Lecture on liver abscess for medical students on a disease endemic to Sarawak. Encompasses basic sciences, classifications, pathophysiology, principles and tips of management.

1. Liver abscess
Chea Chan Hooi
Surgeon
Sibu Hospital

2. Content
• Epidemiology
• Etiology
• Microbiology
• Anatomy
• Clinical features
• Investigations
• Principles of management
• Pyogenic vs. amoebic

3. Epidemiology
• Male
• Endemic area, low socioeconomic area,
agriculture, poor sanitation

4. Etiology
• Biliary tract (30%)
– Extrahepatic obstruction
• Choledocholithiasis
• Strictures
• Tumours (benign & malignant)
• Choledoenterostomy (sump syndrome)
– Choledochoduodenostomy & choledochojejunostomy
– Distal BD blocked by food particles
• Portal pyemia/pyelephlebitis (20%)
– Primary infection in abdominal cavity & seed/emboli into liver via portal vein
– Less common nowadays with early use of antibiotics & prompt proper source control
– Appendicitis still the most common source
• Hematogenous
– Via hepatic artery
– Bacterial endocarditis, urosepsis & IVDU
• Direct implantation
– Penetrating trauma
– Adjacent severe infection – e.g. gangrenous cholecystitis,
• Iatrogenic
– TACE, RFA, PEI
– Laparoscopic hepatobiliary surgery – commonly lap chole
– ERCP
• Cryptogenic
– Commonly in geriatric group, prolonged bed ridden & institutionalised
– Unclear pathophysiology

5. Microbiology
Pyogenic
• Usually polymicrobial from
enteric & biliary source
• Common organisms
encountered
– E. coli 33%
– K. pneumoniae 20%
– Bacteroides spp 24%
– Streptococcal spp 37%
– Microaerophillic strep spp 12%
Amoebic
• Entamoeba histolytica
• Hydatid cysts get infected

6. Anatomy
• Right lobe 80% due to anatomical
considerations
– Right lobe receives portal blood from both SMV &
IMV
– Streaming effect of right PV (wider & straighter)
– Denser network of bile canaliculi
– More hepatic mass

8. Clinical features
• Abdominal pain
• Fever
• Chills & rigors
• Loss of appetite
• Weight loss
• Cough
• Pleuritic chest pain

9. Complications
• Rupture
– Peritoneal cavity
• Subphrenic or localised  percutaneous drainage
• Free rupture  Generalised peritonitis  emergency
laparotomy
– Pleural space*
• Pleurisy, pleural effusion, empyema, bronchohepatic fistula
– Pericardial space*
• Rare but have been reported
• Beware if abscess is located adjacent to diaphragm &
pericardium
*subdiaphragmatic amoebic abscess
• Septic shock

10. Investigations
Radiological
• USG
– The standard 1st line for HPB
imaging
– Poorly demarcated with variable
appearance (hypoechoic –
hyperechoic)
– Gas bubble may be seen
– Colour Doppler will demonstrate
absence of central perfusion
• CT scan
– Differentiate from other pathology
mimicking liver abscess
• HCC (multicystic or infected)
• Necrotic liver mets
• Infected cysts
Blood works
• FBC
• LFT
• RP
• PT/PTT
• ABG
• Blood C+S
• ESR/CRP
• Tumour markers

12. Principles of management
• Resuscitation
• Broad spectrum empirical antibiotics
• Sepsis control
– Percutaneous drainage
– Surgical drainage

13. Percutaneous drainage
• USG or CT guided
• Contraindication
– Location of abscess
– Irretractable coagulopathy
– Immunocompromised patients with diffuse
microabscesses
– Ascites is a relative contraindication
– Might be difficult if <2 – 3 cm

14. Anchovy sauce drainage  amoebic

15. • Failure
– No improvement within 72 hours
– Abscess persists despite adequate drainage
– Further options
• Insert another percutaneous drain
• Surgical drainage
• Complications
– Early
• Injury to liver (bleeding, biloma), lung (pneumo/haemothorax),
blood vessels (IVC, PV, HA)
• Intraperitoneal leakage causing generalised peritonitis
– Late
• Fistula

16. Surgery
• Indications
– Multi-septated
– Multiple abscesses
– Abscess cannot be drained percutaneously d/t location
– Failed antibiotic therapy
– Failed percutaneous drainage
– Coexisting biliary/intra-abdominal disease requiring surgery
– Ruptured intraperitoneally
– Large >5cm
• Approach
– Open
– Laparoscopic

18. TQ!
Q&A?