- Liver abscesses are typically caused by bacterial infections spreading from other sites like the biliary tract or portal vein. Common bacteria include E. coli and K. pneumoniae. Abscesses are usually diagnosed using imaging like ultrasound or CT scan and treated with antibiotics and drainage if large. - Amebic abscesses are caused by Entamoeba histolytica infection spreading from the colon. They present similarly to pyogenic abscesses but are diagnosed serologically or with immunoassays. Metronidazole is the treatment. - Hydatid cysts are caused by the parasite Echinococcus granulosus. Humans are an accidental intermediate host. Cysts usually form in the liver and

1. • Liver abscess; Hydatid Cyst
• M530
• Gunchmaa.N, Ludevdorj.N

4. Pyogenic Abscess

5. Epidemiology
• Patients in their 50s or 60s
• Often related to biliary tract disease
• Cryptogenic in nature (uncertain in origin)

6. Pathogenesis
• An inoculum of bacteria exceeds the livers ability to clear it.
• Tissue invasion
• Neutrophil infiltration
• Abscess formation

7. Biliary tree
• Stone or malignant disease
• Biliary obstruction
• Bile stasis
• Bacterial colonization
• Ascends to liver
• Ascending suppurative cholangitis

8. Portal vein
• Ascending portal vein infection – pyelophlebitis
• Diverticulitis, appendicitis, pancreatitis, IBD etc
• Malignant disease

9. Hepatic artery
• Any systemic infection
• Altered immune response
• Direct infection extension

10. Other causes
• Necrotic liver:
• Trauma
• Hepatic artery embolization
• Thermal ablative procedures

11. Pathology
• 75% right hemiliver
• 20% left hemiliver
• 5% caudate lobe
• Mostly solitary
• 1 mm – 4 cm
• Multiloculated or in single cavity

12. Microbiology
• Either polymicrobial or single organism
• Escherichia coli
• Klebsiella pneumoniae
• Staphylococcus aureus
• Enterococcus sp.

13. Clinical features
• Fever
• Chills
• Jaundice
• RUQ pain
• Tenderness to
palpation
• Hepatomegaly
• Acute or
chronic

14. Complication
• If diaphragm is involved, cough or dyspnea
• Peritonitis secondary to rupture
• Rupture into pleural space or pericardium
• Endogenous endophthalmitis (Klebsiella)

15. Lab findings
• Leukocytosis
• Anemia
• LFT abnormality
• ALP elevated /80%/
• Total bilirubin elevated /20-50%/
• Transaminases increase /60%/
• Hypoalbuminemia, increased PT

16. Radiology
• Chest X-ray
Atelectasis
Right pleural effusion
Elevated right
hemidiaphragm
• Plain abdominal X-ray
- Air fluid levels
- Portal venous gas

17. Radiology
• Ultrasound – round or oval, less echogenic than surrounding liver
• CT – lesions are of lower attenuation than surrounding liver, multiple
small abscesses
• Both are useful in diagnosing intra-abdominal diseases

19. Differential diagnosis
• Amebic abscess
• Echinococcal cyst

20. Treatment
• Immediate broad spectrum IV antibiotics /2 weeks</
• Combination of ampicillin, aminoglycosides, metronidazole
• Aspiration, send for culture.
• Percutaneous catheter drainage
• Contraindications: ascites, coagulopathy, proximity to vital structures
• If larger than 5 cm, surgery is better
• Liver resection if destruction is severe

21. Amebic Abscess

22. Epidemiology
• Largely a disease in tropical or developing countries
• Less than 50% are symptomatic
• Mostly Hispanic men
• 20-40 age
• Socioeconomic status
• Alcohol consumption
• Immunosuppression
• Travel history

23. Pathogenesis
• E.histolytica is a protozoan that exists as trophozoite or cyst
• Fecal-oral route
• When ingested, cysts aren’t degraded in stomach
• Trophozoite released
• Invades colon mucosa
• Enzymatic cellular hydrolysis

24. Pathogenesis
• Localized necrosis
• Cavity forms
• It contains proteinaceous debris
• Surrounded by rim of trophozoites
• Rapid IgA release

25. Pathology
• Cavity full of blood, liquefied liver tissue
• The fluid is odorless
• Glisson capsule resistant to hydrolysis
• Early stage, ill-defined
• Right hemiliver

26. Clinical features
• Last from days to 4 weeks
• Fever
• Chills
• RUQ pain and tenderness
• Hepatomegaly
• Constant, dull abdominal pain
• Diarrhea
• Anorexia
• Jaundice

27. Clinical features
• Acute <10 days
• High fevers, chills, abdominal tenderness
• Multiple lesions usually
• Chronic > 2 weeks
• Single right-sided lesion
• Response is similar in both groups

28. Lab findings
• Mild to moderate leukocytosis with no eosinophilia
• Anemia
• LFT abnormality
• Elevated PT-INR
• Enzyme immunoassay
• Detection kit

