A 50-year-old farmer from Gujranwala presented with abdominal pain, jaundice, and urticaria. Differential diagnoses include liver abscess and hydatid disease. Investigations would include blood tests, imaging like ultrasound and CT, and fluid aspiration/culture. Initial management depends on diagnosis but may include antibiotics, drainage, or anti-parasitic drugs. Liver abscesses are generally pyogenic, amoebic, or fungal in origin and present variably. Hydatid disease involves cyst formation from Echinococcus tapeworms and usually affects the liver. Treatment involves surgery, percutaneous drainage, or anti-parasitic drugs depending on individual factors.

1. LIVER ABSCESSES AND
HYDATID DISEASE
Dr. Muhammad Zoha Farooq
Resident Surgical Oncology

2. Clinical Scenerio
• 50 years old, diabetic hypertensive farmer from
Gujranwala presented to ER with abdominal pain more
localized in right UQ , jaundice and urticaria. Patient gives
Hx for on and off fever since 1 month. His BP is 130/90.
Pulse 88. Temperature 37 C. On examination there is
enlarged liver, no fluid thrill/ shifting dullness. Gut sounds
are audible.
• What is the differential diagnosis?
• What investigations will you order?
• What is initial management?

3. What is Abscess?
• Defined as a collection of pus (dead cells and neutrophils)
• An inflammatory process in response to either an
infectious process or other foreign materials
• Liver abscess may be single or multiple
• Can be of different sizes
• May contain foul smelling pus or reddish brown paste.

4. Incedence and Epidemiology
• Liver – organ most subject to the development of
abscesses
• 13% of total intraabdominal abscesses
• 48% of all visceral abscess
• Mortality - 5-30% of cases
• most common causes of death include sepsis, multiorgan failure,
and hepatic failure
• Equal Male to female ratio. Males have poorer prognosis

5. Types of Liver Abscess
• There are three major forms of liver abscess, classified by
etiology:
• Pyogenic liver abscess, which is most often polymicrobial,
accounts for 80% of hepatic abscess cases in the United States.
• Amoebic liver abscess due to Entamoeba histolytica accounts for
10% of cases.
• Fungal abscess, most often due to Candida species, accounts for
less than 10% of cases.

6. Pyogenic Liver Abscess

7. Pyogenic Liver Abscess
• A pyogenic liver abscess is a type of liver abscess caused
by bacteria, can be single or multiple.
• The right lobe is affected twice as often as the left; 5%
have bilateral involvement.
• No cause found in 15% cases. Most are secondary to
infection originating in the abdomen. Bacterial
endocarditis and dental infection are other causes.
• More common in the immunocompromised and in people
with Liver cirrhosis

8. Etiology of Pyogenic Liver Abscess
• Disorders or bacterial infection of following origins may
invade liver to cause abscess:
• Biliary disease (most common) e.g.: stones, cholangiocarcinoma,
infection
• Colonic disease. e.g.: diverticulitis, appendicitis, Crohn's disease
• Pancreatitis
• Infection of blood
• Intra-abdominal sepsis
• Endocarditic, Dental infection (with streptococci)
• Traumatic, Iatrogenic

9. Common Causative Agents
• Most common species invloved are
• E coli 2/3rd
• Streptococcus fecalis
• Pseudomonas
• Klebsiella pneumoniae
• Proteus vulgaris
• Bacteroides
• Staphylococcus and Streptococcus ( Endocarditits)

10. Amoebic Liver Abscess
• Amoebic liver abscess or amebiasis is a type of liver
abscess caused by Entamoeba Histolytica (Protozoa).
• E. histolytica causes amoebic colitis and dysentery but
liver abscess is the most common extra-intestinal
manifestation of infection
• Route of entry via oro-fecal roue by ingestion of
contaminated food or water. Amoebae invade intestinal
mucosa and can gain access to the portal venous system

11. Amoebic Liver Abscess
• A large necrotic area which is liquefied into thick reddish-
brown pus (Anchovy sauce pus) due to liquefied necrosis,
thrombosis of blood vessels, lysis of liver cells
• It affects the right lobe in 80%.
• This type is common in overcrowded areas with poor
sanitation and in alcoholics.

