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【中医药】Hepatic Abscess.ppt
1. Affiliated Hangzhou First People's Hospital Zhejiang University School
of Medicine
Bei Lu
Nov.12 2018
Department of Hepatopancreatobiliary
Surgery
Email: 18668121616@163.com
WeChat ID: lubei1124
2. Hepatic abscesses may be bacterial, parasitic, or fungal in
origin. Unless otherwise indicated, the remarks in this
section refer to bacterial abscesses.
4. A Biliary
B
Hepatic
artery
C Portal vein
D Lymphangion
E Liver trauma
Hepatic abscesses is a suppurative process elsewhere in
the body , bacteria may enter the liver from the
following pathways:
Pathways
F Unknown
5. Clinical Findings ▶
A thorough history and physical examination are
necessary to attempt to localize the primary
causative site.
7. Right upper quadrant pain
Inflammation causes enlargement of
the liver, resulting in acute expansion
of the liver capsule, accompanied by
right shoulder radiating pain and right
chest pain.
9. Jaundice?
Jaundice present in patients with
multiple abscesses and primary
disease in the biliary tree, biliary
stones, parasite, tumor.
① Hepatic function injury
② Biliary obstruction
14. CT scans
Pyogenic hepatic abscesses
may be single or multiple and
are more frequently found in
the right lobe of the liver. The
abscess cavities are variable
in size and, when multiple,
may coalesce to give a
honeycomb appearance.
15. CT scans
single or multiple cavity in circle or oval
shape.
The density of the wall is slightly higher
than that of the abscess cavity, which is
lower than that of the normal liver tissue.
gas or gas liquid level in 20% of the
lesions.
16. Why are more frequently found in right lobe?
The left hepatic duct is slender, the
right is short and large, the right
anatomical structure is susceptible to
bacterias, and so is the hepatic artery
and portal.
18. Differential Diagnosis ▶
bacterial abscess amebic abscess
History Biliary infection, sepsis endemic area contact
Symptoms Acute, pain, fever>39℃, chill Chronic, fever<39℃
Signs Slight hepatomegaly Significant hepatomegaly
Characteristics of abscess Small, multiple Large, single
Characteristics of pus Yellow pus, bacterial (+) Chocolate pus, bacterial (-)
Routine blood test Significant leukocytosis Slight leukocytosis
Bacterial culture (+) (-)
Stool test Amoeba trophozoite(-) Amoeba trophozoite (+)
Diagnostic treatment Anti-becterial treatment Anti-amebic treatment
19. Complications ▶
A B
C D
E
intrahepatic spread hepatic failure
rupture into the
pleural or peritoneal
cavity
hemobilia
septicemia and septic
shock F bronchopleural fistula
20. Treatment ▶
The current cornerstones of treatment include correction of
the underlying cause, needle aspiration, and IV antibiotic
therapy.
22. A B C
On presentation,
percutaneous
aspiration and culture
of the aspirate may
be beneficial to guide
subsequent antibiotic
therapy.
Initial antibiotic
therapy needs to
cover gram-
negative as well as
anaerobic
organisms.
Antibiotic therapy
must be continued
for at least 8 weeks.
Antibiotics
24. Drainage
Aspiration and placement of a drainage catheter under ultrasound
or CT guidance is beneficial for only a minority of pyogenic
abscesses, because most are quite viscous and drainage is
ineffective.
Aspiration and IV antibiotic therapy can be expected to be effective
in 80 to 90% of patients.
25. Surgical intervention
If this initial mode of therapy fails, the patients should undergo surgical
therapy, including laparoscopic or open drainage.
26. It must be kept in mind throughout the evaluation and treatment of
the presumed pyogenic abscess that a necrotic hepatic malignancy
must not be mistaken for a hepatic abscess. Therefore, early
diagnosis and progression to surgical resection should be
advocated for patients who do not respond to initial antibiotic
therapy.
27. Prognosis ▶
□ Pleural effusion, leukocytosis over 20,000/ L, hypoalbuminemia, and
polymicrobial
infection correlate with a poor outcome.
□ Benign biliary disease remains a major cause of this disease.
□ Multiple hepatic abscesses are associated with a worse prognosis.
29. Amoeba
Entamoeba histolytica is a parasite that is endemic worldwide,
infecting approximately 10% of the world's population.
30. Epidemiology
Amebiasis is most common in
subtropical climates, especially in
areas with poor sanitation.
Entamoeba histolytica exists in a
vegetative form and as cysts
capable of surviving outside the
human body.
31. Route of transmission
The cystic form passes through the mouth
and small bowel unharmed and then
transforms into a trophozoite in the colon,
enters the portal venous system, and is
carried to the liver. Occasionally, the
trophozoite will pass through the hepatic
sinusoid and into the systemic circulation,
which results in lung and brain abscesses.
32. Chocolate abscess
The abscesses formed are variable in
size and can be single or multiple. The
amebic abscess has a necrotic central
portion that contains a thick, reddish
brown, pus-like material. This material
has been likened to chocolate sauce.
33. Diagnosis
Amebiasis should be
considered in patients who
have traveled to an 1endemic
area and present with right
upper quadrant 2pain, 3fever,
4hepatomegaly.
34. Treatment
Metronidazole 750 mg tid for 7 to 10 days is the treatment of choice
and is successful in 95% of cases.
Defervescence usually occurs in 3 to 5 days.
The time necessary for the abscess to resolve depends on the initial
size at presentation and varies from 30 to 300 days.
