an overview on liver abscess its types, diagnosis, interventions and management.

1. LIVER ABSCESS
Dr. S. K. MOHAN
S3 UNIT
SJH & VMMC, NEW DELHI

2. • Pus filled cavity in liver .
1. PYOGENIC LIVER ABSCESS
2. AMOEBIC LIVER ABSCESS
3. FUNGAL LIVER ABSCESS

3. PYOGENIC LIVER ABSCESS
INCIDENCE
• Recent studies shows incidence of 3.6 cases per 100,000 of
population.
• Male: female- 1.5:1
• Age~ >50 years

4. Risk factors
• Cirrhosis
• Diabetes mellitus
• Malignant disorders
• Chronic renal failure.
• Post biliary surgeries
• Post liver transplant

5. Pathogenesis
• Occurs when an inoculum of bacteria regardless of the
route of exposure, exceeds the ability of liver to clear it.
• Organism invades tissue-> neutrophil infiltration and
formation of organized liver abscess.

6. Routes of infection.
1. Via biliary tree.( obstruction –stasis –infection= ascending
suppurative cholangitis)
2. Via portal vein:( drains GI tract- infections /malignancies=
pyelophlebitis)
3. Via hepatic artery( any systemic infections- endocarditis/ immune
compromised conditions.)

7. 4. Via direct extension:-
from suppurative cholecystitis, subphrenic abscess, perinephric abscess, perforation
peritonitis
5. Traumatic – penetrating /blunt trauma – direct inoculation of organisms
6. Cryptogenic :- no specific cause.
( possible explanations- undiagnosed abd. Pathology/diabetes/ malignancy)

10. Sites
• Most c’mon sites –RIGHT HEMILIVER -75%
-LEFT LIVER -20%
-CAUDATE LOBE – 5%
75%
25%
5%
LIVER
RIGHT LIVER LEFT LOBE
CUADATE LOBE

11. • 50% of liver Abscess is solitary
• Size varies from 1mm to 4/5 cm in diameter.
• Can be multi loculated/ single cavity

12. MICROBIOLOGY
• Abscess from pyelophlebitis( portal vein)- mostly
polymicrobial ( >G- ve)
• systemic infections( hepatic A.)- mostly mono microbial.
• 40% of liver abscess- poly microbial.
• 40-60% contains anaerobic organisms.

13. • Most c’mon organism- E. Coli and Klebsiella
pneumonea.
• Others:- staph. Aureus, enterococci, bacteroides,
streptococcus viridans.
• Very rarely (<10%):-pseudomona, proteus, enterobacter,
serratia.

14. Clinical features
• Classic symptoms- FEVER, RIGHT UPPER ABD. PAIN AND
JAUNDICE (BUT RARELY SEEN < 10%)
• FEVER -96%
• CHILLS-80%
• ABD. PAIN- 53%
• JAUNDICE -20%

15. • Anorexia
• Malaise
• Nausea, vomiting
• Cough, chest pain.
• diarrhoea

17. SIGNS
• Fever with right hypochondrial tenderness( 40- 70%) MC findings.
• Jaundice in 25 %
• Hepatomegaly in 50 %
• Chest finding in 50 %

18. INVESTIGATIONS
• NON SPECIFIC
• Leukocytosis in 70-90%
• Anaemia is c’mon
• ALP in 80%
• S. Bil in 20-50%
• Hypoalbuminemia, PT-INR

19. • C-XRAY
• Abnormal in 50% cases
Elevated R hemidiaphragm,
R sided pleural effusion,
Atelectasis

20. • ABDOMINAL XRAY.
• Rarely shows air fluid levels
in liver
• Portal venous gas

21. ULTRASONOGRAPHY
• SENSITIVITY~80-95%
• Shows round/ oval shaped
hypoechoic lesions

23. CT
• Sensitivity~95-100%
• Hypodense heterogenous lesion
• With irregular margins and enhanced rim

24. Differential diagnosis.
• Amoebic liver abscess
• Echinococcal cyst

25. TREATMENT
MEDICAL
• BROAD SPECTRUM IV ANTIBIOTICS COVERING G+, G-,
ANEROBES(PENCILLIN +
AMINOGLYCOSIDES+METRONIDAZOLE)
• 3 RD GEN. CEPHALOSPORIN + METRONIDAZOLES
• SPECIFIC ANTIBIOTICS AS PER CULTURE AND SENSITIVITY
• TREATMENT FOR MIN. 2 WEEKS/ TILL SYMPTOMS SUBSIDES.

