liver abscess. occurs when bacteria/protozoa destroy hepatic tissue, produces a cavity which fills...
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LIVER ABSCESS
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Occurs when bacteria/protozoa destroy hepatic tissue, produces a cavity which fills up with infective organisms, liquefied cells & leucocytes. Necrotic tissue then falls off the cavity from rest of the liver.
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Pyogenic abscess Amoebic abscess
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Pyogenic abscess
Male preponderance Average age – between 43 & 60 years Infective organisms invade liver
directly after liver wound or spread from lungs, skin or other organs by hepatic artery, portal vein, biliary tract
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Origin & causes
1) Biliary tract Underlying biliary diseases is the
most common cause; a) Septic cholangitis b) Biliary stenting c) Sclerosing cholangitis d) Cholangio carcinoma
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2) Portal vein Portal pyaemia following pelvic / GI
infection that leads to Portal Pylephlebitis or septic emboli
a) Appendicitis b) Diverticulitis c) Perforated ulcer b) Pancreatitis
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3) Hepatic artery a) Bacterial endocarditis 4) Trauma a) Penetrating wound b) Blunt trauma
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5) Direct a) Perforated peptic ulcer b) Subphrenic abscess c) Adjacent abscess- Perinephric
abscess
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6) Miscellaneous Obscure in 5 % cases Other unusual causes: a) Cysts- Including Polycystic liver
disease) b) Intrahepatic malignancy c) Hydatid cyst
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Bacteriology
Majority derived from GI tract in >75% cases
Aerobic: a) E.coli – most common cause b)Klebsiella pneumoniae c)Others: Pseudomonas
aerogenosa, Morganella morganii, Serratia marsecens, etc.
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Anaerobic: a) Bacteroides fragilis (most
common) b) Others: Fusobacterium spp.,
anaerobic Streptococci, Clostridium spp., Actinomyces spp.
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Based on size & distribution of focal sites;
a) Macroscopic abscess b) Microscopic abscess
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Macroscopic Microscopic
a) Singleb) Restricted to one
lobe
c) Present subacutely with symptoms of several days to weeks’ duration
d) Require primary drainage
a) Multipleb) Widely distributed
throughout the hepatic parenchyma
c) Manifest acutely over a few days
d) Require primary medical treatment with surgery
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Clinical features Symptoms: Fever Abdominal pain Chills Anorexia Weight loss Nausea, Vomiting Right shoulder pain / irritable cough
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Signs: Hepatomegaly Tenderness Rebound tenderness Jaundice (late)
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Histology
Portal zone infection & surrounding hepatocytes, infiltrated with polymorph
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Investigations1) Routine: a) Hb-anemia b) WBC-luecocytosis c) Blood culture – organisms present2) Liver Function test: a) Elevated serum alkaline phosphatase
(most reliable); b) Elevated serum bilirubin (50%) c) Elevated aminotransferases (48%) d) Hypoalbuminemia (33%)
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3) Chest X-Ray: a) Elevation of right hemidiaphragm b) Right basilar infiltrate4) USG: Differentiate as a round or oval area-
hypoechoic fluid filled area5) CT Scan: Cluster sign- seen when multiple small
abscess aggregate, which suggests beginning of coalescence to single abscess
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6) MRI: Raised lesion with sharp borders 7) Aspiration of material: Diagnostic & Therapeutic
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TreatmentStart with empiric antibiotics: Ampicillin Metronidazole GentamicinSpecific antibiotics (Depending on cultures) 6-16 weeksIf persisting Percutaneous drainage (under USG/CT
guidance) Surgical Drainage
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Indications for surgical drainage: a) Abscess with intra-abdominal
pathology requiring surgery b) Ascitis c) Multiple large abscesses d) Abscess which cannot be
drained percutaneously
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Amoebic Abscess
Commonest extra-intestinal presentation of amoebiasis
Common in alcoholics Caused by Entamoeba histolytica Entry by faeco-oral route
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Pathology
Amoeba multiply-block in intrahepatic portal radicles-focal infarction of liver cells-
proteolytic enzymes released- destiny liver parenchyma
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Site: Right lobe of liver, supraanteriorly, just below the diaphragm
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
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Histology
Necrotic area containing degenerated liver cells, leucocytes, RBCs, connective tissue strands, debris & amoeba
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Clinical features
Symptoms: High grade fever with rigor Weight loss Upper quadrant pain ( Initially
dull aching, later on stabbing) Jaundice (not common)
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Signs: Hepatomegaly (tender) Consolidation in right lower zone
of lungs Pleurisy
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Complications
1) Rupture into lung/pleura a) Empyema b) Hepatobronchial fistula c) Pulmonary abscess d) Pneumonitis e) Pleural effusion
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2) Rupture into pericardium3) Intraperitoneal rupture4) Rupture into portal vein (rare)5) Secondary infection
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Investigations
1) Routine: Leucocytosis Anemia2) Liver function test: Increased Alkaline Phosphatase Increased Transaminase3) Stool examination: cysts/
trophozoites
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4) Aspiration: Anchovy sauce pus5) Chest X-Ray Raised fixed diaphragm Right lateral abscess6) USG (most useful) : Round lesion7) CT : Irregular edge8) Serology: ELISA
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Treatment Metronidazole 750mg orally/i.v. 3 daily
x 4 days If response, continue for 10 days;
followed by luminal agents: Iodoquinol 650mg 3 X 20
days Paramomycin 500mg 3 X 10
days
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If no response, Dihydroemetine 1.5mg/Kg
i.m. 4 X 5 days + Chloroquine phosphate
600mg base/day orally 4 X 2 days, then 300mg base/day orally 4 times
If no response to medical treatment: Percutaneous drainage
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Thank You