This document provides information on the management of liver abscesses. It discusses the two main types - pyogenic and amebic liver abscesses. For pyogenic liver abscesses, it outlines the etiology, clinical features, investigations, and treatment options including antibiotics, aspiration, percutaneous drainage, and surgical drainage. It also discusses amebic liver abscesses, noting they are more common in tropical areas. It provides details on the pathology, clinical features, diagnosis, and treatment of amebic liver abscesses, which typically involves antibiotics or therapeutic aspiration.
LAPAROSCOPIC CHOLECYSTECTOMY- OPERATIVE SURGERY
#surgicaleducator #operativesurgery #laparoscopiccholecystectomy #usmle #babysurgeon #surgicaltutor
Dear viewers,
• Greetings from “Surgical Educator”
• Because of the popular demand by viewers of the YouTube channel “Surgical Educator”, I have decided to create and upload videos on common surgeries.
• I have already uploaded videos on open and Laparoscopic Appendicectomy, Thyroidectomy, Modified Radical Mastectomy and Open Cholecystectomy.
• In this video today, I have discussed Laparoscopic Cholecystectomy- the flagship procedure for laparoscopic surgeries.
• However, these videos are not real surgeries but the theoretical aspect of operative surgery like going through an atlas of operative surgery.
• Along with these videos, I recommend you to watch real operative surgery videos as well and the links are:
• https://www.youtube.com/watch?v=VStEzI1jL8Y
• https://www.youtube.com/watch?v=O8j4kwpzd24
• This will give a very good opportunity for the surgical trainees to mentally rehearse various surgical steps in a sequential manner prior to actual surgery. You can watch the video in the following links:
• surgicaleducator.blogspot.com
• youtube.com/c/surgicaleducator
This presentation gives general overview about different aspects of PILONIDAL DISEASE including pathophysiology, etiology, clinical Presentation, different treatment options available etc
LAPAROSCOPIC CHOLECYSTECTOMY- OPERATIVE SURGERY
#surgicaleducator #operativesurgery #laparoscopiccholecystectomy #usmle #babysurgeon #surgicaltutor
Dear viewers,
• Greetings from “Surgical Educator”
• Because of the popular demand by viewers of the YouTube channel “Surgical Educator”, I have decided to create and upload videos on common surgeries.
• I have already uploaded videos on open and Laparoscopic Appendicectomy, Thyroidectomy, Modified Radical Mastectomy and Open Cholecystectomy.
• In this video today, I have discussed Laparoscopic Cholecystectomy- the flagship procedure for laparoscopic surgeries.
• However, these videos are not real surgeries but the theoretical aspect of operative surgery like going through an atlas of operative surgery.
• Along with these videos, I recommend you to watch real operative surgery videos as well and the links are:
• https://www.youtube.com/watch?v=VStEzI1jL8Y
• https://www.youtube.com/watch?v=O8j4kwpzd24
• This will give a very good opportunity for the surgical trainees to mentally rehearse various surgical steps in a sequential manner prior to actual surgery. You can watch the video in the following links:
• surgicaleducator.blogspot.com
• youtube.com/c/surgicaleducator
This presentation gives general overview about different aspects of PILONIDAL DISEASE including pathophysiology, etiology, clinical Presentation, different treatment options available etc
Brief description of hepatectomy with indications, procedure, pre operative, intra operative and post operative management of the patient. Also describes the various techniques and instrument available for liver resection.
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TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
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Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
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the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
3. PYOGENIC LIVER ABSCESS
HISTORY
• Described since the time of Hippocrates (4000
BC).
• 1890 – Osler documented amoebae in stool and
abscess of the same patient.
• Dieulafoy described multiple hepatic abscess
secondary to pylephlebitis following appendicitis .
