Liver Abcess ppt for surgery residents.

1. LIVER ABSCESS
BY :- DR. SIDDHI VINAYAK
PG RESIDENT
MODERATOR :- DR. SANJAY SHARMA

2. LIVER ABSCESS
• Collection of PURULENT MATERIAL in the liver parenchyma forming a
CAVITY.
• Most common type of visceral abscess.
• Can be:-
• Bacterial (Pyogenic)
• Parasitic (Amoebic)

3. PYOGENIC LIVER ABSCESS

4. PYOGENIC LIVER ABSCESS
• Liver abscess due to Bacteria such as –
• E Coli – Commonest.
• Klebsiella
• Proteus
• Pseudomonas
• Clostridia
• Enterococci, Streptococci

5. CAUSES OF PYOGENIC LIVER ABSCESS
• I. Infection through the portal vein
• Acute appendicitis
• Acute diverticulitis (sigmoid)
• Acute amoebic colitis
• Acute bacillary dysentery
• Ulcerative colitis

6. CAUSES OF PYOGENIC LIVER ABSCESS
• II. Infection through the common bile duct (CBD)
• Stricture of the CBD
• Periampullary carcinoma resulting in stasis of the bile, precipitating
infection (cholangitis)
• Recurrent cholangitis due to stone in the CBD
• ERCP

7. CAUSES OF PYOGENIC LIVER ABSCESS
• Ill. Infection through the hepatic artery
• Septicaemia and pyaemia
• IV. Extension abscess
• Subdiaphragmatic abscess
• Empyema thoracis
• Penetrating injuries
• V. Infection through umbilicus
• Neonatal umbilical sepsis giving rise to pyaemia.

8. ORGANISMS
• Majority of the infective bacteria are derived from gastrointestinal tract.
• In majority of cases, it is polymicrobial infection.
• Bacteroides fragilis is the most common anaerobe (60%).
• E.coli is the most common facultative organism.
• Others are Klebsiella, other gram negatives and even Staph. aureus.

9. SIGNS AND SYMPTOMS
• Fever, chills.
• Insidious onset of RUQ pain, epigastric pain
• Occasionally jaundice
• In Late stages, sepsis,
• Weight loss
• Hepatomegaly
• Amebic abscesses tend to have a more protracted course.

10. CLINICAL FEATURES
• Pain in the right hypochondrjum - 60%.
• High fever, with rigors - 90%.
• Weight loss.
• Jaundice occasionally - 20%.
• Intercostal tenderness.
• Tender, soft liver - 60%.
• Features of toxicity.
• Constitutional symptoms like malaise, lethargy, vomiting.

11. INVESTIGATIONS
• Total WBC count is raised.
• Stool routine examination: Amoebic cysts, culture and sensitivity for
typhoid bacilli.
• Abdominal ultrasound and ultrasound-guided aspiration establishes the
diagnosis.
• When in doubt, CT scan can be done, followed by FNAC which draws frank
pus. Pus is sent for Gram's stain, culture and sensitivity. CT also helps in
the diagnosis of associated conditions such as diverticulitis of the colon.

12. DIAGNOSIS
• Ultrasound abdomen, CT scan. Sensitivity is 90% for USG; 97% for contrast CT scan.
• Elevated LFT, low albumin, high PT, Total count.
• Ultrasound guided aspiration of pus after controlling PI.
• Chest X-ray shows elevated diaphragm often with right sided pleural effusion.
• Blood culture is very relevant.

13. DIFFERENTIAL DIAGNOSIS

14. TREATMENT
• Systemic antibiotics- combination of third generation cephalo-sporins and
metronidazole.
• Ultrasound guided aspiration/ Pigtail catheter - Percutaneous drainage is the
treatment of choice at present.
• Pus should be sent for culture and sensitivity.
• Follow-up USG,LFT assessment of quantity of daily drainage- should be done to
assess the response.
• 75% of pyogenic abscess is drained percutaneously.
• Occasionally, open drainage is required. Open drainage is indicated in recurrent
abscess, failure of percutaneous drainage, large abscess of size more than 5 cm. Open
drainage is becoming less common at present; but in selected patients it may be a
life-saving essential therapeutic modality.
• Treating the primary causes is very essential.

15. TREATMENT
• Open (surgical) method
• Laparotomy is required mainly to treat the primary causes, e.g. appendicectomy,
drainage of appendicular abscess.
• If liver shows a significant abscess, it is drained. Alternately, a pigtail catheter is
introduced into the abscess cavity and brought outside through a separate
opening. It helps to drain for a longer period of time.
• Laparoscopic drainage can also be done.

