LIVER ABSCESS

Dr. B. C. Shrestha
BMCTH
 OBJECTIVES
 Anatomy of liver
 Classification

 Etiology and patho-physiology

 Management
ANATOMY
 CLASSIFICATION

• PYOGENIC
• AMOEBIC
• FUNGAL
• TUBERCULAR (rare)
 EPIDEMIOLOGY

• There is no significant gender, ethnic, or

geographic differences in disease frequency
• Male-to-female ratio is approximately 1.5 to 1
• Comorbid conditions associated with pyogenic
abscess are cirrhosis, chronic renal failure, and
a history of malignancy
 PATHGENESIS
• Routes of hepatic exposure to bacteria are :
 Biliary tree
 Portal vein
 Hepatic artery
 Direct extension of a nearby nidus of infection
 Trauma
 PATHGENESIS
• Routes of hepatic exposure to bacteria are :
 Biliary tree : Biliary obstruction is mostly related
to stone disease or malignancy
 Results in bile stasis with the potential for
subsequent bacterial colonization, infection, and
ascension into the liver
 Other factor : Caroli’s disease, biliary ascariasis,
and biliary tract surgery
 PATHGENESIS
• Routes of hepatic exposure to bacteria are :
• Portal vein : The most common causes are
 Diverticulitis, appendicitis, pancreatitis,
inflammatory bowel disease, pelvic inflammatory
disease, perforated viscus
 Omphalitis in the newborn
 Colorectal malignancy
 PATHGENESIS
• Routes of hepatic exposure to bacteria are :
 Hepatic artery :
 Any systemic infection (e.g., endocarditis,
pneumonia, osteomyelitis) can result in
bacteremia and infection of the liver via the
hepatic artery
 PATHGENESIS

• Routes of hepatic exposure to bacteria are :

 Direct extension :
 Suppurative cholecystitis
 Subphrenic abscess
 Perinephric abscess
 PATHGENESIS
• Routes of hepatic exposure to bacteria are :
 Trauma : Penetrating and blunt trauma can also
result in an intrahepatic hematoma or an area of
necrotic liver, which can subsequently develop
into an abscess
 Pathology and Microbiology

• Most hepatic abscesses involve the right

hemiliver about 75% of cases
• Left liver about 20% of cases
• Caudate lobe about 5%
• Approximately 50% of hepatic abscesses are
solitary but can be multiloculated
 Pathology and Microbiology

• At abdominal exploration, hepatic abscesses

appear tan and are fluctuant to palpation
• Deeper abscesses may not be visible and can
be difficult to palpate
• Surrounding inflammation can cause adhesions
to local structures
 Pathology and Microbiology
• 40 % monomicrobial
• 40 % polymicrobial
• 20 % negative culture
• The most common organisms cultured are Escherichia
coli and Klebsiella pneumoniae
• Other organisms :Staphylococcus aureus, Enterococcus
sp., Streptococcus viridans, and Bacteroides spp
 Clinical features
• Fever, jaundice, and right upper quadrant pain,
with tenderness to palpation only 10% of cases
• Fever, chills, and abdominal pain are the most
common presenting symptoms
 Investigation
 Non specific
 total lymphocyte count: increase leukocytosis
 Increase ESR
 Increase alk phosphate(mild)(67-90%)
 Specific

 Chest x –ray

 Ultrasound of abdomen

 Diagnostic aspiration and culture sensitivity

 CT scan of abdomen
50% of cases, usually demonstrating an elevated right diaphragm, pleural effusion, or
atelectasis
 ULTRASOUND OF PYOGENIC
ABSCESS

Ultrasound usually demonstrates a round or oval area that is

less echogenic than the surrounding liver. Ultrasound can
reliably distinguish solid from cystic lesions sensitivity 80% to
90%
CT SCAN
Lower attenauation and an intense enhancement on
contrast-enhanced CT sensitivity 95% to 100%
 Treatment
Medical
 Broad spectrum antibiotics
triple regime(penicillin , amino glycoside and

Metronidazole)
cephalosporin and Metronidazole

 Specific
 According to culture and sensitivity

 i/v fluids to prevent hepatorenal syndrome

 Analgesic and antipyretics
 Urgent drainage
 Treatment

 To drain or not to drain:

 <5cm, single abscess- needle aspiration or
catheter
 >5cm- catheter
 Also: Surgery, ERCP
 Drainage
 USG guided pig tail catheter drainage

 Open if percutaneous failed

 ERCP in case of obstruction

 AMOEBIC LIVER ABSCESS
 Epidemiology
 M > F 7:1
 10 % world population
 40-50 million amoeba infections/year worldwide
 Age Extremes
 Endemic Areas most susceptible
 Country of origin or Travel
 ETIOLOGY AND PATHOPHYSIOLOGY
 Entemoeba histolytica
 Mode of transmission
 Large intestine (history of dysentery)
 Travel to liver most common superior aspect
near diaphragm through portal vein
 Where proliferates to produce cytolytic enzymes

 Destroy liver tissues

 Abscess which is sterile(anchovy paste or

chocolate sauce
 Amoeba may be found in abscess wall
 Clinical features
 Fever

 Pain Right hypochondrium

 Dysentery

 Tenderness
 Investigation
Specific :
• Chest x-ray
• Ultrasound of abdomen
• Computed tomography of abdomen
50% of cases, usually demonstrating an elevated right diaphragm, pleural effusion, or
atelectasis
USG OF AMEBIC ABSCESS-NOTE PERIPHERAL
LOCATION, ROUNDED SHAPE, POOR RIM WITH
INTERNAL ECHOES

pgme
dical
worl
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 Treatment
• The mainstay of treatment for amebic abscesses is
metronidazole (750 mg orally, three times daily for
10 days), which is curative in over 90% of patients
• Aspiration is recommended for diagnostic
uncertainty
• Failure to respond to metronidazole therapy in 3 to 5
days, or in abscesses thought to be at high risk for
rupture
• Abscesses larger than 5 cm in diameter and in the
left liver are thought to be carry a higher risk of
rupture, and aspiration should be considered
 SUMMARY
 If untreated LA is potentially fatal.
 Must be diagnosed & treated promptly

 Investigations-LFT,USG and CT

 SEROLOGY-corner stone to differentiate

 Pyogenic liver abscess-Antibiotics plus drainage

 Causative pathology should also be treated