liver abscess

1. Prepared by:
Prerit Devkota
2nd year Resident
Department of EM/GP
PAHS
Moderator : Dr. Samyukta K.C

2. LIVER ABSCESS
 Collection of purulent material in liver parenchyma forming a cavity
 Most common type of visceral abscess
 Uncommon
 3.6/100000 populations UK/US
 15/100000 Asia
 Prevalence stable,detection improved ,mortality improved
 Can be:
 Bacterial (pyogenic)
 Parasitic (amoebic)
 Fungal
 Amoebic 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. ---- K. Pneumoniae --- Liver abscess

5. Pathogenesis
 Liver – recieves portal venous bacterial load regularly – clears up –
beyond capacity – abscess
 Asia – gall stones and cholangitis
 West – malignant obstruction

7. Pathogenesis
 Portal vein :
 diverticulitis, appendicitis, pancreatitis, inflammatory bowel
disease, 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

8. Microbiology and Pathology
 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, Enterococcus
 Pseudomonas, Proteus, Enterobacter,Peptostreptococcus
 Fungal and mycobacterial – rare in immunocompromised
 Blood culture : 50 – 60% positive

9. Clinical features
 Classical presentation :
 fever with chills, jaundice and RUQ pain with tenderness on
palpation
 Complications:
 Abscess rupture – peritoneal or pleural or pericardial space
 Sepsis / septic shock
 Klebsiella - endogenous endophthalmitis (3% ) in diabetics

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

11. 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)

12. Investigations
 CBC
 LFT
 Albumin and PT/INR
 CXR (50%) – elevated right hemidiaphragm, right pleural
effusion, or atelectasis
 Abdomina X-ray : air-fluid levels or portal venous gas

13. Imaging
USG Vs. CECT – 85% vs.95% sensetivity

14. Differential Diagnosis
 Hepatitis
 Liver tumors
 Right lower lobe pneumonia
 Acute cholangitis
 Acute cholecystitis
 Hydatid cyst
 Gall Stone

15. Treatment
 Medical and Surgical
 Medical :
 Emperic Atbx :
 Started before pus culture or other reports
 Should cover Streptococci,E.coli,Anarobes,E.histolytica
 Ceftriaxone + Metronidazole , Ampicillin+Metronidazole+Gentamycin,
floroquinolone+Metronidazole
 If Staphylococcus – Vancomycin
 Duration :
 4-6 weeks : if incomplete drainage when surgically intervened
 2-4 weeks : if completely drained

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

18. Open Surgery
 Indications :
o Inadequate response to PCD or PNA
o Abscess with viscious content that blocks catheter
o Infected hepatic malignant neoplasm, hepatolithiasis, or
intrahepatic biliary stricture

19. Follow up

20. Prognosis
 Mortality : 2 – 12 %
 Need for open surgical intervention
 Associated with malignancy
 Anaerobic infection

21. Any Questions???

22. Amoebic Liver Abscess

23. Amoebic Liver Abscess
 Caused by protozoa - E.histolytica
 h/o travel and dysentry or diarrhoea
 Age : 20 – 40 yrs
 M:F = 10:1
 Menstruating women and IDA – low incidence
 Alcohol consumption and immunocompromised state – high risk

24. Pathogenesis

25. Pathology
Anchovy sauce pus
•Odourless
Liquefactive necrosis
Glisson capsule is resistant
to hydrolysis by amoeba

26. Clinical features

27. Investigations
 CBC
 LFT
 PT/INR – elevated
 Indirect hemagglutination test (90%)– circulating
antibodies
 Past Vs. Active infection
 PCR – pus
 X-ray,USG,CT

28. Treatment
 Uncomplicated : Medical therapy
 Metronidazole/Tinidazole/Nitazoxanide – 7 – 10 days
 Paramomycin (20-30 mg/kg/day) / DF – 7 - 10 days
 Pregnant lady : Metronidazole / Chloroquine (6oo mg – 2 days
then 300 mg 3 weeks)
 Complicated : PCD/PNA
 Left lobe abscess
 Lack of clinical response of medical therapy for 5 days
-UpToDate 2020

29. 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%

30. Take Home Messages
 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
 early clinical improvement,
 less duration of hospital stay and
 earlier reduction in 50% reduction of abscess size

31. References
 Sabiston textbook of surgery, 20th edition
 UpToDate 2020
 Kulhari M, Mandia R. Prospective randomized comparative
study of pigtail catheter drainage versus percutaneous
needle aspiration in treatment of liver abscess. ANZ Journal
of Surgery. 2018;89(3):E81-E86.

32. Any Queries???

33. Thank you!!