LIVER INJURY, CYSTS & INFECTIONS iuiu.pptx

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1. LIVER INJURY, CYSTS & INFECTIONS Dr Andrew Kannamwangi IUIU THIRD YEAR LECTURE

2. Outline Liver injury Liver cysts Liver infections

3. Liver injury Liver injury can occur as a contusion, laceration ,avulsion, extension into the thorax & biliary tree. It may be associated with other organ injuries ( ie spleen , kidney , Duodenum, bowel, IVC) . It could also be associated with chest trauma,# ribs& diaphragmatic. It can be due to blunt injury, stab, gun shot injury.

4. Factors making the liver prone to injury The liver size ( Large size of the liver) The Anatomic location Its Friable parenchyma Thin capsule

5. Grading of liver injury

6. Clinical presentation Features of shock due to severe torrential bleeding( pallor,Hypotension , tachycardia, sweating) Distension of the abdomen with dull percusion note, guarding, tenderness & rigidity Oliguria Tachypnoea , respiratory distress & often cyanosis

7. Rupture of right lobe is more common than the left lobe leading to heamoperitoneum Occassionally can cause localised heamatoma which may form an abscess Bile leak from the injured site can lead to B iliary peritonitis

8. Investigations Chest x-ray r/o # ribs, other associated # & elevation on diaphragm(it’s non specific) Abdominal ultrasound Abdominal ct scan contrasted ( Gold standard) Chest ct scan contrasted DPL ( +VE When > 10mls of frank blood in the aspirated fluid) Feacal matter or bile

9. The DPL is fast, sensitive, accurate & simple to perform Invasive, cannot diagnose retroperitoneal injury Lab investigations: CBC (HB Estimation, PLT, Blood grouping +cross-matching Book 5-10 units of blood for transfusion ie requires massive transfusion, FFPs . Coagulation profile (PT/INR, APTT)

10. Limitations of DPL Does not evaluate retroperitoneal heamorrhage Its not useful in determining the origin of the bloody aspirate.

11. Management of liver injury A-General measures Iv fluids, Blood tranfusion (massive), FFPs Have both central venous acess ( large bore canula grey/ green). Bladder catheterization to monitor urine out put.

12. B-Initial management Care of a patient with suspected liver injury should follow ATLS (ABCDE ) A-airway ( Clear airway, cervical spine B-Breathing ( Tension pneumothorax , pulmonary oedema , broncospasms ) C-Circulation ( shock, B/P, PULSE, Hypovolaemia , haemorrhage ) D-Disability (seizure, hypoglyceamia , ICH, Intoxication, level of consciousness) E-Exposure (hypothermia, hyperthermia, critical skin conditions such as fascitis or urticaria ) Primary survey for trauma patients to exclude any other associated injuries.

13. After primary survey attention then is focused on the details of resuscitation Keep patient warm & collect samples for lab (CBC,PT/INR, Blood grouping, x- matching). You can use warm iv fluids, turn off A/c in ER , cover with blankets. Rapid diagnostic for possible visceral injury ( abdominal examination, FAST, DPL)

14. Secondary survey – After stablizing the patient. Non operative/ conservative mgt ( stable ) Ct scan (grade 1,2, 3 liver injury) –( stable ) Admit the patient observe, heamatocrit , B/P, Pulse, Monitor, increase in abdominal distension. Non –stable ( unstable) These require emergency explorative laparotomy . Grade ( 4,5,6 Liver injury) if Stable ICU- Stable-improving D/c.

15. Specific measures P acking the liver wound direct with a mop Laparotomy to assess extent of liver injury & other associated injury Small liver tear is sutured using vicryl or PDS Mattress sutures Pringles manouvre is done to control bleeding on table by occluding the hepatic artery, portal vein temporarily using a vascular clamp. Deep severe injuries hepatic artery ligation, segmental resection , hemihepatectomy , packing the liver temporarily with mops and closing the abdomen.)

16. Cholecystectomy & placement of T-tube in the CBD. Associated IVC injuries are very difficult to manage ( has High mortality). A veno -occlusive bypass btn femoral vein & SVC is done & then repair of IVC is carried out. Mgt of other organ injuries accordingly. Patient postoperatively requires ventillator support , blood transfusion, electrolyte mgt, antibiotics, eg 3 rd generation cephalosporins . FFPs, Cryoprecipitate are also required.

