Liver abscess is a collection of purulent material in the liver parenchyma forming a cavity. It is one of the most common types of visceral abscesses. There are different types including bacterial, parasitic, and fungal abscesses. Amoebic liver abscess is the most common worldwide, while pyogenic liver abscess is more common in the US. Pyogenic liver abscess is usually caused by bacteria like E. coli and involves the right lobe of the liver in males ages 20-40. Abscesses less than 5mm can often be treated medically with antibiotics, while larger abscesses are generally better managed with percutaneous drainage which provides faster clinical improvement and shorter hospital stays compared to needle aspiration

1. Liver Abscess
Presenter : Dr.Mudassir Baig
GASTROENTEROLOGY DEPT.
PIMS HOSPITAL

2. LIVER ABSCESS
 Collection of purulent material in liver parenchyma forming a cavity
 Most common type of visceral abscess
 Uncommon
• 3.6/100000 population UK/US
• 15/100000 Asia
• Prevalence stable, detection improved due to improved investigation methods and as result mortality
improved.
 Types:
• Bacterial (pyogenic)
• Parasitic (ameobic)
• Fungal
 Ameobic liver abscess-worldwide
 Pyogenic Liver Abscess - USA

3. Pyogenic Liver
Abscess

4. Pyogenic Liver Abscess
 Liver abscess due to bacteria :
• Incidence : 2.3/100000 populations
• Male : female = 1.5 : 1
Risk factors:
• DM
• Underlying hepatobiliary or pancreatic disease
• Liver transplant
• Regular use of PPI
• Male gender
• Colorectal Ca.

6. Pathogenesis
• Liver - recieves portal venous bacterial load regularly - clears up -beyond
capacity – abscess
• Asia - gall stones and cholangitis
• West - malignant obstruction
• Portal vein :
• diverticulitis, appendicitis, pancreatitis, inflammatory boweldisease, pelvic
inflammatory disease, perforated viscus, and omphalitis in the newborn
• Hepatic artery:
• systemic infection (endocarditis, pneumonia, osteomyelitis) –bacteremia
• Penetrating/blunt trauma:
• Intrahepatic hematoma/necrosis - infection - abscess

9. Microbiology and Pathoanatomy
• Right lobe-75%
• 50% - solitary
• Polymicrobial - 40% (pyelophlebitis/cholangitis) or monomicrobial(systemic infections)
• Gram negative and anarobes : 40-60%Escherichia coli, Klebsiella pneumoniae, Staphylococcus
aureus, EnterococcusPseudomonas, Proteus, Enterobacter, Peptostreptococcus
• Fungal and mycobacterial - rare in immunocompromised
• Blood culture : 50 - 60% positive

11. Examination
• Fever and RUQ tenderness
• Jaundice - 25%, chest findings - 25%
• Hepatomegaly - 50%
• Ruptured abscess - signs of peritonitis and shock

12. Investigations
• СВС
• LFT
• Albumi
• CXR

15. Diagnosis
• Liver lesion on imaging (USG/CT/MRI)
+
• Purulent material on Aspiration
+
• Isolation of organism from pus(gram stain,AFB stain,c/s,serology,PCR)

17. Treatment
Medical : Empiric Antibiotics
• Started before pus culture or other reports
• Should cover Streptococci, E.coli,Anarobes, E.histolytica
• Ceftriaxone + MetronidazoleAmpicillin+Metronidazole+Gentamycin,floroquinolone+Metronidazole
• If Staphylococcus – Vancomycin
Duration:
• 4-6 weeks: if incomplete drainage when surgically intervened
• 2-4 weeks: if completely drained

18. Surgical Treatment
• PNA or PCD
USG or CT guided
• ERCP drainage - if infection continues through biliary tree
• Single abscess </= 5cmPNA or PCD - 7 days
• Single unilocular >5 cm ---- PCD > PNA - 7 days
• Multiple or multiloculated abscess
PCD > PNA

19. Prospective randomized comparative study of pigtail catheter drainage versus
percutaneous needle aspiration in treatment of liver abscess Mukesh Kulhari and
Rajendra Mandia Department of General Surgery, SMS Medical College, Jaipur,
Rajasthan, India
• Conclusion: Percutaneous catheter drainage is a better modality as
compared to PNA especially in larger abscesses which are partially
liquefied.

20. Open Surgery
Indications :
• Inadequate response to PCD or PNA.
• Abscess with viscous content that blocks catheter.
• Infected hepatic malignant neoplasm, hepatolithiasis or
intrahepatic biliary stricture

22. Prognosis
Mortality: 2 - 12%
Worse prognosis is associated with :
• Need for open surgical intervention
• Associated with malignancy
• Anaerobic infection

24. Amoebic Liver Abscess

25. Amoebic Liver Abscess
• Caused by protozoa - E.histolytica
• History of travel and dysentery or diarrhea
• Age : 20-40 yrs.
• M:F = 10:1
• Menstruating women and IDA - low incidence
• Alcohol consumption and immunocompromised state - high risk

30. Treatment
Uncomplicated: Medical Therapy
• Metronidazole/Tinidazole/Nitazoxanide- 7 - 10 days
• Paramomycin (20-30 mg/kg/day) / DF - 7 - 10 days
• Pregnant lady: Metronidazole / Chloroquine (600 mg - 2 days then 300mg 3
weeks)
Complicated: PCD/PNA
• Left lobe abscess
• Lack of clinical response of medical therapy for 5 days-UpToDate 2020

31. Prognosis
Poor prognosis
• elevated serum bilirubin level (>3.5 mg/dL),
• encephalopathy,
• hypoalbuminemia (<2.0 g/dL),
• multiple abscess cavities
• abscess volume larger than 500 mL
Mortality <1%

32. Summary
• Liver abscess is one of the common cause for RUQ pain in our world -amoebic
liver abscess being most common
• Can be diagnosed clinically aided by radiological investigation
• Mostly involves right lobe in 20 - 40 yrs usually male population with E.coli
being most common organism
• <5 mm - can be managed medically, if >5 mm : better to go for percutaneous
drainage (PCD/PNA) ;
PCD being superior to PNA for
a)early clinical improvement
b)less duration of hospital stay
c)earlier reduction in 50% reduction of abscess size.

33. THANKS