This is a lecture note for 5th-semester MBBS students. Lecture notes on hepatology, liver disease, and liver abscess. Introduction to a liver abscess, pyogenic liver abscess, causes, approach and management of liver abscess.

1. Hepatology lectures for
5th Sem;MBBS
Pratap Sagar Tiwari
MBBS,MD (Medicine),DM (Hepatology)

2. LIVER ABSCESS
PYOGENIC
HYDATID
AMOEBIC
INTRA-PERITONEAL ABSCESS
VISCERAL ABSCESS
LIVER ABSCESS
Note: Hydatid disease is a parasitic infestation by a
tapeworm of the genus Echinococcus.
Infected hydatid are included in liver abscess, for further info; learn hydatid cystic disease
FUNGAL

3. INTRODUCTION: LIVER ABSCESS
• A liver abscess is a space-occupying suppurative lesion in the liver resulting
from the invasion of microorganisms entering directly from an injury, through
the blood vessels, or through the bile ducts. (Schiff)
• The three major forms of liver abscess, classified by etiology, are as follows:
1. Pyogenic abscess, which is most often polymicrobial, accounts for 80% of
hepatic abscess cases in the US.
2. Amebic abscess due to Entamoeba histolytica accounts for 10% of cases [1]
3. Fungal abscess, most often due to Candida species, accounts for fewer
than 10% of cases.
1. Othman N, Mohamed Z, Yahya MM, Leow VM, Lim BH, Noordin R. Entamoeba histolytica antigenic protein detected in pus aspirates from patients with amoebic liver abscess. Exp Parasitol. 2013 Aug. 134 (4):504-10.
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4. PYOGENIC LIVER ABSCESS
• There are four major ways in which pyogenic organisms invade the liver.
First, they may travel though the portal vein from regions drained by it.
Eg;Suppurative appendicitis, pyelophlebitis, Ulceration of the stomach or bowel and
disease of the rectum, spleen and pancreas
Second, blood borne infections: transmitted though hepatic artery.
Eg;Osteomyelitis, acute infections of upper respiratory tract or pyemia from any
source like cholnagitis
Third :direct extension from a contiguous infection.
Eg;Subphrenic abscess, empyema gall bladder, nephritic/perinephric abscess.Infection
of cystic lesions or tumors of liver.
Lastly: trauma, post procedures
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5. INTRODUCTION: LIVER ABSCESS
Source
Biliary Source multiple and of small size and involve both lobes of the liver
Septic emboli from the PV solitary and tend to be more common in the right lobe of liver
Contiguous source solitary and localized to one lobe only
Approximately 60-75% are solitary and they are mainly located in the RT
lobe as a result of the streaming pattern of PBF, secondary to the fact that the right lobe is supplied predominantly by
the SMV and because most of the hepatic volume is in the RT lobe.
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6. RISK FACTORS FOR DEVELOPMENT OF HA
Diabetes mellitus
Immunocompromised state
Liver Cirrhosis
Use of PPI
Advanced age
Male Gender
DM is present in up to 40% of cases and is more commonly a/w abscesses due to Klebsiella pneumoniae [6,7] .
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7. Microbiology
Gram-tive Aerobic Bacteria 50-70% Gram+tive Aerobic Bacteria 25%
Escherichia coli
Klebsiella pneumoniae
Enterobacter spp.
Pseudomonas spp.
Proteus spp.
Enterococcus spp.
Streptococcus pyogenes
Staphylococcus aureus
Streptococcus milleri group
Anaerobic Bacteria 40-50%
Bacteroides spp.
Fusobacterium spp.
Others
Candida spp.
Mycobacterium
tuberculosis
Sleisenger 7

8. CLINICAL FEATURES
Pre antibiotic era
Spiking fevers
Pain RUQ
Shock Acute presentation
Present Context
Low grade fever
Anorexia
Weight loss
Dull pain abdomen Sub-Acute presentation
Only 10% of pts will have the “characteristic” symptom triad of fever, jaundice, and right
upper quadrant (RUQ) tenderness. (Zakim/Boyer)
When an abscess is situated near the dome of the liver, pain may be referred to the rt shoulder, or a
cough resulting from diaphragmatic irritation or atelectasis may be present.
In 1928 penicillin, the first true antibiotic, was discovered by Alexander Fleming, Professor of Bacteriology at St. Mary's Hospital in London
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9. PHYSICAL EXAMINATION
Fever
PHTN may follow recovery if the PV has been thrombosed.
Ascites is rare
In the absence of cholangitis, jaundice is present only late in the course of the illness.
Splenomegaly is unusual, except with a chronic abscess.
Hepatomegaly
Liver tenderness
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10. • Liver imaging : USG, CT LIVER
• Needle aspiration under ultrasound guidance confirms the diagnosis
and provides pus for culture.
• A leucocytosis is frequently found, ↑ plasma ALP activity, ↓serum
albumin.
• Chest X-ray: raised right diaphragm and lung collapse, or an effusion
at the base of the right lung.
• Blood cultures: positive in 50–80%.
INVESTIGATION

11. USG
PLA (A) Initial US showing debris inside the abscess cavity. (B) Liquefied pus inside the abscess. (SCHIFF)
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12. CT SCANS: PLA
PLA in the RL showing a hypointense rim which is secondary
to peripheral inflammation.
Ref: SCHIFF
CT scan shows a low attenuation defect in the
right lobe of the liver. Note gas in bile ducts (arrow).
Ref: Sherlock.
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13. CT SCAN: PLA: CLUSTER SIGN
(a)Arterial phase CECT shows a hypoattenuating lesion consisting of smaller aggregating cystic
lesions, known as the “cluster” sign.
(b) Portal venous phase CT depicts enhancement of the irregular septa within the abscess.
Source: https://radiologykey.com/focal-hepatic-infections/ 13

14. GENERAL APPROACH
Suspicious?
USG/CT
Send blood & Aspirate Culture
Send Serum IgG/IgM Elisa for
Entamoeba
Start Empirical Antibiotics
Adjust antibiotics as per C & S
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15. MODALITIES OF MANAGEMENT
1. Management with Antibiotics
2. USG guided Aspiration: percutaneous needle aspiration
3. Drainage:
➢CT or US-guided percutaneous catheter drainage
➢Surgical drainage
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For a solitary abscess <5 cm in diameter, confirmed by aspirate and with available antimicrobial
sensitivity, resolution can be achieved with antibiotics alone.

16. EMPIRICAL ANTIBIOTIC REGIME
• Antibiotic therapy choices involve combining broad spectrum
antibiotics:
➢Third-generation cephalosporin plus clindamycin or metronidazole.
➢Broad spectrum penicillin plus aminoglycosides.
➢Second-generation cephalosporin plus aminoglycosides.
Schiff
Treatment should be started immediately after specimens have been
obtained for culture without waiting for definitive results.
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17. COMPLICATIONS OF PYOGENIC LIVER ABSCESS
• Pleural or pericardial effusion
• Empyema
• Portal vein thrombosis =24 %
• Hepatic Vein thrombosis= 22 %
• Splenic vein thrombosis
• Rupture into the pericardium, thoracic and abdominal fistula formation, and sepsis.
• Metastatic septic endophthalmitis occurs in as many as 10% of diabetic patients
with a liver abscess caused by Klebsiella pneumoniae.
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18. DIFFERENCES BETWEEN AMOEBIC AND PLA
Schiff
ALA are usually solitary and present in Rt lobe
near the diaphragm.
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19. END OF SLIDES
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