Management of liver abscess

1. MANAGEMENT OF LIVER
ABSCESS
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2. LIVER ABSCESS
•2 TYPES
-PYOGENIC
-AMOEBIC
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3. PYOGENIC LIVER ABSCESS
HISTORY
•Described since the time of Hippocrates (4000
BC).

•1890 – Osler documented amoebae in stool and
abscess of the same patient.
•Dieulafoy described multiple hepatic abscess
secondary to pylephlebitis following appendicitis .
•In 1938 Ochsner's classic review heralded surgical
drainage as the definitive therapy.
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4. •INCIDENCE: 0.016%
•Majority clinically silent
•Peak at 7
th
decade
•Men and women equally affected
•Elderly and immunosuppressed more
affected
•RACE: no role
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5. ETIOLOGY
•Biliary causes – 40%
-partial or complete obs of biliary
tract with ascending cholangitis
-biliary manipulations like
cholangiography,PCT etc
•Portal venous route –20%
-perforated Ca colon
-diverticulitis
-appendicitis with pylephlebitis
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6. •Hepatic arterial route –12%
-iv drug abuse and its
complications
-systemic bacteremia
-umbilical artery catheterisation
-hepatic artery chemoembolisation
•Traumatic causes-4%
-penetrating trauma to liver
-cryosurgical ablation of liver
tumors
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7. •Direct extension-6%
-subphrenic abscess
-perforated peptic ulcers
-gangrenous cholecystitis
•Cryptogenic abscess-20%
-asso with DM,malignancy,
immunosuppression
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8. Pathology
•Usually multiple , small abscesses
•More on right lobe of liver
BACTERIOLOGY
•Staph aureus,Strepto pyogenes,Strepto
milleri,strepto faecalis
•E coli,Klebsiella,Proteus
•Bacteroids,Clostridium,Actinomyces
•TB
•Fungi-Candida,Aspergillus
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9. CLINICAL FEATURES
•SYMPTOMS
-Fever (continuous or spiking)
- Chills, Malaise
- Anorexia,Weight loss
-Pain
-Nausea and vomiting
-Pruritus,Diarrhoea,Cough
-PUO
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10. •SIGNS
-Tenderness in right upper
quadrant
-Hepatomegaly
-Jaundice,right upper quad
mass,ascites,pleural effusion
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11. IVESTIGATIONS
•LABORATORY
-Leucocytosis with shift to left
WBC count >10000/mm3
-Anaemia
PCV <36%
-Hypoalbuminemia
Albumin <3g/dl
-LFT
-ALP
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12. -Gamma glutamyl transpeptidase
-Bilurubin >2 gram/dl
-SGOT

BLOOD CULTURE
Aspiration of abscess and C & S
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13. RADIOLOGICAL
•X-RAY ABD
-Right upper quad gas, air-fluid level in
abscess cavity or ileus
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15. •USG ABDOMEN
-used as a preliminary screen
-identify lesions > 2cm in dia
-differentiating cystic from solid
lesions
-diagnosis of gall stones
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16. Echo-poor area in the right lobe
of liver
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17. Multiple abscess in the right lobe
of liver
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18. •CT SCAN
-investigation of choice
-better diagnosis of concurrent or
causative pathology
-abscess > 0.5 cm in dia
-small abscesses near diaphragm and those
in fatty liver
CONTRAST ENHANCED CT
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19. Multiloculated abscess in the
right lobe
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20. An abscess in the left lobe
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21. Multiloculated tubercular liver
abscess
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22. •MRI
-lesions as small as 0.3 cm in dia
-best for defining hepatic venous
anatomy
-useful for patients requiring liver
resection
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23. •NUCLEAR MEDICINE LIVER
SCAN
Previously used
•X-RAY CHEST
Right pleural effusion
Atelectasis
Elevated hemi diaphragm
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24. •BARIUM CONTRST STUDIES OF
UPPER AND LOWER GIT
•Endoscopic retrograde
cholangiography/ERC
•Per cutaneous cholangiography/PTC
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25. TREATMENT
•An untreated hepatic abscess is
nearly uniformly fatal due to
complications that include sepsis,
empyema, or peritonitis from
rupture into the pleural or
peritoneal spaces, and
retroperitoneal extension.
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26. Treatment options
•Antibiotics
•Aspiration
•Percutaneous drainage
•Surgical drainage.
Percutaneous drainage plus i.v antibiotics
treatment of choice
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27. ANTIBIOTICS
•REGIMEN
-Broad spectrum synthetic penicillin
-Aminoglycoside/3
rd
gen cephalosporin
-Metronidazole
•Aminoglycoside toxicity-aztreonam,
imipenem
•Penicillin allergy-imipenem
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28. •Duration of treatment must be
individualised
•iv antibiotics for 2 weeks
•Oral antibiotics for 1 month
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29. Multiple abscesses are more problematic
and can require up to 12 weeks of
therapy.
Both the clinical and radiographic
progress of the patient should guide the
length of therapy
FUNGAL ABSCESS – Amphotericin B,
Fluconazole
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30. ASPIRATION
•Useful in young , otherwise healthy
patients with solitary abscess and no
co-existing intra-abdominal pathology
•Pus can be collected for C & S
•Must be radiologically guided
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31. PERCUTANEOUS DRAINAGE
•Must be radiologically guided
•Most useful for critically ill patients who
cannot undergo surgery
•Best for solitary, uniseptate abscess
•Absolute CI – associated biliary or intra-
abdominal pathology, coagulopathy
•Relative CI – multiple abscesses and
generalised ascites
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32. PROCEDURE
•MODIFIED SELDINGER TECHNIQUE
•Localise abscess with USG/CT guidance
•A 20-gauge teflon sleeve with needle stop is introduced
through safest anatomic route possible
• Insert a J wire
•A no. 8-14 french dialator and then pigtail catheters are
advanced over the wire
•Abscess evacuated by manual syringe suction
•Catheter secured to skin
•Catheter irrigated 2-3 times/day with sterile saline
•Kept in place till output < 10cc/day or cavity collapse
documented by serial CT
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33. SURGICAL DRAINAGE
•EXPLORATORY LAPAROTOMY
-For diagnosing intra-abdominal pathology
-provides concurrent Rx of both abscess
and its source
-best for multiple abscesses and those
inaccessible to PCD, co-existing biliary
pathology
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34. •EXTRA PERITONEAL APPROACH
-subcostal
-transpleural
-retroperitoneal
. Used only for selected abscesses located
superiorly in liver dome

