This presentation gives general overview of liver abscess.

1. Liver Abscess
Muhammad Haris Janjua
Resident, Surgical unit I
SIMS/Services Hospital, Lahore.

2. Classification
• Pyogenic abscess,
– polymicrobial,
• Amoebic liver abscess
– Entamoeba histolytica
• Fungal abscess
– Candida species

3. Pathophysiology

4. • More common in Right lobe
WHY?

5. • Left lobe receives blood from
– Inferior mesenteric
– Splenic veins
• Right lobe receives blood from
– Superior mesenteric
– Portal veins
• Streaming effect in portal circulation is
causative.

6. • The most common infecting agents are gram-
negative bacteria;
– Escherichia coli
• Other common organisms include
– Streptococcus faecalis,
– Klebsiella, and
– Proteus vulgaris.
• In patients with endocarditis and infected indwelling
catheters,
– Staphylococcus and
– Streptococcus species are common

7. Presentation

8. Common presentation
• Fever (either continuous or spiking)
• Chills
• Right upper quadrant pain
• Tender hepatomegaly
• Anorexia
• Malaise
• Diarrhea in present in 1/3 patients with amoebic liver abscess

9. Differential diagnosis
• Acute Gastritis
• Bacterial Pneumonia
• Biliary Disease
• Cholecystitis
• Hepatocellular Carcinoma
• Hydatid Cysts
• Parapneumonic Pleural Effusions and Empyema Thoracis

10. Diagnosis
• Lab tests
• Most common
– Neutrophilic leucocytosis
– Elevated ESR
– Elevated AP levels
• elevations of transaminase and bilirubin levels
are variable

11. • Blood cultures are positive in roughly 50% of cases.
• Culture of abscess fluid should be the goal in
establishing microbiologic diagnosis
• ELISA should be performed
– to detect E histolytica in patients either from endemic
areas or who have traveled to endemic areas.
• Indirect Haemagglutinin assays (IHA) is the most
sensitive test (90%).

12. Imaging studies

14. Principals of Management of
Pyogenic liver abscess
• Drain the pus
• Institute appropriate antibiotics, and
• Deal with any underlying source of infection,
Percutaneous drainage combined with antibiotics has
become the first line and mainstay of treatment for
most PLAs

15. Drainage Options
• Percutaneous
– Needle aspiration
– Catheter drainage
• Surgical drainage
– Open
– Laproscopic

16. Percutaneous needle aspiration
• Under CT or USG guidance, needle aspiration of
cavity material can be performed.
• Needle aspiration enables
– rapid recovery of material for microbiologic and
pathologic evaluation.
• Large percentage requires second or third
aspirations to achieve success

17. Percutaneous catheter drainage
• Percutaneous drainage has become the
standard of care.
• Should be the first intervention considered for
– Small cysts.
– The pus is too thick to be aspirated
– The wall is thick and non-collapsible
– The PLA is multi-loculated

18. • Advantages include
– reduced costs, recovery time,
– it eliminates the need for general anesthesia
– This also allows for gradual, controlled drainage.

19. Percutaneous catheter drainage
• A catheter is placed under ultrasonographic or
CT guidance via the Seldinger or trocar
techniques.
• The catheter is flushed daily until output is
less than 10 mL/day or cavity collapse is
documented by serial CT.

20. • Contraindications to catheter drainage
include
• coagulopathy;
• a difficult access path to the cavity;
• peritonitis; and/or
• a complicated, multiloculated, thick-
walled abscess with viscous pus.

21. Antibiotic therapy
• Antibiotic therapy should cover gram negative
organisms and anaerobes
• First line antibiotics are
– Penicillin's, aminoglycosides and metronidazole or
– Cephalosporin and metronidazole
• Can be changed after Culture report

22. • IV antibiotic therapy should be
continued for at least 8 weeks
• Some studies suggest antibiotics should be
administered parenterally for 2 weeks
• Then appropriate oral agents may be used for a
further 6 weeks

23. Surgical drainage
• Indications of surgical drainage include
– Failure of non operative treatment
– Intraperitoneal rupture
– the presence of a complicated, multiloculated,
thick-walled abscess with viscous pus
– treatment of underlying intra-abdominal processes,
• peritonitis;
• existence of a known abdominal surgical pathology (eg,
diverticular abscess)

24. Approaches
Open
• A transperitoneal approach
– allows for abscess drainage and
– abdominal exploration to identify previously
undetected abscesses and the location of an etiologic
source
• Transpleural approach
– For high posterior lesions,
– easier access to the abscess,
– the identification of multiple lesions or a concurrent
intra-abdominal pathology is lost

25. Laparoscopic approach
• Used in select cases
• Experienced and well equipped setups

26. Management of amoebic liver abscess
Medical
• Metronidazole 750 mg three times a day for 7
to 10 days is the treatment of choice
• successful in 95% of cases.

27. • Aspiration of the abscess rarely is needed
–with large abscesses,
–Those who appear to be superinfected.
–Large abscess having impending rupture /
compression sign
–Thin rim of liver tissue around the abscess (<10
mm)
–Sero-negative abscesses
–Failure in the improvement following non-
invasive treatment after 4 to 5 days

28. • Abscesses of the left lobe of the liver
at risk for rupture into the
pericardium should be treated with
aspiration and drainage.

29. Open drainage
• Rupture of amoebic abscess in adjacent
viscera is indication of open drainage

30. • The amebic abscess has
• Necrotic central portion that contains a thick,
reddish brown, pus-like material.
• This material has been likened to anchovy
paste or chocolate sauce.

32. Treatment of intestinal carriage
• Luminal amebicidal agent
• Paromomycin
– 25-30 mg/kg/d orally for 7 days in three divided
doses
– Iodoquinol
– Diloxanide furoate

33. Long-Term Monitoring
• Weekly serial computed tomography (CT) or
ultrasound examinations to document
adequate drainage of the abscess cavity.
• Maintain drains until the output is less than 10
mL/day
• Monitor fever curves.
– Persistent fever after 2 weeks of therapy may
indicate the need for more aggressive drainage

34. • For patients with an underlying malignancy,
definitive treatment, such as surgical removal
of the mass, should be pursued if at all
possible.
• Patients on prolonged parenteral antibiotics
monitoring of RFTs and TLC may be needed.

35. Complications of liver abscess
– Sepsis
– Empyema resulting from contiguous spread or
intrapleural rupture of abscess
– Rupture of abscess with resulting peritonitis
– Endophthalmitis when an abscess is associated
with K pneumoniae bacteremia.

36. Available at surgicalpresentations