17. Complications of sequelae of liver injury Shock & heamorrhage Liver abscess or septiceamia Bile leak , biliary peritonitis, biliary fistulas Disseminated intravascular coagulation (DIC) Hepatic artery aneurysm, arteriovenous & arterio-biliary fistulas ( Heamobilia ) Complications of massive blood transfusion Electrolyte imbalance Respiratory complications Liver failure CBD stricture causing obstructive Jaundice.

18. INFECTIONS OF THE LIVER 1-Ameobic liver abscess It is common in tropical countries (Africa and India) It is caused by a parasite Entameoba histolytica esp in Africa Its common in Alcoholics & cirrhotic patients It is often called a tropical abscess It commonly affects Males btn 20-40 yrs of age with h/o travel to endemic area. Poverty is associated with higher rates of infection M:F RATIO 10:1

19. Pathology Infection occurs commonly from the ceacum after an attack of typhylitis ( inflammation of the ceacum ) thru superior mesenteric vein & portal vein Infection from rectosigmoid colon spreads thru the inferior mesenteric vein and portal vein to the liver. Trophozoites destroy the hepatocytes by releasing histiolysin , a cytolytic agent. It causes Ameobic hepatitis with multiple micro- abscess formation. It leads to liquefaction necrosis, thrombosis of blood vessels, release & break down of RBCs

20. It causes formation of “ Anchovy sauce ” pus which is chocolate brown coloured and odourless .( ie contains dead liver cells, RBCs and necrotic material ). Pus may be green coloured if mixed with bile Secondary infection is common (30%), by E. coli, staph aureus , strept leading to presentation as pyogenic liver abscess.

21. Bse of perihepatitis , liver is fixed to Diaphragm leading to sympathetic pleural effusion on the right side It’s commonly acute but also can present as a chronic entity with a capsule that remains dormant for a long period. It sometimes gets calcified

22. Clinical presentation of ameobic liver abscess It occurs after an attack of ameobic dysentry or after many months of an attack or h/o dysentry may not exist at all. Fever, rigors & chills Wt loss Non productive cough Shoulder pain Right hypochondrial pain Soft tender , smooth liver with and increased liver span Intercostal tenderness is elicited which is a useful clinical sign

23. Clinical presentation cont’d Right sided pleural effusion may be present Mild jaundice esp in cirrhotics & multiple abscesses signifying poor prognosis Tenderness rigidity& skin oedema in the right hypochondrium in acute cases In chronic cases smooth, firm/ hard , non tender liver may be palpable without acute features

24. Investigations CBC - Wbc count increased LFTs may show altered bilirubin , ALT, AST , ALP & albumin Prothrombin time may be increased if so give vit K 10mg x5/7 if it persist then FFPs are needed to rectify the PT. Abd ultrasound scan( hypoechoic , anechoic) altered echogenicnicity size , location , no. of abscess, nature of liver .) CXR Raised fixed diaphragm ( tenting), pleural effusion, soft tissue shadow.

25. Indirect heamaglutination test (95%+VE) ELISA & Gel diffusion precipitative test are reliable A bd CT scan contrasted shows raised daiphragm , abscess cavity (low density area), size, no. and location of abscess, presence of effusion, changes in the lung. Sigmoid/ colonoscopy are used to identify the active ulcers. Scrappings of the ulcer show trophozoites .

26. Treatment 1-Drugs – Metronidazole 800mg tds or Iv metro 500mg tds x10/7 or tinidazole 500mg bd x5/7 Prophylactic IV OR P.O Antibiotics are essential to control secondary to infection ( ceftotaxime , cirpo , amoxycillin ) Small abscesses <3cm respond to drugs). Other drugs (a)- IM Dihydroemetine 1.5mg /kg/dayx5/7 (b)- Chloroquine 250mg bd given for 10-14 days

27. Drugs used for ameobic infection. Metronidazole , tinidazole , secnidazole , ornidazole Dihydroemetine inj Chloroquine , tetracycline Diloxane furoate , iodoquinol , paramomycin as cyst eradicators. 2- Aspiration In case of large abscess & infected abscess aspiration with a wide bore needle is done under U/S guidance after correcting PT.

