Liver abscess, types, causes, diagnosis and management

1. Patel Institute Of Nursing & Allied Health Sciences
By: Farooq Marwat

2.  At the end of this presentation, student will know about:
 Abscess
 Liver Abscess
 Types of Liver Abscess
 Incidence Rate and Epidemic Data about Liver abscess
 Who are at risk
 Clinical Manifestations
 Diagnosis
 Treatment
 Complication
 Prognosis

3. What is Abscess
 Abscess may be define as a collection of pus
(dead cells and neutrophils) that has
accumulated within a tissue because of an
inflammatory process in response to either
an infectious process (usually caused by
bacteria or parasites) or other foreign
materials

4. Liver abscess

5. Liver abscess
 A liver abscess is a collection of pus in the liver caused
by bacteria, fungi, or parasites. It may occur as a single
lesion or as multiple lesions of different sizes. The
abscess may contain thick, bad smelling pus or
reddish-brown anchovy paste-like fluid with no odor.
 Occurs when bacteria/protozoa destroy hepatic tissue,
produces a cavity which fills up with infective
organisms, liquefied cells & leucocytes. Necrotic tissue
then falls off the cavity from rest of the liver.

6. Incidence & Epidemiology

7. Incidence & Epidemiology
 Liver – organ most subject to the development of
abscesses
 13% of total intraabdominal abscesses
 48% of all visceral abscess
 Mortality - 5-30% of cases
 most common causes of death include sepsis,
multiorgan failure, and hepatic failure
 Equal Male to female ratio. Males have poorer
prognosis

8. Types Of Liver Abscess
 There are three major forms of liver abscess, classified
by etiology:
 Pyogenic liver abscess, which is most often
polymicrobial, accounts for 80% of hepatic abscess cases
in the United States.
 Amoebic liver abscess due to Entamoeba histolytica
accounts for 10% of cases.
 Fungal abscess, most often due to Candida species,
accounts for less than 10% of cases.

9. Pyogenic Liver Abscess

10. Pyogenic Liver Abscess
 A pyogenic liver abscess is a type of liver abscess
caused by bacteria, can be single or multiple.
 The right lobe is affected twice as often as the left; 5%
have bilateral involvement.
 No cause found in 15% cases. Most are secondary to
infection originating in the abdomen. Bacterial
endocarditis and dental infection are other causes.
 More common in the immunocompromised and in
people with Liver cirrhosis.

11. Pyogenic Liver Abscess

12. Etiology
 Disorders or bacterial infection of following origins
may invade liver to cause abscess:
 Biliary disease (most common) e.g.: stones,
cholangiocarcinoma, infection
 Colonic disease. e.g.: diverticulitis, appendicitis, Crohn's
disease
 Pancreatitis
 Infection of blood
 Intra-abdominal sepsis
 Endocarditic, Dental infection (with streptococci)
 Traumatic, Iatrogenic

13. Common Causative Agents
 Most common species invloved are
 Streptococcus milleri
 Pseudomonas
 E. coli
 Klebsiella pneumoniae
 Proteus vulgaris
 Bacteroides
 Opportunistic Pathogens (Staphylococcus)`

14. Amoebic Liver Abscess
 Amoebic liver abscess or amebiasis is a type of liver
abscess caused by Entamoeba Histolytica (Protozoa).
 E. histolytica causes amoebic colitis and dysentery but
liver abscess is the most common extra-intestinal
manifestation of infection
 Route of entry via oro-fecal roue by ingestion of
contaminated food or water. Amoebae invade
intestinal mucosa and can gain access to the portal
venous system.

15.  Causes a large necrotic area which is liquefied into
thick reddish-brown pus (Anchovy sauce pus) due to
liquefied necrosis, thrombosis of blood vessels, lysis of
liver cells
 It affects the right lobe in 80%.
 This type is common in overcrowded areas with poor
sanitation and in alcoholics.
Amoebic Liver Abscess

16. Amoebic Liver Abscess

17. Fungal Liver Abscess
 Fungal abscesses is a less common type,
primarily due to Candida albicans and occur
in individuals with prolonged exposure to
antimicrobials, hematologic malignancies,
solid-organ transplants, and congenital and
acquired immunodeficiency.