12. Amoebic Liver Abscess

13. Fungal Liver Abscess
• Fungal abscesses is a less common type,
• Primarily due to Candida albicans
• Occur in individuals with
1. Prolonged exposure to Antimicrobials
2. hematologic malignancies
3. solid-organ transplants
4. congenital and acquired immunodeficiency.

14. Clinical Presentation
1. Fever with Chills
2. Abdominal pain
3. Anorexia
4. Weight loss
5. Nausea, Vomiting
6. Right shoulder pain / irritable cough
7. Cough and Dyspnea
8. Hepatomegaly
9. Tenderness
10. Rebound tenderness
11. Jaundice (late) 1/3

15. People At Risk
• Age: Advanced age, particularly in people older than 70 years.
• Health: Having a long-term disease, (cancer, diabetes,
tuberculosis) or splenectomy, a weak immune system, AIDS.
• Taking Drugs: Such as steroids, chemotherapy, prolong use
of antibiotics (fungal abscess).
• Lifestyle: Drinking too much alcohol, too often. Living in over
crowding area, poor sanitation
• Nutrition: Being malnourished (having poor nutrition).
• Activity: Traveling to places where ameobiasis is common.
Eating foods and drinking liquids that are sold in the street may
further increase risk.

16. Laboratory Studies
1. CBC
1. Increased WBC, usually Neutrophilic Leukocytosis.
2. Raised erythrocyte sedimentation rate (ESR).
3. Mild normochromic normocytic anaemia.
2. Liver function studies
1. Hypoalbuminemia
2. Elevation of alkaline phosphatase
3. Elevations of transaminase and bilirubin levels (variable)

17. Laboratory Studies
3. Blood cultures are positive in roughly 50% of cases.
4. Stool DR: Stools can contain cysts or trophozoites of
E. histolytica.
5. Serology should be carried out if E. histolytica is
suspected.
6. Culture of abscess fluid should be the goal in
establishing microbiologic diagnosis. Usually done
through Percutaneous needle aspiration (under CT or
Ultrasound Guidance)

18. Imaging Studies
1. Chest X-Ray: May show raised right hemi-diaphragm on.
2. Ultrasonography
a) Can show abscess
b) Allow guided percutaneous aspiration and drainage and biliary
tree examination.
3. CT scanning
a) Can show the abscess,
b) Allow guided aspiration and drainage
c) Show other intra-abdominal abscesses or a possible cause
such as diverticular disease, appendicitis, etc.
d) Good for the detection of small abscesses.
4. MRI

19. Imaging
CXR Sono

20. CT SCAN

21. Medical Managment
• Antibiotics
• Pyogenic liver abscess: Broad spectrum antibiotics should be
started before waiting for culture results.
• Usually start treatment with tri-therapy included the use of penicillin,
amino-glycoside and metronidazole.
• A third-generation cephalosporin can be considered in the elderly
or if renal function is impaired.
• Antibiotic therapy can be modified once culture results are
available.
• Treatment may be needed for up to 12 weeks and should be
guided by the clinical picture and radiological monitoring.

22. Medical Managment
• Amoebic liver abscess:
• Metronidazole is the treatment of choice. 95% of patients with
amoebic liver abscess recover with this alone. Most patients show
a response to treatment within 72-96 hours.
• Diloxanide furoate should be prescribed for 10 days to eliminate
intestinal amoebae after the abscess has been successfully
treated.
• Antifungal agents such as amphotericin B are used if fungal
abscess is suspected.