28. Previously without U/S aspiration used to be done by passing needle in the right 6 th intercostal space in midaxillary line. Its now done thru 8 th ICS 3-Percutaneous drainage Under u/s guidance a pig tail catheter is placed into the abscess cavity pecutaneously to drain the pus. Catheter tube & Abscess cavity has to be washed & irrigated at regular intervals with normal saline. NB : Aspirated fluid is sent for c/s cytology & study of trophozoites , microscopy. Risks: Bleeding & infection

29. Treatment cont’d 4-Surgery Indications :- Recurence after aspirations Thick pus Multiloculated abscess Left lobe abscess b’se of danger of rupture into the pericardial cavity Ruptured abscess Caudate lobe abscess Multiple abscess

30. Proceedure Through trans- sphincteric approach, abscess area is opened, pus is evacuated, malecot’s catheter is placed & brought out thru a separate stab incision Catheter is kept in situ until drainage stops completely Complete drainage is confirmed by repeat u/s. D/C advise Avoid Alcohol , Rpt LFTS , Rpt Abd u/s, Chloroquine 260mg bd x10/7 & Diloxamide furoate 500mg tds x10/7

31. Complications of ameobic liver abscess Rupture into the lungs –expectoration of chocolate coloured sputum Rupture into the peritoneum- peritonitis requiring emergency laparotomy It can rupture into pleural cavity leading to empyema Rupture into bronchus can lead to broncho -pleural fistulae leading into coughing Anchovy sauce pus Rupture into the bare area of the liver causing retroperitoneal abscess Rupture into the intestines or the skin ( ameobiassis cutis) Rupture into pericardial cavity causing cardiac tamponade Septiceamia and liver failure can occur ameobic liver abscess with cirrhosis

32. Pyogenic liver abscess Aetiology Bile ducts causing ascending cholangitis Portal vein pylephlebitis from appendicitis or diverticulitis Direct extension from the contagious dse Trauma due to the blunt or penetrating injuries Hepatic artery due to septiceamia Cryptogenic

33. Predisposing factors Children Chronic granulomatous dse Compliment deficiencies Leukemia Malignancy Sickle cell nemia Polycystic liver dse Adult Diabetes mellitus Cirrhosis Chronic pancreatitis Peptic ulcer dse Inflamatory bowel dse Jaundice Pyelonephritis Malignancy

34. Clinical presentation symptoms percentage fever 83 Weight loss 60 pain 55 Nausea and vomitting 50 malaise 50 chills 37 Anorexia 34 Cough and pleurisy 30 pruritis 17 diarrhoea 12

35. Clinical presentation signs percentage Right upper quadrant tenderness 52 Hepatomegaly 40 Jaundice 31 Right upper quadrant mass 25 Ascitis 25 Pleural effusion or rub 20

36. Investigations LFTS shows increased –ALP in 87% of pts CBC-WBC >10,000 in 71% of patients Albumin <3g/dl in 55% of patients Hematocrit <36% in 53 % of pts Bilirubin >2ng/dl in 24 % of pts

37. Radiology Plain CXR shows raised right hemidiaphragm ,Right pleural effusion ,Right lower lobe atelectasis . Plain abdominal xray shows hepatomegaly , airfluid levels in the presence of gas forming organisms, portal venous gas in case of phlebitis. Ultrasound this can distinguish solid from cystic lesions, is 80-95 sensitive

38. Abd Ct scan= 95%-100% sensitive Not limited by shadowing from the ribs or air Lesions are detectable to arround 0.5cm Cholangiography often via indwelling biliary stent, may visualise the abscess

39. Treatment Antibiotic administration ( aminoglycosides , clindamycin , ampicillin , Vancomycin , fluoroquinolones , metronidazole ) Fungal infections – Amphotericin –B, Fluconazole . Drainage( aspiration or percutaneous catheter drainage Surgery – Surgical drainage Extra- peritoneally via the 12th rib resection to avoid contamination of the peritoneal cavity. Trans-peritoneal surgical exploration

40. Indications for surgical drainage Failed non-operative therapy Those with multiple macroscopic abscesses Those on steroids Concomitant Ascites

41. Complications Up to 40% of pts develop complications from Pyogenic liver abscess Generalised sepsis/ septiceamia ( most common) Pleural effusion Empyema Pneumonia Peri -hepatic abscess Hemobilia Hepatic vein thrombosis

42. HYDATID CYST OF THE LIVER It is caused by Echinococcus granulosus a dog Tape worm Life cyle of echinococcus granulosus Infected offal of sheep or goat ingested by dog ( definitive host ) and the EG released develops in the dog’s intestine , ova expelled from dog intestine to grass and vegetables, eggs are ingested by sheep, cattle or human beings ( intermediate host ). Thru portal vein liver larva form, hydatid cysts (70% in liver),

43. Most commonly involved segment is segment vii 27%, commonly right lobe in 66%, both lobes in 16% & only left lobe is involved in 17%.