18. Clinical Manifestation
1. Fever with Chills, (PUO in Amoebic Abscess)
2. Abdominal pain
3. Anorexia
4. Weight loss
5. Nausea, Vomiting
6. Right shoulder pain / irritable cough
7. Cough and Dyspnea
8. Hepatomegaly
9. Tenderness
10. Rebound tenderness
11. Jaundice (late)

19. People at Risk

20. People at Risk
 Age: Advanced age, particularly in people older than 70 years.
 Health: Having a long-term disease, (cancer, diabetes,
tuberculosis) or splenectomy, a weak immune system, AIDS.
 Taking Drugs: Such as steroids, chemotherapy, prolong use of
antibiotics (fungal abscess).
 Lifestyle: Drinking too much alcohol, too often. Living in over
crowding area, poor sanitation
 Nutrition: Being malnourished (having poor nutrition).
 Activity: Traveling to places where amebiasis is common.
Eating foods and drinking liquids that are sold in the street may
further increase risk.

21. Laboratory Studies
1. CBC
1. Increased WBC, usually Neutrophilic Leukocytosis.
2. Raised erythrocyte sedimentation rate (ESR).
3. Mild normochromic normocytic anaemia.
2. Liver function studies
1. Hypoalbuminemia
2. Elevation of alkaline phosphatase
3. Elevations of transaminase and bilirubin levels (variable)

22. 3. Blood cultures are positive in roughly 50% of cases.
4. Stool DR: Stools can contain cysts or trophozoites of E.
histolytica.
5. Serology should be carried out if E. histolytica is
suspected.
6. Culture of abscess fluid should be the goal in
establishing microbiologic diagnosis. Usually done
through Percutaneous needle aspiration (under CT or
Ultrasound Guidance)
Laboratory Studies

23. Imaging Study
1. Chest X-Ray: May show raised right hemi-diaphragm on.
2. Ultrasonography
a) Can show abscess and also allow guided percutaneous aspiration
and drainage and biliary tree examination. A Doppler ultrasound
study may be done to check for blood flow in your liver.
3. CT scanning
a) Can show the abscess, allow guided aspiration and drainage and
show other intra-abdominal abscesses or a possible cause such as
diverticular disease, appendicitis, etc. It is good for the detection
of small abscesses.
4. Liver Scan
5. MRI

24. CXR USG

25. CT Scan

26. Medical Management
 Antibiotics
 Pyogenic liver abscess: Broad spectrum antibiotics should
be started before waiting for culture results.
 Usually start treatment with tri-therapy included the use of
penicillin, amino-glycoside and metronidazole.
 A third-generation cephalosporin can be considered in the
elderly or if renal function is impaired.
 Antibiotic therapy can be modified once culture results are
available.
 Treatment may be needed for up to 12 weeks and should be
guided by the clinical picture and radiological monitoring.

27.  Amoebic liver abscess:
 Metronidazole is the treatment of choice. 95% of
patients with amoebic liver abscess recover with this
alone. Most patients show a response to treatment
within 72-96 hours.
 Diloxanide furoate should be prescribed for 10 days to
eliminate intestinal amoebae after the abscess has been
successfully treated.
 Antifungal agents such as amphotericin B are used if
fungal abscess is suspected.
Medical Management

28. Surgical Management or Drainage
 Most patients with pyogenic liver abscess or with very large
amoebic abscesses, may not recover with antibiotics alone
need drainage guided by ultrasonography or CT.
 Percutaneous aspiration can be carried out for small
abscesses although
 Catheter drainage carried out for larger abscesses.
 Open surgery may be necessary if
 Abscess ruptured
 Signs of peritonitis,
 Abscess 5 cm
 Appendicitis.

31. Nursing Management
 Pain Management: Alleviation or reduction in pain
 Nutrition Management: Assisting with or providing
a balanced dietary intake of foods and fluids.
 Infection Protection: Infection Control, Prevention
and early detection of infection in a patient at risk.

32. Complications
1. Return of Abscess
2. Widespread infection in abdomen.
3. Overwhelming sepsis.
4. Rupture of the abscess into adjacent structures
(pleural, peritoneal and pericardial spaces).
5. Secondary infection of amoebic liver abscesses.

33. Prognosis
 Pyogenic liver abscess
 Mortality rate is 5-30%.
 Condition such as Diabetes Mellitus, immunodeficiency,
malignancy, affect prognosis.
 Amoebic liver abscess
 Mortality rates have fallen to 1-3%.