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Liver abscess
- 1. Identification of liverspecimen • Size- largest organ • Reddish brown • Rubbery to touch • Anatomical right & left lobes • Covered by: – Glisson’s capsule & visceral peritonium – Ligaments: right and left triangular, falciform & lesser omentum • Uncovered area- Bare Area • Gall bladder, IVC, hilum etc.
- 3. Identification of liverspecimen.. • Cut surface/partial hepatectomy: – Reddish brown/ tan pink/fleshy parenchyma – Capsular surface smooth – Multiple cut bile ducts: • Variable sizes • Bile stained
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- 6. Liver abscess • Spaceoccupying lesions (SOL) • Collection of: – Pyogenic material- frank pus – “Anchovy sauce” pus – Greenish pus • Number of SOL: – Solitary – Multiple
- 8. Liver abscess • Whattypes of liver abscess you know? • Commonly 2 types: – Amoebic – Pyogenic • Others : – Tubercular – fungal
- 9. Liver abscess • Whatcauses amoebic liver abscess? • Parasite: Entamoeba Hystolytica • What causes pyogenic liver abscess? • Bacteria: – E. coli & Streptoccocus milleri—commonest – Other enteric organism- Klebsiella, Proteus vulgaris, Streptococcus fecalis, Pseudomonas – Mixed growth – Opportunistic Staphyloccoci
- 10. Liver abscess • Aetiologyof amoebic liver abscess? 1. Endemic to Entamoeba Histolytica - tropical countries Indian subcontinent & Africa 4. Diabetes Mellitus 2. Chronic alcohol intake 5. Immunosuppressed state 3. Liver cirrhosis 6. Reproductive age females
- 11. Liver abscess • Aetiologyof pyogenic liver abscess? 1. Biliary sepsis: a. Empyema gallbladder. b. Cholangitis. c. After biliary tract surgery. d. Instrumentation. 4. Super added infections: a. Amoebic liver abscess. b. Hydatid cyst. 2. Portal vein sepsis: a. Appendicitis. b. Diverticulitis. c. any severe abdominal sepsis. 5. Cryptogenic liver abscess—No identified primary infection. (m.c.c.) 3. Distant infections: a. Pneumonia. b. Upper U.T.I. c. Endocarditis. 6. Trauma- becoming common cause 7. Diabetics
- 12. Liver abscess • Whatis the clinical presentation? • Amebic abscess- more common in males • Symptoms: – Pain- right upper abdomen (throbbing) – Fever, with rigors with malaise – Occasionally jaundice – May be associated dysentery – Weakness – Decreased appetite/ loss of weight – If complicated- difficulty breathing, fainting etc.
- 13. Liver abscess • Whatsigns can be found? • Signs: – Tenderness-right hypochondrium – Intercostal tenderness- right – Hepatomegaly: smooth, soft – Icterus – Signs of complications: • Peritonitis, pleural effusion, ascitis, bronchopleural fistula etc – Signs of sepsis
- 14. Liver abscess • Whatare the complications of liver abscess? • Pleural effusion- right sided • Ascites • Jaundice • Rupture- – brochopleural fistula/ empyema (m.c.) – peritonitis – Retroperitonial abscess – Subphrenic abscess – Cardiac temponade – Into intestines & skin (amoebic cutis)
- 15. Liver abscess • Whatare other complications of liver abscess? • Superinfection of amoebic abscess • Budd Chiary syndrome • Liver failure / Hepatic encephalopathy • Septicemia, later shock • Death
- 16. Liver abscess • Howdoes amoebic liver abscess develop? 1. Mature cyst (faeces) 2. Contaminate food & water 3. Ingestion of cyst 4. Pass through stomach undamaged 5. Cyst wall lysis occurs by trypsin (alkaline medium) 6. Excystation 7. Release of quadrinucleate amoebae 8. Metacyst trophozoites formed 9. Habitat in crypts of caecum commonly, often in sigmoid colon as to form trophozoites.
