The document describes the identification and characteristics of the liver and liver abscesses. It notes that the liver is the largest organ, reddish brown and rubbery. It has right and left lobes covered by Glisson's capsule. Liver abscesses can be amoebic or pyogenic, containing pus, and can be solitary or multiple. Amoebic abscesses are caused by the parasite Entamoeba histolytica while pyogenic abscesses are usually caused by bacteria like E. coli. Clinical presentation includes pain, fever and jaundice. Complications include pleural effusion, ascites and rupture. Diagnosis involves ultrasound, CT and serology tests. Treatment involves antibiotics and sometimes percutaneous drainage.

1. Identification of liver specimen
• 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 liver specimen..
• Cut surface/partial hepatectomy:
– Reddish brown/ tan pink/fleshy parenchyma
– Capsular surface smooth
– Multiple cut bile ducts:
• Variable sizes
• Bile stained

4. Amoebic liver abscess

5. Pyogenic liver abscess

6. Liver abscess
• Space occupying lesions (SOL)
• Collection of:
– Pyogenic material- frank pus
– “Anchovy sauce” pus
– Greenish pus
• Number of SOL:
– Solitary
– Multiple

8. Liver abscess
• What types of liver abscess you know?
• Commonly 2 types:
– Amoebic
– Pyogenic
• Others :
– Tubercular
– fungal

9. Liver abscess
• What causes 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
• Aetiology of 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
• Aetiology of 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
• What is 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
• What signs 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
• What are 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
• What are other complications of liver abscess?
• Superinfection of amoebic abscess
• Budd Chiary syndrome
• Liver failure / Hepatic encephalopathy
• Septicemia, later shock
• Death

16. Liver abscess
• How does 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
• How diagnosis 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
• How do 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
• How do 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
• What is 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
• What is 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
• Is surgery 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
• What follow 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
• What is 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

31. Thank you!
Doubts?

32. Quiz