23. Surgical Mangment and Drainage
• Most patients with pyogenic liver abscess or with very large
amoebic abscesses, may not recover with antibiotics alone
need drainage guided by ultrasonography or CT.
• Percutaneous aspiration can be carried out for small
abscesses although
• Catheter drainage carried out for larger abscesses.
• Open surgery may be necessary if
• Abscess ruptured
• Signs of peritonitis,
• Abscess 5 cm

24. Percutaneous Aspiration and Catheter
Drainage

26. Complications
1. Return of Abscess
2. Widespread infection in abdomen.
3. Overwhelming sepsis.
4. Rupture of the abscess into adjacent structures
(pleural, peritoneal and pericardial spaces).
5. Secondary infection of amoebic liver abscesses.

27. Prognosis
• Pyogenic liver abscess
• Mortality rate is 5-30%.
• Condition such as Diabetes Mellitus, immunodeficiency,
malignancy, affect prognosis.
• Amoebic liver abscess
• Mortality rates have fallen to 1-3%.

28. HYDATID DISEASE OF
LIVER

29. Etiology

30. Life Cycle

31. Clinical Features
• Can involve any organ.
• liver (63%), lungs (25%), muscles (5%), bones (3%), kidneys
(2%), brain (1%), and spleen (1%).
• The clinical presentation of a hydatid cyst is largely
asymptomatic until complications occur.
• The most common presenting symptoms are abdominal pain,
dyspepsia, and vomiting.
• The most frequent sign is hepatomegaly/palpable mass.
• Jaundice and fever are each present in about 8% of patients.
• Bacterial superinfection of a hydatid cyst can occur and
present like a pyogenic abscess.
• Rupture of the cyst into the biliary tree.
• Free ruptures can result in disseminated echinococcosis and
a potentially fatal anaphylactic reaction.

32. Laboratory Studies
• Leukocytosis
• Eosinophilia is present in 25%
• Hypogammaglobinemia is present in 30%.
• Serodiagnostic techniques
• Indirect hemagglutination test and the enzyme-linked
immunosorbent assay (ELISA) have a sensitivity of 80%
overall (90% in hepatic echinococcosis, 40% in pulmonary
echinococcosis) and are the initial screening tests of
choice.
• Immunodiffusion and immunoelectrophoresis demonstrate
antibodies to antigen 5 and provide specific confirmation
of reactivity.
• The ELISA test is useful in follow-up to detect recurrence.

33. Imaging - SONO
• currently the primary
diagnostic technique
and has diagnostic
accuracy of 90%.
• This scan is of a
multiloculated cyst.

34. Gharbi’s Classification
• Type I : pure cystic fluid
Collection (spherical-oval,
thick-walled)
• Type II : fluid Collection
with membrane separation
• Type III : Fluid collection
with septa
• TypeIV: heterogeneous
(hypoechoic-hyperechoic-
intermediate) pattern
• Type V: completely
calcified (Reflecting) walls

35. CT Scan
• More sensitive than
sono, 95-100%.

36. Treatment
• The treatment of choice is surgery.
• Available Options:
• Medical
• Per-cutaneous
• Endoscopic
• Surgical

37. Medical Treatment
• Small Cysts , asymptomatic cysts and patients unsuitable
for surgical resection.
• ALbendazole- Relies on diffusion through the cyst
membrane
• Mebendazole
• 400mg BID in cycles of 28 days with 2 weeks period off
between the cycles.
• Usually 3 cycles are sufficient.

38. PERCUTANEOUS DRAINAGE OF
HYDATID CYST (PAIR)
• This technique, performed using either ultrasound or CT
guidance
• involves aspiration of the contents via a special cannula,
followed by injection of a scolicidal and then reaspiration.
• The cysts should be larger than 5 cm in diameter and type
I or II according to the Gharbi ultrasound classification of
liver cysts
• PAIR can be performed on type III cysts as well.