- 19. Liver abscess • Howdiagnosis is made? • Ultrasound abdomen is diagnostic – Space occupying lesion – Altered echogenecity (anechoic, hypoechoic) – Site, size, number & nature – Associated complications • CECT abdomen • CXR- – raised right hemidiaphragm, effusion, soft tissue shadow
- 20. Liver abscess • Howdo you investigate a patient with history suggestive of liver abscess? • Blood tests- – CBC: may show low Hb, raised TLC – LFT: altered bilirubin, liver enzymes, albumin – Prothombin Time/INR: can be raised • USG abdomen • CXR • CECT – chest & abdomen
- 22. Liver abscess • Howdo you investigate a patient with history suggestive of liver abscess? • Amoebic serology: ELISA/ Indirect haemagglutination/ gel diffusion tests/ counter immuno-electrophoresis • USG guided spirated Pus: culture & sensitivity • Colonscopy/sigmoidoscopy: amoebic typhilitis/ active ulcers- showing trophozoites
- 23. Liver abscess • Whatis the treatment? • Drugs: – Amoebic abscess: • Metronidazole- Tab. 800mg TDS/ Inj. 750mg i.v. TDS x 10d • Or Tinidazole, Secnidazole, Ornidazole (nitroimidazoles) • To control/ prevent secondary infection- cefotaxime, ciprofloxacin, amoxycillin • Cyst eradicators/ luminal amoebicides- Diloxanate furoate, iodoquinol, paromonycin • Other drugs- dihydroemetine, chloroquine (tissue amoebicides)
- 24. Liver abscess • Whatis the treatment? • Drugs: – Pyogenic liver abscess: • Systemic antibiotics- Combination of third generation cephalosporin+ metronidazole • USG guided drainage: – Percutaneous aspiration (therapeutic) – Percutaneous Indwelling catheter drainage • Open drainage • Treat primary cause in case of pyogenic abscess
- 25. Liver abscess • When& how is percutaneous drainage of liver abscess done? • Indication: – Abscess not responding symptomatically to drugs – Large abscess (>200cc, >10cm- RT) – Any size in caudate lobe – Seronegative abscess – Abscess in pregnancy – Diagnostic: in case of dilemma
- 26. Liver abscess • When& how is percutaneous drainage of liver abscess done? • Prerequisite: – Clinical diagnosis – Patient’s consent – Normal coagulation profile – Abscess accessible
- 27. Liver abscess • When& how is percutaneous drainage of liver abscess done? • Technique : – Under real time USG guidance • Wide bore needle with 10-50cc syringe • Catheter tube: red rubber/malecot, pigtail catheter – Introduced through abdomen (preferrably) or intercostal space, under local anesthesia & sterility – Pus sent: C/S, cytology, trophozoite detection
- 28. Liver abscess • Issurgery even required? • What are the indications? • Non responsive (symptomatically) to percutaneous drainage i.e. failure – Thick pus – Multiloculated abscess – Multiple abscess • Complications- rupture • What is the approach? Transperitonial
- 29. Liver abscess • Whatfollow up advice will you give? • Abstain from alcohol intake • Complete course of drugs • Repeat LFT • Repeat USG abdomen, if symptoms recur or do not resolve
- 30. Liver abscess • Whatis the prognosis? • Mortality in amoebic liver abscess is 4% & rises with rupture esp. pericardia (30%) • Poor prognostic factors Rupture Diabetes Serum bilirubi n >3.5 mg% Cirrhosis Serum albumin <2.0 g/dl Multiple abscesses Liver failure,, anaemia Volume of abscess >500 ml
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Editor's Notes
- #24 Tinidazole 600 mg BD dose for 5 days. • IV or oral antibiotics are essential to control secondary infection (cefotaxime, ciprofloxacin, amoxycillin). (Small abscesses < 3 cm respond to drugs). • Other drugs: 1. Injection dihydroemetine 1.5 mg/kg/day IM for 5 days should be given under cardiac monitoring. 2. Chloroquine 250 mg BD given for 10-14 days. Drugs used for amebic infection • Metronidazole, Tinidazole, Secnidazole, Ornidazole • Dihydroemetine injection • Chloroquine, tetracycline • Diloxanate furoate, iodoquinol, paromonycin—as cyst eradicators