• In 1938 Ochsner's classic review heralded surgical
drainage as the definitive therapy.pgmedicalworld.com
4. • INCIDENCE: 0.016%
• Majority clinically silent
• Peak at 7th
decade
• Men and women equally affected
• Elderly and immunosuppressed more
affected
• RACE: no role
pgmedicalworld.com
5. ETIOLOGY
• Biliary causes – 40%
-partial or complete obs of biliary
tract with ascending cholangitis
-biliary manipulations like
cholangiography,PCT etc
• Portal venous route –20%
-perforated Ca colon
-diverticulitis
-appendicitis with pylephlebitis
pgmedicalworld.com
6. • Hepatic arterial route –12%
-iv drug abuse and its
complications
-systemic bacteremia
-umbilical artery catheterisation
-hepatic artery chemoembolisation
• Traumatic causes-4%
-penetrating trauma to liver
-cryosurgical ablation of liver
tumors pgmedicalworld.com
7. • Direct extension-6%
-subphrenic abscess
-perforated peptic ulcers
-gangrenous cholecystitis
• Cryptogenic abscess-20%
-asso with DM,malignancy,
immunosuppression
pgmedicalworld.com
8. Pathology
• Usually multiple , small abscesses
• More on right lobe of liver
BACTERIOLOGY
• Staph aureus,Strepto pyogenes,Strepto
milleri,strepto faecalis
• E coli,Klebsiella,Proteus
• Bacteroids,Clostridium,Actinomyces
• TB
• Fungi-Candida,Aspergilluspgmedicalworld.com
9. CLINICAL FEATURES
• SYMPTOMS
-Fever (continuous or spiking)
- Chills, Malaise
- Anorexia,Weight loss
-Pain
-Nausea and vomiting
-Pruritus,Diarrhoea,Cough
-PUO
pgmedicalworld.com
10. • SIGNS
-Tenderness in right upper
quadrant
-Hepatomegaly
-Jaundice,right upper quad
mass,ascites,pleural effusion
pgmedicalworld.com
15. • USG ABDOMEN
-used as a preliminary screen
-identify lesions > 2cm in dia
-differentiating cystic from solid
lesions
-diagnosis of gall stones
pgmedicalworld.com
18. • CT SCAN
-investigation of choice
-better diagnosis of concurrent or
causative pathology
-abscess > 0.5 cm in dia
-small abscesses near diaphragm and those
in fatty liver
CONTRAST ENHANCED CT
pgmedicalworld.com
22. • MRI
-lesions as small as 0.3 cm in dia
-best for defining hepatic venous
anatomy
-useful for patients requiring liver
resection
pgmedicalworld.com
23. • NUCLEAR MEDICINE LIVER
SCAN
Previously used
• X-RAY CHEST
Right pleural effusion
Atelectasis
Elevated hemi diaphragm
pgmedicalworld.com
24. • BARIUM CONTRST STUDIES OF
UPPER AND LOWER GIT
• Endoscopic retrograde
cholangiography/ERC
• Per cutaneous cholangiography/PTC
pgmedicalworld.com
25. TREATMENT
• An untreated hepatic abscess is
nearly uniformly fatal due to
complications that include sepsis,
empyema, or peritonitis from
rupture into the pleural or
peritoneal spaces, and
retroperitoneal extension.
pgmedicalworld.com
28. • Duration of treatment must be
individualised
• iv antibiotics for 2 weeks
• Oral antibiotics for 1 month
pgmedicalworld.com
29. Multiple abscesses are more problematic
and can require up to 12 weeks of
therapy.
Both the clinical and radiographic
progress of the patient should guide the
length of therapy
FUNGAL ABSCESS – Amphotericin B,
Fluconazole
pgmedicalworld.com
30. ASPIRATION
• Useful in young , otherwise healthy
patients with solitary abscess and no
co-existing intra-abdominal pathology
• Pus can be collected for C & S
• Must be radiologically guided
pgmedicalworld.com
31. PERCUTANEOUS DRAINAGE
• Must be radiologically guided
• Most useful for critically ill patients who
cannot undergo surgery
• Best for solitary, uniseptate abscess
• Absolute CI – associated biliary or intra-
abdominal pathology, coagulopathy
• Relative CI – multiple abscesses and
generalised ascites
pgmedicalworld.com
32. PROCEDURE
• MODIFIED SELDINGER TECHNIQUE
• Localise abscess with USG/CT guidance
• A 20-gauge teflon sleeve with needle stop is introduced
through safest anatomic route possible
• Insert a J wire
• A no. 8-14 french dialator and then pigtail catheters are
advanced over the wire
• Abscess evacuated by manual syringe suction
• Catheter secured to skin
• Catheter irrigated 2-3 times/day with sterile saline
• Kept in place till output < 10cc/day or cavity collapse
documented by serial CTpgmedicalworld.com
33. SURGICAL DRAINAGE
• EXPLORATORY LAPAROTOMY
-For diagnosing intra-abdominal pathology
-provides concurrent Rx of both abscess
and its source
-best for multiple abscesses and those
inaccessible to PCD, co-existing biliary
pathology
pgmedicalworld.com
34. • EXTRA PERITONEAL APPROACH
-subcostal
-transpleural
-retroperitoneal
. Used only for selected abscesses located
superiorly in liver dome
pgmedicalworld.com
35. • TRANSPERITONEAL APPROACH
-Standard Rx for patients requiring surgical
drainage
-Bimanual exmn of liver and intraoperative USG
possible
-Abscess opened with cautery after localisation
-Loculations broken down with finger dissection
