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Management of liver abscess
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- 2. LIVER ABSCESS • 2TYPES -PYOGENIC -AMOEBIC pgmedicalworld.com
- 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 arterialroute –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% -subphrenicabscess -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 inright upper quadrant -Hepatomegaly -Jaundice,right upper quad mass,ascites,pleural effusion pgmedicalworld.com
- 11. IVESTIGATIONS • LABORATORY -Leucocytosis withshift to left WBC count >10000/mm3 -Anaemia PCV <36% -Hypoalbuminemia Albumin <3g/dl -LFT -ALP pgmedicalworld.com
- 12. -Gamma glutamyl transpeptidase -Bilurubin>2 gram/dl -SGOT BLOOD CULTURE Aspiration of abscess and C & S pgmedicalworld.com
- 13. RADIOLOGICAL • X-RAY ABD -Rightupper quad gas, air-fluid level in abscess cavity or ileus pgmedicalworld.com
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- 15. • USG ABDOMEN -usedas a preliminary screen -identify lesions > 2cm in dia -differentiating cystic from solid lesions -diagnosis of gall stones pgmedicalworld.com
- 16. Echo-poor area inthe right lobe of liver pgmedicalworld.com
- 17. Multiple abscess inthe right lobe of liver pgmedicalworld.com
- 18. • CT SCAN -investigationof 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
- 19. Multiloculated abscess inthe right lobe pgmedicalworld.com
- 20. An abscess inthe left lobe pgmedicalworld.com
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- 22. • MRI -lesions assmall as 0.3 cm in dia -best for defining hepatic venous anatomy -useful for patients requiring liver resection pgmedicalworld.com
- 23. • NUCLEAR MEDICINELIVER SCAN Previously used • X-RAY CHEST Right pleural effusion Atelectasis Elevated hemi diaphragm pgmedicalworld.com
- 24. • BARIUM CONTRSTSTUDIES OF UPPER AND LOWER GIT • Endoscopic retrograde cholangiography/ERC • Per cutaneous cholangiography/PTC pgmedicalworld.com
- 25. TREATMENT • An untreatedhepatic 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
- 26. Treatment options •Antibiotics •Aspiration •Percutaneous drainage •Surgicaldrainage. Percutaneous drainage plus i.v antibiotics treatment of choice pgmedicalworld.com
- 27. ANTIBIOTICS • REGIMEN -Broad spectrumsynthetic penicillin -Aminoglycoside/3rd gen cephalosporin -Metronidazole • Aminoglycoside toxicity-aztreonam, imipenem • Penicillin allergy-imipenem pgmedicalworld.com
- 28. • Duration oftreatment must be individualised • iv antibiotics for 2 weeks • Oral antibiotics for 1 month pgmedicalworld.com
- 29. Multiple abscesses aremore 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 inyoung , 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 • Mustbe 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 SELDINGERTECHNIQUE • 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 • EXPLORATORYLAPAROTOMY -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 PERITONEALAPPROACH -subcostal -transpleural -retroperitoneal . Used only for selected abscesses located superiorly in liver dome pgmedicalworld.com
- 35. • TRANSPERITONEAL APPROACH -StandardRx 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 -Limitedrole -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 byEntamoeba 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 usuallylarge, 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
- 41. Bottle of anchovysauce and amoebic pus 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 hemagglutinationtest/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 amebicabscess-Note peripheral location, rounded shape, poor rim with internal echoes pgmedicalworld.com
- 46. CT showing superficialabscess pgmedicalworld.com
- 47. CT scan ofamebic 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 uncomplicatedamebic 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 • Highrisk 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 • Mostuseful for pulmonary, peritoneal and pericardial complications • Risk of secondary infection pgmedicalworld.com
- 51. Surgical drainage-Indications • Leftlobe 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 intoperitoneum or thorax • Abscess eroding into nearby structures • Secondary infection • Hemobilia • Liver failure • Diaphragm perforation • Bronchopleural,biliopleural and biliobronchial fistulas pgmedicalworld.com
- 53. Brownish pus aspiratedfrom gall bladder adherent to inferior surface amoebic liver abscess. pgmedicalworld.com
- 54. Showing rupture ofa left lobe amoebic liver abscess into pericardium as seen at autopsy pgmedicalworld.com
- 55. Amoebic liver abscessruptured into pleural space pgmedicalworld.com
- 56. SUMMARY • If untreatedLA 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 casestreated 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
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