16. COMPLICATIONS
• Septicemia
• Liver failure
• Rupture (Rare) & Peritonitis can occur.

17. AMOEBIC LIVER ABSCESS

18. AMOEBIC LIVER ABSCESS
• Common in India and other tropical countries.
• Caused by parasite Entamoeba histolytica.
• More common in alcoholics and cirrhotic patients.
• Commonest extraintestinal presentation (8-10%) of amoebiasis.
• Infection commonly occurs from the caecum after an attack of amoebic typhlitis
through the superior mesenteric vein and portal vein. Infection from sigmoid
colon spreads through the inferior mesenteric vein and portal vein to liver.

19. AMOEBIC LIVER ABSCESS
• Right lobe is commonly involved over posterosuperior surface - because of streamline elect and larger size of the
right lobe.
• Trophozoites destroy the hepatocytes by releasing histolysin a cytolytic agent.
• It causes amoebic hepatitis with multiple micro abscesses formation.
• It leads into liquefaction necrosis, thrombosis of blood vessels. release and, breaking of red cells. It causes formation
of “Anchovy sauce” pus which is chocolate brown colored and odorless.
• Contains dead liver cells, RBCs, necrotic material (But no WBC)
• Secondary infection is common (30%).
• Amoebic abscess is usually sterile unless infected.

20. AMOEBIC LIVER ABSCESS
• In majority of the cases, pus is sterile.
• Secondary infection occurs in about 20 to 30% of the cases.
• Amoebae are rarely present in the pus but are present in the wall of the abscess
cavity. The wall contains monocytes, plasma cells, lymphocytes and fibroblasts.
• Abscesses are multiple which fuse to form a single large abscess cavity in about
70% of the cases. Due to perihepatitis, abscess gets fixed to the diaphragm
resulting in immobility of the diaphragm.

21. LIFE CYCLE OF ENTAMOEBA HISTOLYTICA

22. CLINICAL FEATURES
• It is common in males (10:1)
• H/o amoebic dysentery
• Fever
• Loss of weight
• Chills and rigors,
• Non- productive cough, shoulder pain.
• Pain in the right hypochondrium -30%. Soft, tender, smooth, liver with increased liver span--70%.
• Intercostal tenderness is elicited which is a useful clinical sign.
• Right sided pleural effusion may be evident. Mild jaundice
• In chronic amoebic liver abscess, smooth, firm/hard, nontender liver may be palpable.

23. INVESTIGATIONS
• Increased TLC.
• Low Hb% in 50% çases.
• Altered Liver function tests (altered bilirubin and albumin level).
• Prothrombin time may be widened and if it is so injection vitamin K 10 mg IM or IV for 5 days should be given.
• Even with this if P.T. remains widened then fresh frozen plasma (FFP) is needed to rectify the P.T. Serum alkaline
phosphatase, SGPT, SGOT levels are altered.
• US abdomen shows altered echogenicity (anechogenic, hypoechogenic), size, location, number of abscess, nature of
the liver- 90% sensitivity.
• Chest X-ray findings: Raised fixed diaphragm (tenting) ,Pleural effusion & Soft tissue shadow

24. INVESTIGATIONS
• CT scan shows raised diaphragm; abscess cavity (low density area) -its size, location, number;
presence of effusion; changes in the lung- -95% sensitivity.
• Sigmoidoscopy/colonoscopy are used to identify the active ulcers. Scrapings of the ulcer show
trophozoites.

25. TREATMENT
• I. Conservative line of management •
• It is indicated in amoebic hepatitis.
• Tab. Metronidazole 400-800 mg, 3 times a day is given for 14 days. The only
recognisable side-effect is metallic taste.
• If the condition does not improve, injection dryhydroemetine1.5 mg/kg body
weight to a total of 60 mg/day IM for 5 days is given.
• Choloroquine 250mg BD for 10-14 days.

26. TREATMENT
• II. USG-guided needle aspiration/pigtail catheter drainage
• It is indicated in cases of amoebic liver abscess (large abscess >10cm).
• Before it is aspirated, bleeding profile (BT, CT, PT) should be normal and injection
vitamin K 10 mg, IM should be given for at least 3 days.
• US-guided aspiration is also the treatment of choice where metronidazole is
contraindicated, e.g. 1st trimester of pregnancy.
• It can be easily done under local anaesthesia
• Can be repeated, if pus recollects.
• Typically it is anchovy sauce pus. Aspiration is followed by insertion of pig tail
catheter. Before removal of the catheter do a repeat ultrasound to check for residual
pus.

27. TREATMENT
• Ill. Surgery (open drainage) and laparoscopic:-
• Indications –
• 1. Failure of US-guided needle aspiration.
• 2. Ruptured amoebic liver abscess with amoebic peritonitis.

28. COMPLICATIONS
• Amoebic peritonitis, resulting in acute abdomen with shock. It has to be treated
like any peritonitis- laparotomy, drainage of pus and drain the abscess cavity to
outside (possibility of amebiasis cutis is still present but rare).
• Rupture into pleural space causing pleural effusion.
• Rupture into the bronchus resulting in coughing out anchovy sauce (may be a
natural cure) -bronchopleural fistula.
• Amoebic pericardial effusion occurs due to rupture of left liver lobe abscess into
pericardial space.

