This document discusses liver abscesses, including their classification, presentation, risk factors, and management. There are three main types of liver abscess - pyogenic (polymicrobial), amoebic (caused by Entamoeba histolytica), and fungal. Common symptoms include fever, right upper quadrant pain, and tender hepatomegaly. Risk factors vary depending on the type but include diabetes, cancer, travel to endemic areas, and alcohol use. Treatment involves drainage of pus via percutaneous or surgical methods along with antibiotics. Factors determining the need for drainage versus medical management alone depend on the size and characteristics of the abscess.

1. Dr. Achu Jacob Philip
Liver Abscess

2. Classification
 Pyogenic abscess-polymicrobial,
 Amoebic liver abscess - Entamoeba histolytica
 Fungal abscess - Candida species.
 TB - Rare

3. Pathophysiology
 Liver largest portion of reticuloendothelial
system so continuous exposure to bacteria from
enteric tract.

4. Common presentation
 Fever (either continuous or spiking)
 Chills
 Right upper quadrant pain
 Tender hepatomegaly
 Anorexia
 Malaise
 Diarrhea in present in 1/3 patients with amoebic liver
abscess

6. Risk Factors
 PYOGENIC
 DM
 Cancer
 Liver Transplant
 ENTAMOEBA
 Pregnancy
 Endemic area travel (short or long term)
 Alcoholic
 Steroids
 Cancer

7. PYOGENIC LIVER ABSCESS

8. EPIDEMIOLOGY
 MALE > FEMALE
3 : 1
 MORE IN RIGHT LOBE, SUPERIOR ASPECT
 INCREASED INCIDENCE IN DIABETES
MELLITIS

9. Patho physiology of PYOGENIC
ABCESS
 Pyogenic
 Peritonitis
 To liver via portal circulation
 Direct Spread
 Biliary infections(ascending cholingitis)
 Hematogenous Seeding
 Bacteremia, septecemia(unusual)
 Adjacent infections
 Sub phrenic abscess, Cholecystitis
 Sites: Right lobe most common

10.  Mostly multiple abscesses/sometimes single
 40 % monomicrobial
 40 % polymicrobial
 20 % negative culture

11. Amoebic abscess
 Epidemiology
 M > F 7:1
 10 % world population
 40-50 million amoeba infections/year worldwide
 Age :Extremes
 Endemic Areas most susceptible
 Pathology:
 Two-stage life cycle.
 The trophozoite (amoeba stage) is motile.
 The cyst stage is nonmotile.
 Trophozoites are found in the intestinal and extraintestinal
lesions.
 Cysts predominate in the stools, with some trophozoites
present.

13. Mode of transmission
 Large intestine (history of dysentery)
 Travel to liver most common superior aspect near
diaphragm through portal vein
 Where proliferates to produce cytolytic enzymes
 Destroy liver tissues
 Abscess which is sterile(anchovy paste or chocolate
sauce)
 Organism may be found in abscess wall.

14. SIGN AND SYMPTOMS
 Fever
 Pain right hypochondrium
 Dysentery
 Tenderness right hypochondrium -30%
 Intercostal tenderness
 Signs of pleural effusion
 Increase in liver span –70% acute

15. INVESTIGATIONS
 NON SPECIPIC
 Increase TLC - Leukocytosis
 Increase LFT’s
 Most common biochemical abnormality(alk phosphate)
 SPECIFIC
 USG
 CT SCAN
 IMAGE GUIDED ASPIRATION ANCHOVY
SAUCE LIKE
 CULTURE AND SENSTIVITY
 Fluorescent antibody test for Entamoeba(can be
positive even after clinical cure)

17. X-Ray of the chest to see whether there is any pneumonitis or effusion caused by
the irritation of the nearby abscess

18. 18
Amoebic liver abscess burst into the right pleural cavity

19. USG of amebic abscess-Note peripheral
location, rounded shape, poor rim with
internal echoes

20. CT scan of amebic abscess (A). The lesion is peripherally located and
round. Rim is nonenhancing but shows peripheral edema (black arrows).
Note the extension into the intercostal space (white arrows).