39. Indications For PAIR
•Patients with:
• lesion ≥ 5 cm in diameter (TYPE 1)
• Cysts with detachment of membranes (TYPE2) and/or with daughter
cysts (TYPE 3),
• Multiple cysts if accessible to puncture
• Infected cysts
•Also
• Pregnant women
• Children >3 years old
• Patients who fail to respond to chemotherapy alone
• Patients in whom surgery is contraindicated
• Patient who refuse surgery
• Patients who relapse after surgery

40. Contraindications For PAIR
• Non-cooperative patients and inaccessible or risky
location of the cyst in the liver.
• Cyst in spine, brain and/or heart.
• Inactive or calcified lesion.
• Cysts communicating with the biliary tree.
• Cysts open into the abdominal cavity, bronchi and urinary
tract.

41. PAIR step by Step
•PAIR Protocol (Minimum Requirements):
1. Prophylaxis with albendazole
2. Puncture and parasitological examination (if possible) or fast
test for antigen detection in cyst fluid
3. Aspiration of cystic fluid (10-15 cc)
4. Test for bilirubin in cyst fluid
5. If bilirubin present: →→ →→ stop procedure
6. If no bilirubin present: →→ →→ aspirate all cystic fluid
7. Injection of 95 % ethanol solution or hypertonic saline (1/3 of
the amount of aspirated fluid)
8. Re aspiration of protoscolicide solution after 15 minutes

43. Surgical Treatment
• Indications:
1. Large liver cysts with multiple daughter cysts
2. superficially located single liver cysts that may rupture
(traumatically or spontaneously)
3. liver cysts with biliary tree communication
4. pressure effects on vital organs or structures
5. infected cysts.

44. Surgical Treatment
• Contraindications:
1. extremes of age
2. Pregnancy
3. severe preexisting medical conditions
4. multiple cysts in multiple organs
5. cysts that are difficult to access
6. dead cysts
7. calcified cysts
8. very small cysts are contraindications.

45. Principles of Hydatid Surgery
• 1) Total removal of all infective components of the cysts
• 2) The avoidance of spillage of cyst contents at time of
surgery
• 3) Management of communication between cyst and
adjacent structures
• 4) Management of the residual cavity
• 5) Minimize risks of operation
• All the surgical procedures can be divided into two large
groups, conservative group and radical group

46. Conservative Technique ( Open
Cystectomy)
• conservative technique
• aspiration of the cyst,
• instillation of scolicidal agents
• evacuation of the cyst contents and leaving the pericyst.
• The residual pericyst is managed by marsupialization,
which consists of suturing the edges of opened pericyst
with the skin,
• capitonnage (suture obliteration)

47. Radical Surgical Procedures
• Pericystectomy
• Lobectomy
• Hepatectomy .
• Radical procedures have lower rate of recurrences but
many authors consider them inappropriate, claiming that
intraoperative risks are too high for a benign disease

48. LAPAROSCOPIC MANAGEMENT OF
HYDATID CYSTS
• A special instrument has been developed for the removal
of the hydatid cyst with the laparoscope called the
perforator-grinder-aspirator apparatus.
• The instrument penetrates the cyst, grinds the particulate
matter and sucks it all out.
• The advantage of this instrument over that of conventional
suction apparatus is that it does not gets blocked by the
daughter cysts and laminated membranes..

49. Follow Up
• Chemotherapy:
• Postoperative treatment with benzimidazoles for 1 month
who have undergone complete resection or PAIR
successfully.
• Continued for 3-6 months for patients, incompletely
resected cyst, spillage during surgery or PAIR.

50. Follow Up
• Laboratory tests:
• Patients on benzimidazoles should have a CBC count and
liver enzyme evaluation performed at biweekly intervals
for 3 months and then every 4 weeks to monitor for
toxicity.
• ELISA or indirect hemagglutination tests are usually
performed at 3-, 6-, 12-, and 24-month intervals as
screening for recurrence of resected disease or
aggravation of existing disease.

51. Follow UP
• Imaging:
• Ultrasonography
• CT scan
• at the same intervals as the laboratory tests or as
clinically indicated

52. THANK YOU