- #25 Tinidazole 600 mg BD dose for 5 days. • IV or oral antibiotics are essential to control secondary infection (cefotaxime, ciprofloxacin, amoxycillin). (Small abscesses < 3 cm respond to drugs). • Other drugs: 1. Injection dihydroemetine 1.5 mg/kg/day IM for 5 days should be given under cardiac monitoring. 2. Chloroquine 250 mg BD given for 10-14 days. Drugs used for amebic infection • Metronidazole, Tinidazole, Secnidazole, Ornidazole • Dihydroemetine injection • Chloroquine, tetracycline • Diloxanate furoate, iodoquinol, paromonycin—as cyst eradicators
- #26 Tinidazole 600 mg BD dose for 5 days. • IV or oral antibiotics are essential to control secondary infection (cefotaxime, ciprofloxacin, amoxycillin). (Small abscesses < 3 cm respond to drugs). • Other drugs: 1. Injection dihydroemetine 1.5 mg/kg/day IM for 5 days should be given under cardiac monitoring. 2. Chloroquine 250 mg BD given for 10-14 days. Drugs used for amebic infection • Metronidazole, Tinidazole, Secnidazole, Ornidazole • Dihydroemetine injection • Chloroquine, tetracycline • Diloxanate furoate, iodoquinol, paromonycin—as cyst eradicators
- #27 Tinidazole 600 mg BD dose for 5 days. • IV or oral antibiotics are essential to control secondary infection (cefotaxime, ciprofloxacin, amoxycillin). (Small abscesses < 3 cm respond to drugs). • Other drugs: 1. Injection dihydroemetine 1.5 mg/kg/day IM for 5 days should be given under cardiac monitoring. 2. Chloroquine 250 mg BD given for 10-14 days. Drugs used for amebic infection • Metronidazole, Tinidazole, Secnidazole, Ornidazole • Dihydroemetine injection • Chloroquine, tetracycline • Diloxanate furoate, iodoquinol, paromonycin—as cyst eradicators
- #28 Tinidazole 600 mg BD dose for 5 days. • IV or oral antibiotics are essential to control secondary infection (cefotaxime, ciprofloxacin, amoxycillin). (Small abscesses < 3 cm respond to drugs). • Other drugs: 1. Injection dihydroemetine 1.5 mg/kg/day IM for 5 days should be given under cardiac monitoring. 2. Chloroquine 250 mg BD given for 10-14 days. Drugs used for amebic infection • Metronidazole, Tinidazole, Secnidazole, Ornidazole • Dihydroemetine injection • Chloroquine, tetracycline • Diloxanate furoate, iodoquinol, paromonycin—as cyst eradicators
- #29 Tinidazole 600 mg BD dose for 5 days. • IV or oral antibiotics are essential to control secondary infection (cefotaxime, ciprofloxacin, amoxycillin). (Small abscesses < 3 cm respond to drugs). • Other drugs: 1. Injection dihydroemetine 1.5 mg/kg/day IM for 5 days should be given under cardiac monitoring. 2. Chloroquine 250 mg BD given for 10-14 days. Drugs used for amebic infection • Metronidazole, Tinidazole, Secnidazole, Ornidazole • Dihydroemetine injection • Chloroquine, tetracycline • Diloxanate furoate, iodoquinol, paromonycin—as cyst eradicators
- #30 Tinidazole 600 mg BD dose for 5 days. • IV or oral antibiotics are essential to control secondary infection (cefotaxime, ciprofloxacin, amoxycillin). (Small abscesses < 3 cm respond to drugs). • Other drugs: 1. Injection dihydroemetine 1.5 mg/kg/day IM for 5 days should be given under cardiac monitoring. 2. Chloroquine 250 mg BD given for 10-14 days. Drugs used for amebic infection • Metronidazole, Tinidazole, Secnidazole, Ornidazole • Dihydroemetine injection • Chloroquine, tetracycline • Diloxanate furoate, iodoquinol, paromonycin—as cyst eradicators
- #31 Tinidazole 600 mg BD dose for 5 days. • IV or oral antibiotics are essential to control secondary infection (cefotaxime, ciprofloxacin, amoxycillin). (Small abscesses < 3 cm respond to drugs). • Other drugs: 1. Injection dihydroemetine 1.5 mg/kg/day IM for 5 days should be given under cardiac monitoring. 2. Chloroquine 250 mg BD given for 10-14 days. Drugs used for amebic infection • Metronidazole, Tinidazole, Secnidazole, Ornidazole • Dihydroemetine injection • Chloroquine, tetracycline • Diloxanate furoate, iodoquinol, paromonycin—as cyst eradicators