This document provides information on liver abscesses, including their classification, etiology, pathophysiology, diagnosis, and management. It discusses pyogenic and amoebic liver abscesses. Pyogenic abscesses are usually polymicrobial and result from bacterial infection spreading to the liver via the bloodstream or adjacent organs. Amoebic abscesses are caused by Entamoeba histolytica infection and spread from the intestines to the liver via the portal vein. Key diagnostic tests include ultrasound, CT scan, and serology. Pyogenic abscesses are typically treated with antibiotics and drainage of larger abscesses, while amoebic abscesses often resolve with antiamoebic medications alone. Prompt diagnosis and treatment are

2. OBJECTIVES
 Anatomy of liver
 Classification
 Etiology and patho-physiology
 Management

3. ANATOMY OF LIVER

4. CLASSIFICATION
PYOGENIC
 Gram Positive
 Gram-negative
 Anaerobic
 Staph aureus,Strepto pyogenes,Strepto milleri,strepto
faecalis
 E coli,Klebsiella,Proteus
 Bacteroids,Clostridium,Actinomyces
AMOEBIC
CANDIDA
TB (rare)

5. PATHO PHYSIOLOGY
 Liver largest portion of reticuloendothelial system
so continuous exposure to bacteria from enteric
tract
 Due to high level of reticuloendothelial tissue, non-
viral infections are uncommon

6. RISK FACTORS
 PYOGENIC
 DM
 Cancer
 Liver Transplant
 ENTAMOEBA
 Pregnancy
 Steroids
 Cancer
 Endemic area travel (short or long term)

7. PYOGENIC LIVER ABSCESS

8. EPIDEMIOLOGY
 MALE > FEMALE
3 : 1
 MORE IN RIGHT LOBE, SUPERIOR ASPECT
 INCREASED INCIDENCE IN DIABETES MELLITIS

9. PATHO PHYSIOLOGY OF PYOGENIC
ABCESS
 PYOGENIC:
 Peritonitis
 To liver via portal circulation
 Direct Spread
 Biliary infections(ascending cholingitis
 Hematogenous Seeding
 Bacteremia, septecemia(unusual)
 Adjacent infections
 Sub phrenic abscess, Cholecystitis
 Sites: R lobe most common
 Blood supply

10. …PATHO PHYSIOLOGY
 Mostly multiple abscesses/sometimes single
 40 % monomicrobial
 40 % polymicrobial
 20 % negative culture

11. SIGN AND SYMPTOMS
 Rigors high swinging temp(90 %)
 Tender palpable liver(50 %)
 Jaundice 1/3
 Charcot’s triad
 Or non-specific malaise over month

12. INVESTIGATIONS
 NON SPECIFIC
 total lymphocyte count: increase leukocytosis
 Increase ESR
 Increase alk phosphate(mild)(67-90%)
 SPECIFIC
 USG
 DIAGNOSTIC ASPIRATION & CULTURE SENSITIVITY
 CT scan

13. ULTRASOUND OF PYOGENIC ABSCESS

14. CT SCAN

15. TREATMENT
 MEDICAL
 BROAD SPECTRUM ANTIBIOTICS
 triple regime(penicillin , amino glycoside and Metronidazole)
 cephalosporin and Metronidazole
 SPECIFIC
 ACCORDING TO CULTURE SENSITIVITY
 i/v fluids to prevent hepatorenal syndrome
 ANALGESICS & ANTIPYRATICS
 Urgent drainage

16. CONTINUED
 INVASIVE
 TO DRAIN OR NOT TO DRAIN:
 <5cm, single abscess- needle aspiration or catheter
 >5cm- catheter
 Also: Surgery, ERCP
 URGENT DRAINAGE
 USG GUIDED, AND PIG TAIL CATHETER
 OPEN
 ERCP IN CASE OF OBSTRUCTION

17. AMOEBIC LIVER ABSCESS

18. AMOEBIC ABSCESS
 Epidemiology
 M > F 7:1
 10 % world population
 40-50 million amoeba infections/year worldwide
 Age Extremes
 Endemic Areas most susceptible
 Country of origin or Travel

19. GEOGRAPHIC DISTRIBUTION

20. ETIOLOGY AND PATHOPHYSIOLOGY
 Entemoeba histolytica

22. MODE OF TRANSMISSION
 Large intestine (history of dysentery)
 Travel to liver most common superior aspect near
diaphragm through portal vein
 Where proliferates to produce cytolytic enzymes
 Destroy liver tissues
 Abscess which is sterile(anchovy paste or chocolate
sauce
 Amoeba may be found in abscess wall

23. SIGN AND SYMPTOMS
 Fever
 Pain RHC
 Dysentery
 Tenderness

24. INVESTIGATIONS
 NON SPECIPIC
 Increase TLC
 Increase LFT’s
 Most common biochemical abnormality(alk phosphate)
 SPECIFIC
 USG
 CT SCAN
 IMAGE GUIDED ASPIRATION ANCHOVY SAUCE LIKE
 CULTURE AND SENSTIVITY
 Fluorescent antibody test for Entamoeba(can be positive even
after clinical cure)
 If serology is negative , amoebiasis is uncertain

25. USG OF AMEBIC ABSCESS-NOTE PERIPHERAL
LOCATION, ROUNDED SHAPE, POOR RIM WITH
INTERNAL ECHOES
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26. CT SHOWING SUPERFICIAL ABSCESS
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27. PERIPHERALLY LOCATED AND ROUND. RIM IS
NONENHANCING BUT SHOWS PERIPHERAL EDEMA
(BLACK ARROWS). NOTE THE EXTENSION INTO THE
INTERCOSTAL SPACE (WHITE ARROWS).
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28. TREATMENT
 NON INVASIVE
 Metronidazole 400-800 mg TDS …….7 to 10 days
 INVASIVE
 Ultrasound guided aspiration
 Surgery
 Amoeba: drainage not usually required
 Exceptions:
 Verge of rupture
 Abx not working
 Imminent need to exclude other dx
 Large abscess

29. COMPARISON

30. PROGNOSIS & NATURAL HISTORY
• Mortality 2-12%
• Often due to co morbidities, not
necessarily abscess itself

31. SUMMARY
 If untreated LA is potentially fatal.
 Must be diagnosed & treated promptly
 Investigations-LFT,USG and CT
 SEROLOGY-corner stone to differentiate
 Pyogenic liver abscess-Antibiotics plus drainage
 Causative pathology should also be treated

32.  ALA-most cases treated with amebicidal agents
alone with drainage procedures reserved for
resistant or complicated cases
 Luminal amebicides should also be given
 When there is high index of suspicion for LA Rx
should not be withheld until diagnosis is confirmed

33. REFERRENCES
 Baily and love

34. Thank you