26. Pigtail insertion
Usg guided aspiration

27. INVASIVE
• PERCUTANEOUS DRAINAGE
1. Abscess size < 5 cm- needle aspiration ( 60% success rate)/ catheter
drainage(~100% success rate)
2. Abscess size >5cm- catheter drainage
3. Percutaneous catheter drainage is the treatment of choice now a days
4. Surgery should be reserved for patients who require sxical treatment for
primary pathological process

28. • Similar success / mortality rate is seen in percutaneous and surgical
management.
• Mortality rate is 50-100% if
treated with antibiotcs with out any drainage

29. COMPLICATIONS
• RUPTURE OF ABSCESS
To pleural cavity-empyma pleuroperitoneal
fistula
To peritoneum –peritonitis
To pericardial cavity- tamponade/ effusion
To bronchi-

30. • Sepsis
• Shock
• Mortality <3 %

31. AMEBIC LIVER ABSCESS

32. • Caused by entemoeba hystolytica, a protozoan
• Seen mainly in tropical and developing countries
• Endemic in India, Mexico, Africa and S. America
• ~40,000 to 100,000 deaths every year.

33. Incidence
• Male to female -10:1
• Age – 20- 40 years

34. Risk factors
• Alcoholics
• Travel to endemic area
• Immunocompromised conditions
• malnutrition

35. Pathogensis
• E. histolytica- aprotozoan
– exists in 2 forms.
• Spreads feco orally by cysts
• Humans – principal host-
• Sigmoid colon and ceacum.

36. Life cycle

39. Pathology
• Due to liquefactive necrosis of liver– a cavity of blood +
necrotic tissues
• Necrosis continues until Glissons capsule– so cavity is
typically crisscrossed by portal triads

42. Clinical features
• ~ 80% of patients presented with prolonged symptoms <10 days
• Abdominal pain -92%
• Fever-90%
• Abdominal tenderness- 78%
• Hepatomegaly-50%
• anorexia-, diarrhoea, jaundice, wt. loss., symptoms of complicatns

43. • Acutely (<10 days)- 50% have multiple lesions
• Patients presents
• Chronic(>2 weeks)- 80% single right sided lesion

44. Investigations
NON SPECIFIC
• Leuckocytosis without eosinophils
• Anaemia
• Deranged LFT- mc increased PTINR
• Only 30 % have detectable ameba in stool.

45. SPECIFIC
• Circulating anti amoebic antibodies are present in 95% patients.
• Enzyme immune assays 99% sensitivity (ELISA)
• Entemeba antigen detecting kits

46. Radiology
• C xray- 50% abnormal
• USG ABD- 90% SENSITIVITY- round lesions abutting liver capsules
• HYPOECHOGENIC LESION
• NO RIM ECHOS

47. • CT
• Hypodense and heterogenous
• No RIM ENHANCEMENT

48. Differential diagnosis
• Viral hepatitis
• Echinococcal disease
• Cholangitis, cholecystitis

49. Treatment
TISSUE AMEBOCIDES
1. METRONIDAZOLE 750MG PO/IV Q8H X 10 DAYS( Curative in
> 90%)
2. TINIDZOLE/ORNIDAZOLE
3. EMETINE HYDROCHLORIDE- more effective but cardiac SE.
4. CHLOROQUINE- less effective.1GM(600MG base )OD X 3 DAYS
then 500mg( 300mg base) OD FOR 2-3 weeks

50. LUMINAL AMEBOCIDES
• IODOQUINOL 650MG TID X 20 DAYS OR
• PARAMOMYCIN 500MG TID X 10 DAYS OR
• DILOXAANIDE FUROATE 500MG TID X 10 DAYS

51. • SURGICAL INTERVENTIONS
• Indications for aspiration
• Size >5cm
• Impending rupture
• Left lobe abscess – pericardial rupture
Indications for laparotomy- intestinal perforation, pericardial
rupture

53. COMPLICATIONS
• RUPTURE OF ABSCESS
To plueral cavity-empyma pleuroperitoneal
fistula
To peritoneium –peritonitis/intestine fistula
To pericardial cavity-tamponade/ effusion
To bronchi-fistula
Death in 5-50% in ruptured cases

54. • SECONDARY INFECTIONS
• AMEBOMA-
• INTESTINAL ULCER PERFORATION
• PERCUTANEOUS FISTILA - RARE

55. Thanks…..
SKM25