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Abscess of liver

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  • 1. Level of competence 4 ABSCESS OF LIVER
  • 2. 2 types : Right lobe Right lobe (65%) (65%) Both lobes Both lobes (30%) (30%) Left lobe (5%) Left lobe (5%)
  • 3. ETIOLOGIES
  • 4. Amebic Bile is lethal to amebas, thus infection of gall bladder & bile duct do not occur
  • 5. PATHOPYSIOLOGY
  • 6. AMEBIC Bile is lethal to amebas → infection of gallbladder or bile duct do not occur
  • 7. Pathophysiology • • • Ingestion contaminated water or food containing E. histolytica cysts infective cyst form of the parasite survives passage through the stomach and small intestine. Excystation occurs in the bowel lumen, where motile and potentially invasive trophozoites are formed. In most infections the trophozoites aggregate in the intestinal mucin layer and form new cysts, resulting in a selflimited and asymptomatic infection. In some cases, adherence to and lysis of the colonic epithelium, mediated by the galactose and N-acetyl-Dgalactosamine (Gal/GalNAc)–specific lectin, initiates invasion of the colon → neutrophils responding to the invasion contribute to cellular damage. Once the intestinal epithelium is invaded, extraintestinal spread to the peritoneum, liver, and other sites may follow.
  • 8. CLINICAL MANIFESTATION PYOGENIC AMEBIC Nonspesific, fever (absent in 30%), chills, RUQ pain (45%), malaise, weight lose More severe RUQ pain, fever 90% cases Dominate by underlying disease : appendicitis, diverticulitis, biliary disease Recent travel to endemic area, but maybe remote Comorbid common : DM, malignancy, alcholism, cardiovascular, chronic renal disease Previous colonic amebiasis (only 5-15%), concurrent hepatic abcess & amebic dysenteri are unusual Eosinophilia, high bilirubin, blood culture + 50%, aspirates + bacteria 75-90% Most aspiration does not yield an organism (tropozoite < 20%); odorless, serologic + only invasive amebiasis, negative asymptomatic carrier, gel diffusion precipitin (best test)
  • 9. Laboratory & Diagnostic • Routine lab not diagnostic for both abcess : WBC (↑), anemia (normocytic normochromic), sed rate (↑) • LFT nonspesific : 90% high AP, AST/ALT ↑ but to a lesser degree, low albumin (<2mg%) poor prognostic
  • 10. • CXR : 50-80% abnormal (RLL atelectasis, R pleural eff, R hemidiaphragm elevation) • U/S initial test of choice : noninvasive, high sensitivity 80-90%; to distinguish cyst from solid lesion/visualizing biliary tree • CT (IV contrast) : smaller abcess, asses peritoneal cavity
  • 11. ASPIRATE • Pyogenic (multipel abcess, coexistent biliary disease, intraabdominal inflammatory process) • Non amebic • Amebic aspiration : pyogenic can’t be roled out, respond to amebic therapy has not occurred within 24-48 hours, abcess is large (size greater than 5 cm) & painful • Surgical drainage of amebic abcess : located in left lobe, respon therapy is not dramatic in 4-5 days
  • 12. PYOGENIC PYOGENIC • Antibiotic : aminoglicoside/ cephalosporin (gram -), clindamycin/metronidazole (anaerobes), penicillin/ampicillin (enterococci) • Surgery percutaneus drainage : conservative measure fail, to treat primary intraabdominal lesion 76% cure rate, 60% either alone TREATMENT AMEBIC AMEBIC • Metronidazole drug active against extraintestinal form of amebiasis : 750mg TID x 10 days • Eradicates intestinal form : iodoquinol 650mg TID x 20 days • Consider aspiration if failing therapy
  • 13. CoMPLICATION & PROGNOSIS PYOGENIC AMEBIC Untreated 100% mortality Rapid clinical improvement is observed in less than 1 week with antiamebic drug therapy alone Ruptur into peritoneal cavity : subphrenic, perihepatic, subhepatic abscesses or peritonitis; metastatic ruptur emboli (lung, brain) similar Left lobe abscess : cardiac tamponade, pericarditis Abscess in dome of liver or complicated by bronchopleural fistula Depends on rapidity diagnosis & underlying illness Generally do well with treatment Morbidity high (50%), mortality 5-10% (prompt recognation & adequate AB) higher in multipel abscesses Morbidity 4.5%, mortality 2.2%
  • 14. Independent risk factors predicting a higher mortality – – – – – – Bilirubin level greater than 3.5 mg/dL Encephalopathy Volume of abscess cavity greater than 500 mL at presentation Serum albumin less than 2 g/dL Hemoglobin less than 8 g/dL Multiple abscesses

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