-Biopsy of abscess wall and nl liver taken
-Abscess site irrigated and soft, closed-suction
drains placed within abscess cavity in
dependent locationspgmedicalworld.com
36. • HEPATIC RESECTION
• Wedge resection or formal lobectomy
-Isolated lobar involvement with single or
multiple non healing abscesses
-Patients with infected hepatic malignancy
-Hemobilia
-Chronic granulomatous d/s
pgmedicalworld.com
37. • LAPAROSCOPIC SURGERY
-Limited role
-Useful in diagnosing concurrent abd
pathology
-Laparoscopically guided liver biopsy
-Catheter placed under laparoscopic
guidance
pgmedicalworld.com
38. AMOEBIC LIVER ABSCESS
• Tropical and subtropical areas of world
are endemic
• Early descriptions came from India
• Osler reported co-existent hepatic and
colonic amoebiasis in 1890
• Exceed PLA in overall frequency
pgmedicalworld.com
39. • Caused by Entamoeba histolytica
• Reaches liver from colon via
-Portal vein
-Mesenteric lymphatics
-Intraperitoneal spread
• Incidence : 0.0013%
• More among low socioeconomic gps
• More among men
• Peak at 3rd
and 4th
decades of life
pgmedicalworld.com
40. PATHOLOGY
• Abscess usually large, single and superficial
• Right lobe usually affected
• Fluid interior, inner wall, outer capsule
-Abscess fluid resembles “anchovy sauce”
-Reddish brown due to digested liver tissue
and RBC
-Sterile and odourless
• Inner wall contains trophozoites-biopsy
pgmedicalworld.com
42. CLINICAL FEATURES
• Pain, diarrhoea, cough
• Shock
• Fever and jaundice – less common
INVESTIGATIONS
Laboratory
• LFT abnormalities – less common
• PT increase
• Stool exmn : cyst and trophozoites
-only in 15-50%
pgmedicalworld.com
43. SEROLOGY
• Indirect hemagglutination test/IHA
Gel diffusion precipitin/GDP
• Positive if dilutions exceed 1:128
• Result within 24 hrs
DIAGNOSTIC ASPIRATION
• To r/o PLA when serology is negative
• CI in malignancy and echinococcal cyst
pgmedicalworld.com
44. RADIOLOGY
• USG – Imaging modality of choice
• CT Scan – suspecting PLA
- Positive serological test with
negative hepatic sonogram
• MRI
• Nuclear medicine liver scan
• X-RAY CHEST
pgmedicalworld.com
45. USG of amebic abscess-Note peripheral
location, rounded shape, poor rim with
internal echoes
pgmedicalworld.com
47. CT scan of amebic abscess (A). The lesion is
peripherally located and round. Rim is
nonenhancing but shows peripheral edema (black
arrows). Note the extension into the intercostal
space (white arrows).
pgmedicalworld.com
48. TREATMENT
• ANTIBIOTICS
Most uncomplicated amebic liver abscesses can be treated
successfully with amebicidal drug therapy alone.
After completion of treatment with tissue amebicides, administer
luminal amebicides(diloxanide furoate) for eradication of the
asymptomatic colonization state.
Failure to use luminal agents can lead to relapse of infection in
approximately 10% of patients.
Metronidazole drug of choice for amebic liver abscess (750 mg 3
times a day orally for 10 days)
Alternatives :Emetine(cardiotoxic) ,chloroquinepgmedicalworld.com
49. THERAPEUTIC ASPIRATION
• High risk of abscess rupture, as defined by cavity
size greater than 5 cm/250ml vol
• Left lobe liver abscess, which is associated with
higher mortality and frequency of peritoneal leak
or rupture into the pericardium
• Treatment failure in which pain and fever persists
despite 3 days of antibiotics.
• When metronidazole is CI – pregnancy
• To relieve pressure symptoms
pgmedicalworld.com
50. PERCUTANEOUS DRAINAGE
• Most useful for pulmonary, peritoneal and
pericardial complications
• Risk of secondary infection
pgmedicalworld.com
51. Surgical drainage-Indications
• Left lobe abscess not amenable to percutaneous
drainage
• Life threatening haemorrhage with or without
intraperitoneal rupture of abscess.
• Amoebic abscess eroding into neighbouring
structures
• Septicemia from secondary infection
• Failure of response to conservative therapy
pgmedicalworld.com
52. COMPLICATIONS
• Rupture into peritoneum or thorax
• Abscess eroding into nearby structures
• Secondary infection
• Hemobilia
• Liver failure
• Diaphragm perforation
• Bronchopleural,biliopleural and
biliobronchial fistulas
pgmedicalworld.com
53.
Brownish pus aspirated from gall bladder
adherent to inferior surface amoebic liver
abscess.
pgmedicalworld.com
54. Showing rupture of a left lobe amoebic liver
abscess into pericardium as seen at autopsy
pgmedicalworld.com
56. SUMMARY
• If untreated LA is potentially fatal.
• Must be diagnosed & treated promptly
• Investigations-LFT,USG and CT
• SEROLOGY-corner stone to differentiate
• PLA-Antibiotics plus drainage
• Causative pathology should also be treated
pgmedicalworld.com
57. • 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
pgmedicalworld.com
