1) Liver abscesses can be either pyogenic (caused by bacteria) or amoebic (caused by the parasite Entamoeba histolytica). 2) Pyogenic liver abscesses are more common in western countries and are usually caused by E. coli or Klebsiella pneumoniae, while amoebic liver abscesses are more common in Asia and Africa. 3) The most common causes of pyogenic liver abscesses are infections that spread from the biliary tract, while amoebic liver abscesses usually originate from ingesting cysts of E. histolytica through contaminated food or water.

1. LIVER ABSCESS
Suman Raj Baral
MS, General Surgery

2. ANATOMY ??
ANATOMY - BASICS

3. SURGICAL ANATOMY

4. Pyogenic Liver Abscess
• Liver is the most common site of abdominal visceral abscess
• PLA accounts for majority of hepatic abscess
• NO significant gender, ethnic or geographic differences in disease
frequency
• Associated comorbid conditions are Cirrhosis, CRF and history of
malignancy

5. Aetiology
•E.coli : MC in western countries
•Klebsiella pneumonia: MC in Asian countries
•Staphylococcus : MC in children suffering from chronic granulomatous
disease
• Multiple Abscesses occur in those with biliary origin
• Solitary Abscesses tend to be multiple and polymicrobial

6. Routes of Transmission
•Biliary Tract (MC)
• CBD stones leading to cholangitis (Asia)
• Hilar Cholangiocarcinoma in western countries
• CBD Strictures
Portal Vein : 2nd
MC
Hepatic Artery: Hematogenous Spread, usually monomicrobial, staphylococcus or
streptococcus
Direct Extension: From Subdiaphragmatic Abscess, Suppurative Cholecystitis, empyema
in chest, Perinephric abscess
Penetrating or Blunt Trauma
Cryptogenic: undiagnosed abdominal pathology, resolved infectious processes at the time of presentation or host factors such
as diabetes or malignancy rendering liver for more susceptible to transient hepatic artery or portal vein bacteremia

7. Clinical Features
• MC presentation is Fever.
• MC LFT abnormality is raised ALP.
• Classic Presentation: Fever, Jaundice(25%)and right upper quadrant
pain and tenderness
• MC presenting symptoms: Fever, Chills and Abdominal Pain
• Usually single, involves right lobe
• Malignancy, jaundice, deranged LFT and sepsis are associated with
poor prognosis

8. Diagnosis
• USG and CT are the main diagnostic modalities
• USG- round, oval area that is less echogenic than the surrounding liver
• CT- Similar findings of USG with and lesions are of lower attenuation
than surrounding parenchyma
• Confirmed by aspiration and culture.
• Chest X-ray: Elevated Hemi-diaphragm, right sided pleural effusion or
• atelectasis

9. Treatment
• Percutaneous Catheter Drainage + IV Antibiotics : Treatment of
Choice
• After 2 weeks of parenteral antibiotics, oral agents to be continued
for next 4 weeks
LAPARATOMY ??

10. Amoebic Liver Abscess
• Caused by Entamoeba histolytica, cysts acquired through faeco-oral
route.
• Usually Solitary and more common in right lobe
• Trophozoites reach the liver through portal venous system
• Majority of patients are young age groups

11. Pathogenesis
• MC form of invasive
disease is colitis,
frequently affecting
cecum and ascending
colon
• In colon- flask
shaped ulcers seen.
• Synchronous hepatic
abscess seen in 1/3rd
of patients with
active amoebic colitis

12. Clinical Features
• MC Symptom is abdominal pain.
• Typical clinical picture- patient of 20-40 yrs age group, with history of
travel to endemic area, presents with fever, chills, anorexia, right
upper quadrant pain
• Active colitis and abscess rarely occur simultaneously, as a rule
colonic lesions are silent.
• Raised PT(prothrombin time) is MC LFT abnormality.

13. Diagnosis
• USG and CT are the main diagnostic modalities
• CT- peripheral rim enhancement in CT distinguishes from
• Pyogenic Liver Abscess.
• Confirmed by serological tests(ELISA) for anti-amoebic antibodies
• Cultures are usually sterile or negative
• CXR- Elevated Hemi-diaphragm, right sided pleural effusion or
atelectasis
• - REDDISH –BROWN ANCHOVY SAUCE paste more reliable
characteristic feature.

14. Treatment
• Metronidazole (750mg TDS for 10-14 days)is the mainstay of
treatment and curative in over 90% cases
• Clinical improvement seen within 3 days
• Luminal agents include iodoquinol, paromomycin and diloxanide
furoate
• Average time for radiological resolution of abscess is 3-9 months.

15. Indications for Aspiration
• Diagnostic Uncertainty
• Failure to respond to therapy in 3-5 days
• Pyogenic Superinfection
• High risk of rupture (size->5cm, left lobe abscess)
• Pregnancy

16. Complications
• Most frequent complication- Rupture into peritoneal cavity, pleural
cavity or pericardium
• Size appears to be the most important risk factor for rupture
• Rupture into peritoneal cavity- Laparatomy
• Rupture into pleural cavity- Thoracentesis

17. LET’S DIFFERENTIATE
Clinical Features Amoebic Liver Abscess Pyogenic Liver Abscess
Age(yrs) 20-40 >50
M:F >10:1 1.5:1
Solitary vs Multiple Solitary 80% Solitary 50%
Location Usually Right Liver Usually right liver
Travel to endemic area Yes No
Diabetes Uncommon(2%) More Common
Alcohol Use Common Common
Jaundice Uncommon Common
Elevated Bilirubin Uncommon Common
Elevated ALP Common Common
Positive Blood Culture No Common
Positive Amoebic Serology Yes No

18. Thanks !!