathology • Abscess of unknown aetiology 75% of pyogenic abscess is drained percutaneously . Percutaneous aspiration without drainage tube placement is also used; but repeated guided aspirations are required

27. Open (surgical) method Laparotomy is required mainly to treat the primary causes, e.g. appendicectomy , drainage of appendicular abscess. If liver shows a significant abscess, it is drained. Alternately, a pigtail catheter is introduced into the abscess cavity and brought outside through a separate opening. It helps to drain for a longer period of time. Laparoscopic drainage can also be done INDICATIONS • Abscess with intra-abdominal pathology • Ascites • Deep-seated abscess • Multiple abscesses recurrent abscess failure of Percutaneous drainage large abscess of size >5 cm.

28. OVERVIEW OF PLA

29. Amoebic liver abscess

30. ™ . Acute —present with high fever, chills, rigors, tender, soft palpable liver, with intercostal tenderness. ™ . Chronic —present with firm/hard, smooth, nontender palpable liver without acute features. ™ . Systemic —present with fever, chills and rigors, loss of appetite, reduced weight, and jaundice. ™ . Abdominal —present with pain and tenderness, localised guarding and rigidity, mass in right upper abdomen (tender, soft liver), ascites , splenomegaly , abdominal wall oedema . ™ . Thoracic —present with dry cough, chest pain in right lower part, right shoulder pain, pleural effusion, and intercostal tenderness. ™ . Features of complications —rupture/infection/ septicaemia /liver failure. Clinical Features

31. Complications of amoebic liver abscess

32. Only few slides left Only few slides are left

33. Investigations leukocytosis , anemia, hypoalbuminemia, elevated alkaline phosphatase hyperbilirubinemia . Initial approach liver ultrasound . early phase of infection, abscesses are hyperechoic ill-defined lesions. As necrosis ensues, they appear well defined and hypoechoic In CT scans, abscesses appear as well-defined avascular hypodense lesions with a hyperdense halo after contrast administration CT scan of amebic abscess. The lesion is peripherally located and round. The rim is nonenhancing but shows peripheral edema (black arrows). Note the extension into the intercostal space (white arrow).

34. Sigmoidoscopy /colonoscopy are used to identify the active ulcers. Scrapings of the ulcer show trophozoites . Technetium 99 nuclear image liver scanning is helpful in differentiating amoebic from pyogenic abscess as amoebic abscess do not contain WBCs. Amoebic abscess shows cold lesion with a hot rim or halo whereas pyogenic abscess is entirely hot. (ELISA) detecting serum antibodies against E. histolytica Parasite isolation in stools has been reported in only 24% of the patients . Treatment Drug therapy Aspiration Percutaneous Drainage Surgery Laparoscopic approach Transperitoneal approach

35. Drainage of amoebic liver abscess transperitoneally and placing Malecot’s /pigtail catheter into the abscess cavity Aspiration of the amoebic liver abscess under US guidance or through right 8th intercostal space in midclavicular line.

36. Effective treatment options in amoebic liver abscess in a tertiary care setting in West Bengal: an observational study, India}, year={2018}, url ={https://api.semanticscholar.org/CorpusID:54587032}