MANAGEMENT OF LIVER ABSCESS

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LIVER ABSCESS

• 2 TYPES-PYOGENIC

-AMOEBIC

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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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• INCIDENCE: 0.016%

• Majority clinically silent

• Peak at 7th decade

• Men and women equally affected

• Elderly and immunosuppressed more affected

• RACE: no role

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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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• 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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• Direct extension-6%-subphrenic abscess-perforated peptic ulcers-gangrenous cholecystitis

• Cryptogenic abscess-20%-asso with DM,malignancy, immunosuppression

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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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CLINICAL FEATURES

• SYMPTOMS -Fever (continuous or spiking) - Chills, Malaise - Anorexia,Weight loss -Pain

-Nausea and vomiting -Pruritus,Diarrhoea,Cough -PUO

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• SIGNS-Tenderness in right upper

quadrant-Hepatomegaly

-Jaundice,right upper quad

mass,ascites,pleural effusion

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IVESTIGATIONS• LABORATORY

-Leucocytosis with shift to left WBC count >10000/mm3 -Anaemia PCV <36% -Hypoalbuminemia Albumin <3g/dl -LFT

-ALPpgmedicalworld.com

-Gamma glutamyl transpeptidase

-Bilurubin >2 gram/dl

-SGOT

BLOOD CULTURE

Aspiration of abscess and C & S

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RADIOLOGICAL

• X-RAY ABD-Right upper quad gas, air-fluid

level in abscess cavity or ileus

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• 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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Echo-poor area in the right lobe of liver

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Multiple abscess in the right lobe of liver

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• 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 liverCONTRAST ENHANCED CT

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Multiloculated abscess in the right lobe

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An abscess in the left lobe

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Multiloculated tubercular liver abscess

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• 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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• NUCLEAR MEDICINE LIVER SCAN

Previously used• X-RAY CHEST

Right pleural effusionAtelectasisElevated hemi diaphragm

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• BARIUM CONTRST STUDIES OF UPPER AND LOWER GIT

• Endoscopic retrograde cholangiography/ERC

• Per cutaneous cholangiography/PTC

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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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Treatment options

•Antibiotics

•Aspiration

•Percutaneous drainage

•Surgical drainage.

Percutaneous drainage plus i.v antibiotics treatment of choice

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ANTIBIOTICS

• REGIMEN

-Broad spectrum synthetic penicillin

-Aminoglycoside/3rd gen cephalosporin

-Metronidazole • Aminoglycoside toxicity-aztreonam,

imipenem• Penicillin allergy-imipenem

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• Duration of treatment must be individualised

• iv antibiotics for 2 weeks

• Oral antibiotics for 1 month

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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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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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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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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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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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• EXTRA PERITONEAL APPROACH -subcostal

-transpleural -retroperitoneal. Used only for selected abscesses located

superiorly in liver dome

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• 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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• 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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• LAPAROSCOPIC SURGERY-Limited role-Useful in diagnosing concurrent abd

pathology-Laparoscopically guided liver biopsy-Catheter placed under laparoscopic

guidance

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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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• 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 3rd and 4th decades of life

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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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Bottle of anchovy sauce and amoebic pus

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CLINICAL FEATURES

• Pain, diarrhoea, cough• Shock• Fever and jaundice – less common

INVESTIGATIONSLaboratory• LFT abnormalities – less common• PT increase• Stool exmn : cyst and trophozoites

-only in 15-50%

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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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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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USG of amebic abscess-Note peripheral location, rounded shape, poor rim with

internal echoes

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CT showing superficial abscess

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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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TREATMENT

• ANTIBIOTICSMost 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) ,chloroquinepgmedicalworld.com

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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PERCUTANEOUS DRAINAGE

• Most useful for pulmonary, peritoneal and pericardial complications

• Risk of secondary infection

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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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COMPLICATIONS

• Rupture into peritoneum or thorax• Abscess eroding into nearby structures• Secondary infection • Hemobilia • Liver failure• Diaphragm perforation• Bronchopleural,biliopleural and

biliobronchial fistulaspgmedicalworld.com

  Brownish pus aspirated from gall bladder adherent to inferior surface amoebic liver

abscess.

 

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Showing rupture of a left lobe amoebic liver abscess into pericardium as seen at

autopsy

 

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Amoebic liver abscess  ruptured into pleural space

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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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• 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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THANK YOU

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