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Liver Abscess
Muhammad Haris Janjua
Resident, Surgical unit I
SIMS/Services Hospital, Lahore.
Classification
• Pyogenic abscess,
– polymicrobial,
• Amoebic liver abscess
– Entamoeba histolytica
• Fungal abscess
– Candida species
Pathophysiology
• More common in Right lobe
WHY?
• 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.
• 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
Presentation
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
Differential diagnosis
• Acute Gastritis
• Bacterial Pneumonia
• Biliary Disease
• Cholecystitis
• Hepatocellular Carcinoma
• Hydatid Cysts
• Parapneumonic Pleural Effusions and Empyema Thoracis
Diagnosis
• Lab tests
• Most common
– Neutrophilic leucocytosis
– Elevated ESR
– Elevated AP levels
• elevations of transaminase and bilirubin levels
are variable
• 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%).
Imaging studies
Liver abscess
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
Drainage Options
• Percutaneous
– Needle aspiration
– Catheter drainage
• Surgical drainage
– Open
– Laproscopic
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
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
• Advantages include
– reduced costs, recovery time,
– it eliminates the need for general anesthesia
– This also allows for gradual, controlled drainage.
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.
• 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.
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
• 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
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)
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
Laparoscopic approach
• Used in select cases
• Experienced and well equipped setups
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.
• 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
• Abscesses of the left lobe of the liver
at risk for rupture into the
pericardium should be treated with
aspiration and drainage.
Open drainage
• Rupture of amoebic abscess in adjacent
viscera is indication of open drainage
• 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.
Liver abscess
Treatment of intestinal carriage
• Luminal amebicidal agent
• Paromomycin
– 25-30 mg/kg/d orally for 7 days in three divided
doses
– Iodoquinol
– Diloxanide furoate
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
• 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.
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.
Available at surgicalpresentations

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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
  • 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
  • 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%).
  • 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.