21. Complication of Liver abscess
•Rupture and peritonitis
•Rupture into lung
•Bronchopleural fistula
•Subphrenic abscess
•Rupture into bare area of liver – retroperitoneal abscess
•Amoebiasis cutis
•Cardiac tamponade
•Septicemia,encephalopathy and liver failure

22. Principals of Management of
Pyogenic liver abscess
• Drain the pus
• Institute appropriate antibiotics, and
• Deal with any underlying source of infection,
Percutaneous drainage combined with
antibiotics has become the first line and
mainstay of treatment for most PLAs

23. Drainage Options
 Percutaneous
 Needle aspiration
 Catheter drainage
 Surgical drainage
 Open
 Laproscopic

24. Percutaneous needle aspiration
 Under CT or USG guidance, needle aspiration of
cavity material can be performed.
 Needle aspiration enables
 rapid recovery of material for microbiologic and
pathologic evaluation.
 Large percentage requires second or third
aspirations to achieve success

25. Percutaneous catheter
drainage
 Percutaneous drainage has become the standard of
care.
 Should be the first intervention considered for
 Small cysts.
 The pus is too thick to be aspirated
 The wall is thick and non-collapsible

26. Advantages include
 reduced costs, recovery time,
 it eliminates the need for general anesthesia
 This also allows for gradual, controlled drainage.

27. Contraindications to catheter
drainage
• Coagulopathy;
• Difficult access path to the cavity;
• peritonitis; and/or
• Complicated, multiloculated, thick-walled
abscess with viscous pus.

28. Antibiotic therapy
 Antibiotic therapy should cover gram negative
organisms and anaerobes
 First line antibiotics are
 Penicillin's, aminoglycosides and metronidazole or
 Cephalosporin and metronidazole
 Can be changed after Culture report

29. Surgical drainage
 Indications of surgical drainage include
 Failure of non operative treatment
 Intraperitoneal rupture
 the presence of a complicated, multiloculated, thick-
walled abscess with viscous pus
 treatment of underlying intra-abdominal processes,
 peritonitis;
 existence of a known abdominal surgical pathology (eg,
diverticular abscess)

30. Approaches for open drainage
 Transperitoneal approach
allows for abscess drainage and
abdominal exploration to identify previously undetected
abscesses and the location of an etiologic source
 Transpleural approach
For high posterior lesions,
easier access to the abscess,
the identification of multiple lesions or a concurrent
intra-abdominal pathology is lost

31. Ruptured liver abscess- Surgical
approach

32. Management of amoebic liver abscess
Medical
 Metronidazole 750 mg three times a day for 10 to 14 days is the
treatment of choice
 Tinidazolle 600 mg BD x 5days
 Other drugs : Choroquine 250mg BD 10 to 14 days
 successful in 95% of cases.
Aspiration of the abscess rarely is needed
 Large abscesses.
 Large abscess having impending rupture / compression sign.
 Thin rim of liver tissue around the abscess (<10 mm).
 Sero-negative abscesses.
 Failure in the improvement following non-invasive treatment after 4 to
5 days.

33. “Abscesses of the left lobe of the
liver at risk for rupture into the
pericardium should be treated
with aspiration and drainage.”

34. Open drainage
 Rupture of amoebic abscess in adjacent viscera is indication of
open drainage.
Treatment of intestinal carriage
 Luminal amoebicidal agent
 Paromomycin
 25-30 mg/kg/d orally for 7 days in three divided doses
 Iodoquinol
 Diloxanide furoate

35. Long-Term Monitoring
 Weekly serial computed tomography (CT) or ultrasound
examinations to document adequate drainage of the abscess
cavity.
 Maintain drains until the output is less than 10 mL/day.
 Monitor fever curves.
 Persistent fever after 2 weeks of therapy may indicate
the need for more aggressive drainage.