This document summarizes key information about liver abscesses, including pyogenic, amebic, and fungal types. Pyogenic liver abscess is most common, with risk factors like cirrhosis, diabetes, and biliary diseases. Organisms usually enter via the biliary tract or bloodstream. Ultrasound and CT are useful for diagnosis, showing hypoechoic or hypodense lesions. Treatment involves antibiotics, with drainage for larger abscesses. Amebic liver abscess is caused by Entamoeba histolytica and presents similarly, treated with metronidazole or other amebicides. Complications of both include rupture and spread of infection.

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