29. Radiology
• Plain chest x-ray: elevated right hemidiaphragm, pleural effusion,
atelectasis
• Ultrasound: Round lesions, liver capsule, without significant rim
echoes. Contents are hypoechogenic, nonhomogenous
• CT: more sensitive
• Nuclear studies: to differentiate from pyogenic abscess. No
leukocytes, does not light up

31. Differential
diagnosis
• Viral hepatitis
• Echinococcal disease
• Cholangitis
• Cholecystitis
• Appendicitis
• Liver tumor
• Pyogenic abscess

32. Treatment
• Metronidazole 750 mg orally, three times daily, 10 days
• Emetine hydrochloride
• Chloroquine
• After liver abscess is treated, iodoquinol, paromomycin, diloxanide
furoate to treat carrier state
• If failure of metronidazole in 3-5 days, diagnostic aspiration
• Larger than 5 cm, in left side – aspiration
• Radiologic resolution 3-9 months

33. Hydatid Cyst

34. • Hydatid disease or echinococcosis is a zoonosis that is common
worldwide because the dog is a definitive host.
• Human contract the disease from dogs, but there is no human to
human transmission

35. • 3 species that cause hydatid cyst:
• Echinococcus granulosus
• Echinococcus multilocularis
• Echinococcus ligartus
• Humans are end stage to the parasite.

36. • In the human duodenum, the parasitic embryo releases an
oncosphere containing hooklets that penetrate the mucosa, allowing
access to the bloodstream.
• In the blood, it can reaches the liver or lungs, where the parasite
develops its larval stage

37. • 3 weeks after infection, a visible hydatid cyst develops, which then
slowly grows in a spherical manner.

38. • The cyst wall itself has 2 layers, an outer gelatinous membrane
(ectocyst) and an inner germinal membrane (endocyst).
• Brood capsules are small, intracystic cellular masses in which future
worm heads develop into scoleces. In a definitive host, the scoleces
develops into an adult tapeworm.

39. Hydatid cysts can die with:
• degeneration of the membranes
• Development of cystic vacuoles
• Calcification of the wall
• Calcification of a hydatid cyst, however, doesn’t always imply that the
cyst is dead

40. • Hydatic cysts are diagnosed in equal numbers of en and woman at an
average age of about 45 years.
• Approximately 75% of hydatid cysts are located in the right liver and
are solitary

41. • The clinical presentation of a hydatid cyst is largely asymptomatic
until complications occur.
• Dyspepsia
• Abdominal pain
• Vomiting
• Hepatomegaly are the most common symptoms.

42. • Jaundice and fever are each present in approximately 8% of patients.
• Bacterial super infection of a hydatid cyst can occur and be
manifested like a pyogenic abscess

43. • Rupture of the cyst into the biliary tree or bronchial tree or free
rupture into the peritoneal , pleural, or pericardial cavities can occur.

44. Diagnosis
• Serologic tests are available to evaluate antibody response, but all are
plagued by low sensitivity and specifity
• Ultrasound is more common, but it depends on the stage of the cyst
at the time of examination

45. • Simple hydatid cyst is well circumscribed with budding signs on the
cyst membrane
• May contain free floating hyperechogenic hydatid sand
• A rosette appearance is seen when daughter cysts are present

46. • Cyst can be filled with an amorphous mass, which can be
diagnostically misleading
• Calcification in the wall of the cyst is highly suggestive of hydatid
disease

48. • Similar findings are seen on CT or MRI scans
• In patients with suspected biliary involvement, ERCP or percutaneous
transhepatic cholangiography may neccesary

49. Treatment
• Primarily surgical
• Most cyst should be treated
• But in older patients with small, asymptomatic, densely calcified
cysts, conservative management ( drainage nad evacuation) is
appropriate.

50. • Epinephrine and steroids taken by anesthesiologist
• Packing off the abdomen is important because rupture can result in
anaphylaxis and diffuse seeding

51. • Then cyst ih aspirated through a closed suctionsystem and flushed
with a scolicidal agent (hypertonic saline)

52. • The cyst is then unroofed which can then be followed by a number of
possibilities, including
• excision ( or pericystectomy)
• Marsupialization procedures
• Leaving the cyst open
• Drainage of the cyst
• Omentoplasty
• Partial hepatectomy

53. • Pericystectomy or formal partial
hepatectomy can also be
performed without entering thy
cyst.

54. • Simple suture repair is often sufficient, but major biliary repairs,
approaches through the common bile duct, or postoperative ERCP
may be neccesary
• Recurrence rates after surgical treatment is generally 5% or less

55. • Preoperative treatment my decrease the risk of spillage.
• Albendazole or mebendazole is effective with E.granulosus infection,
but cyst appearance occurs 50% of patients
• Medical treatment without resection or drainage should be
considered only for widely diseminated disese or poor surgical
candidate

56. Thank you!