44. Course of disease Parasite may die & cyst eventually may get calcified Cyst may enlarge and is palpable per Abdomen It may cause complications like jaundice due to pressure over biliary tree. Rupture into the peritoneal cavity causes anaphylactic reaction which may cause life threatening shock. ( Aanphylactic shock).

45. Rupture into the biliary channels is commonest ( 60%), rupture in bowel and pleural cavity. Secondary infection causing suppuration & septiceamia Secondary cysts in the lung, spleen, mesentry , retroperitoneum & other organs. Hepatic dysfunction Disseminated abd hydatidosis can occur

46. Clinical features of Hydatid cyst Asymptomatic palpable liver with classical thrill ( hydatid thrill) Jaundice & abdominal pain Features of anaphylaxis Right upper quadrant discomfort, dyspepsia, wt loss, fatigue, vomitting Splenomegaly occasionally, pleural effusion, cholangitis , allergic asthma, fever

47. Camellotte sign following intrabilliary rupture, gas enters into the cyst causing partial collapse of the cyst wall.

48. Differential diagnosis Hepatoma Ameobic liver abscess Cystic liver disease

49. Complications Anaphylaxis Rupture Obsrtructive jaudice - ERCP sphicterotomy may be needed Infection Calcification Liver failure

50. Investigations Abd u/s- shows rosettes of daughter cysts, double contoured membrane of the cyst due to detachment of the cyst membranes & calcifications of cyst wall Intra-operative ultrasound is useful A bd XRAY – shows calcified cysts Abd Ct scan most accurate in identifying cysts ( cart wheel like ? Multi-vesicular rosette like)

51. Investigations cont’d Primary serological tests ELISA, Indirect heamoglutinin test, latex agglutination test, Immunoflourescence antibody test, immunoelectrophoresis ( 80-90%) sensitivity for liver hydatid cyst. LFTs Secondary serological test – PCR, Immunoblotting Casoui test Complement fixation test MRI In jaundiced pts to visualise the billiary tree & its relation to hydatid cysts ERCP can also identify biliary communication with the cysts though MRI Is superior at this

52. Treatment Drugs - Mebendazole & albendazole 4/7 days prior to intervention & continue for a 1/12 to 3/12 after intervention. Drug therapy is used for inoperable cysts, multiple or multi-organ cysts, recurrent hydatid cysts, surgically unfit pts, cysts in lung, bone, brain, eyes Praziquantel 60mg/kg combined with albendazole for 2/52 Mebendazole 600mg daily for 4 weeks Albendazole 4 week cycles with 2 weeks drug free interval

53. PAIR TECHNIQUE PAIR Technique ( percutaneous aspiration injection & reaspiration ) is done under u/s or CT Scan guidance. Under LA cyst is punctured using a cholangiography 22 gauge needle thru thickest part of the cyst wall 50% of the fluid is apirated , All daughter cysts are aspirated Radiopaque dye is injected to see if any communications are present 15-20% hypertonic saline is injected into the cysts and after 20 mins reaspiration is done. A sclerosant alcohol is then injected PAIR TECHNIQUE has low morbidity & mortality / complications & similar results to open surgery.

54. surgery Surgery is still choice & gold standard therapy for hydatid d’se Abd is opened & peritoneal cavity packed with mops, ( black or coloured mops are used to identify white solices and prevent any spillage into Abd cavity. Fluid from the cyst is aspirated scolicidal agents ( cetrimide , chlorhexidine , alcohol, Hypertonic saline 15-20%, 10% povidone iodine) are injected into the cyst cavity and left in for15-20mins

55. White mops soaked in hypertonic saline are kept in the cyst cavity & gall bladder is gently squeezed to see for the bile staining of the MOP in the cavity which confirms communication. Laparoscopic pericystectomy is becoming popular however the main problem is spillage & difficulty in preventing it. Liver resection is ocassionally done ie segemental resection & hemihepatectomy .

56. Cystobiliary communication with the cyst is obliterated by suturing the communication with vicryl or PDS suture with a T- tube drainage of bile duct. Pericholecystectomy is done by peeling off the cyst wall & abdomen is closed with or without a drain; Marsupilization . Other drainage proceedures eg cholecsytojejunostomy , hepatico-jejunostomy , rouxen -y hepaticojejunostomy .

57. Asignment Read about Malignant Hydatid dse a benign Condition caused by echinococcus multilocularis

58. CONTRAINDICATIONS TO SURGERY Deeply situated cyst Densely adherent cyst Inaccessible cysts > 3 cysts Calcified cysts Cysts in other organs