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35. •TRANSPERITONEAL APPROACH
-Standard Rx for patients requiring surgical
drainage
-Bimanual exmn of liver and intraoperative USG
possible
-Abscess opened with cautery after localisation
-Loculations broken down with finger dissection
-Biopsy of abscess wall and nl liver taken
-Abscess site irrigated and soft, closed-suction
drains placed within abscess cavity in
dependent locations
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36. •HEPATIC RESECTION
•Wedge resection or formal lobectomy
-Isolated lobar involvement with single or
multiple non healing abscesses
-Patients with infected hepatic malignancy
-Hemobilia
-Chronic granulomatous d/s
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37. •LAPAROSCOPIC SURGERY
-Limited role
-Useful in diagnosing concurrent abd
pathology
-Laparoscopically guided liver biopsy
-Catheter placed under laparoscopic
guidance
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38. AMOEBIC LIVER ABSCESS
•Tropical and subtropical areas of world
are endemic
•Early descriptions came from India
•Osler reported co-existent hepatic and
colonic amoebiasis in 1890
•Exceed PLA in overall frequency
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39. •Caused by Entamoeba histolytica
•Reaches liver from colon via
-Portal vein
-Mesenteric lymphatics
-Intraperitoneal spread
•Incidence : 0.0013%
•More among low socioeconomic gps
•More among men
•Peak at 3
rd
and 4
th
decades of life
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40. PATHOLOGY
•Abscess usually large, single and superficial
•Right lobe usually affected
•Fluid interior, inner wall, outer capsule
-Abscess fluid resembles “anchovy sauce”
-Reddish brown due to digested liver tissue
and RBC
-Sterile and odourless
•Inner wall contains trophozoites-biopsy
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41. Bottle of anchovy sauce and amoebic pus
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42. CLINICAL FEATURES
•Pain, diarrhoea, cough
•Shock
•Fever and jaundice – less common
INVESTIGATIONS
Laboratory
•LFT abnormalities – less common
•PT increase
•Stool exmn : cyst and trophozoites
-only in 15-50%
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43. SEROLOGY
•Indirect hemagglutination test/IHA
Gel diffusion precipitin/GDP
•Positive if dilutions exceed 1:128
•Result within 24 hrs
DIAGNOSTIC ASPIRATION
•To r/o PLA when serology is negative
•CI in malignancy and echinococcal cyst
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44. RADIOLOGY
•USG – Imaging modality of choice
•CT Scan – suspecting PLA
- Positive serological test with
negative hepatic sonogram
•MRI
•Nuclear medicine liver scan
•X-RAY CHEST
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45. USG of amebic abscess-Note peripheral
location, rounded shape, poor rim with
internal echoes
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46. CT showing superficial abscess
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47. 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).
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48. TREATMENT
•ANTIBIOTICS
Most uncomplicated amebic liver abscesses can be treated
successfully with amebicidal drug therapy alone.
After completion of treatment with tissue amebicides, administer
luminal amebicides(diloxanide furoate) for eradication of the
asymptomatic colonization state.
Failure to use luminal agents can lead to relapse of infection in
approximately 10% of patients.
 Metronidazole drug of choice for amebic liver abscess (750 mg 3
times a day orally for 10 days)
Alternatives :Emetine(cardiotoxic) ,chloroquine
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49. THERAPEUTIC ASPIRATION
•High risk of abscess rupture, as defined by cavity
size greater than 5 cm/250ml vol
•Left lobe liver abscess, which is associated with
higher mortality and frequency of peritoneal leak
or rupture into the pericardium
•Treatment failure in which pain and fever persists
despite 3 days of antibiotics.
•When metronidazole is CI – pregnancy
•To relieve pressure symptoms
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50. PERCUTANEOUS DRAINAGE
•Most useful for pulmonary, peritoneal and
pericardial complications
•Risk of secondary infection
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51. Surgical drainage-Indications
•Left lobe abscess not amenable to percutaneous
drainage
•Life threatening haemorrhage with or without
intraperitoneal rupture of abscess.
•Amoebic abscess eroding into neighbouring
structures
•Septicemia from secondary infection
•Failure of response to conservative therapy
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52. COMPLICATIONS
•Rupture into peritoneum or thorax
• Abscess eroding into nearby structures
•Secondary infection
•Hemobilia
•Liver failure
•Diaphragm perforation
•Bronchopleural,biliopleural and
biliobronchial fistulas
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53.  
Brownish pus aspirated from gall bladder
adherent to inferior surface amoebic liver
abscess.
 
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54. Showing rupture of a left lobe amoebic liver
abscess into pericardium as seen at autopsy
 
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55. Amoebic liver abscess ruptured into pleural space
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56. SUMMARY
•If untreated LA is potentially fatal.
•Must be diagnosed & treated promptly
•Investigations-LFT,USG and CT
•SEROLOGY-corner stone to differentiate
•PLA-Antibiotics plus drainage
•Causative pathology should also be treated
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57. •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
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58. THANK YOU
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