29. HYDATID CYST OF LIVER

30. HYDATID CYST OF THE LIVER
• The disease is caused by Echinococcus granulosus, transmitted by dogs which
are the chief mediators (host) and man is the intermediate host. After swallowing
the ova, they penetrate gastric mucosa , reach retroperitoneal structures,
penetrate portal vein directly and then enter into liver.
• Having reached liver, the organisms grow and develop their own protective layer
and form hydatid cyst.

31. LAYERS OF THE HYDATID CYST
• 1. The adventitia (pseudocyst) : This is the fibrous layer derived from the liver
tissue. It is the reaction of liver to the parasite. It is adherent to the liver and
cannot be separated, also known as pericyst.
• 2. The ectocyst (laminated membrane): It is white and elastic and is produced by
endocyst. It is this layer which gets peeled off at surgery.
• 3. The endocyst: This is called germinal epithelium and it is the innermost part of
hydatid cyst. It secretes hydatid fluid inside and ectocyst outside. Within the
hydatid fluid, scolices of Echinococcus granulosus develop.

32. CLINICAL FEATURES
• It can be silent-without any symptoms throughout life, accidentally discovered on
routine examination.
• Dragging pain in the upper abdomen due to hepatomegaly.
• Liver is enlarged, has a smooth surface, and is nontender.
• Typical hydatid thrill can be present on rare occasions. Hydatid thrill is demonstrated
by 3-finger method. Keep 3 fingers over the liver, percuss over the middle finger and
get the impulse by other 2 fingers (fluid thrill).
• Patient may present as an emergency with severe abdominal pain following minor
trauma.
• May present as an emergency with features of anaphylactic shock without any
obvious cause.

33. INVESTIGATIONS
• 1. USG can detect the cyst, localise the cyst and is used for aspiration purposes.
• 2. Plain X-ray abdomen may demonstrate speckled calcification.
• 3. CT scan may be necessary in selected cases. The cyst which is superficial and
has reached surface, should be operated upon.
• 4. ERCP if there is obstructive jaundice-in such cases, a wide sphincterotomy
should be given so as to allow free drainage of the hydatid contents into the
duodenum.
• 5. Cason's intradermal test: Sensitivity and specificity of this test is low and
hence, no longer used.
• 6. ELISA and immunoelectrophoresis may point towards the diagnosis.

34. HASSEN GHARBI'S ULTRASOUND BASED
CLASSIFICATION OF LIVER HYDATID CYSTS (1981)
• Type 1 - Pure fluid collection
• Type 2 - Fluid collection with split wall
• Type 3 - Fluid collection with septa
• Type 4 - Heterogeneous appearance
• Type 5- Reflecting thick walls

35. WHO CLASSIFICATION OF LIVER HYDATID
CYST
• Type - CL - Active; unilocular; no cyst wall; early stage; not fertile.
• Type - CE 1 - Active; cyst wall present; hydatid sand present; fertile.
• Type - CE 2 - Active; multivesicular rosette like cyst wall; fertile.
• Type-CE3 - Transitional; detaching laminated membrane; water-lily sign;
beginning of degeneration
• Type - CE 4 - Inactive; degenerative contents; no daughter cysts; not fertile
• Type - CE 5 - Inactive; thick calcified wall; not fertile

36. TREATMENT - CONSERVATIVE
• Calcified cysts are dead cysts. They are left alone.
• Symptomless, small hydatid cyst can be left alone. Once symptomatic, or if the
size is more than 5 cm, they may be treated.
• Medical treatment: • Albendazole 8 mg/kg or 400 mg BD is given for 21* days
followed by drug holiday for 2 weeks.
• If no improvement occurs maximum of 3 such cycles can be given.

37. TREATMENT - SURGERY
• 1. Laparotomy and isolation of the cyst from peritoneal cavity by packs dipped in
hypochlorite solution.
• 2. Aspirate the contents and inject scolicidal agents such as salon or hypertonic
saline.
• 3. Incise the cyst, peel off the laminated membrane by using sponge-holding forceps.
• 4. An attempt to remove adventitial layer may result in bleeding. It need not be
removed.
• 5. At surgery, all laminated membrane, endocyst has to be removed. Perfect
haemostasis must be achieved. Any bile leak to be sutured. Postoperative significant
bile leak is managed by ERCP stenting.

38. TREATMENT - PRECAUTIONS
• Albendazole should be given before surgery.
• Avoid spillage into the peritoneal cavity to avoid peritoneal hydatid.
• Injection hydrocortisone 100 mg IV before, during and after surgery to avoid
anaphylactic shock.

39. TREATMENT - PERCUTANEOUS DRAINAGE
• It is done after taking all necessary precautions/equipment with all emergency
drugs and with CT/US guidance.
• It is also called PAIR: Puncture, Aspiration, Injection and Reaspiration.