liver disease

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
pgme
dical
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26. CT SHOWING SUPERFICIAL ABSCESS
pgme
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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).
pgme
dical
worl
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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