LIVER ABSCESS

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.

Pyogenic abscess Amoebic abscess

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

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

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

3) Hepatic artery a) Bacterial endocarditis 4) Trauma a) Penetrating wound b) Blunt trauma

5) Direct a) Perforated peptic ulcer b) Subphrenic abscess c) Adjacent abscess- Perinephric

abscess

6) Miscellaneous Obscure in 5 % cases Other unusual causes: a) Cysts- Including Polycystic liver

disease) b) Intrahepatic malignancy c) Hydatid cyst

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.

Anaerobic: a) Bacteroides fragilis (most

common) b) Others: Fusobacterium spp.,

anaerobic Streptococci, Clostridium spp., Actinomyces spp.

Based on size & distribution of focal sites;

a) Macroscopic abscess b) Microscopic abscess

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

Clinical features Symptoms: Fever Abdominal pain Chills Anorexia Weight loss Nausea, Vomiting Right shoulder pain / irritable cough

Signs: Hepatomegaly Tenderness Rebound tenderness Jaundice (late)

Histology

Portal zone infection & surrounding hepatocytes, infiltrated with polymorph

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%)

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

6) MRI: Raised lesion with sharp borders 7) Aspiration of material: Diagnostic & Therapeutic

TreatmentStart with empiric antibiotics: Ampicillin Metronidazole GentamicinSpecific antibiotics (Depending on cultures) 6-16 weeksIf persisting Percutaneous drainage (under USG/CT

guidance) Surgical Drainage

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

Amoebic Abscess

Commonest extra-intestinal presentation of amoebiasis

Common in alcoholics Caused by Entamoeba histolytica Entry by faeco-oral route

Pathology

Amoeba multiply-block in intrahepatic portal radicles-focal infarction of liver cells-

proteolytic enzymes released- destiny liver parenchyma

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

Histology

Necrotic area containing degenerated liver cells, leucocytes, RBCs, connective tissue strands, debris & amoeba

Clinical features

Symptoms: High grade fever with rigor Weight loss Upper quadrant pain ( Initially

dull aching, later on stabbing) Jaundice (not common)

Signs: Hepatomegaly (tender) Consolidation in right lower zone

of lungs Pleurisy

Complications

1) Rupture into lung/pleura a) Empyema b) Hepatobronchial fistula c) Pulmonary abscess d) Pneumonitis e) Pleural effusion

2) Rupture into pericardium3) Intraperitoneal rupture4) Rupture into portal vein (rare)5) Secondary infection

Investigations

1) Routine: Leucocytosis Anemia2) Liver function test: Increased Alkaline Phosphatase Increased Transaminase3) Stool examination: cysts/

trophozoites

4) Aspiration: Anchovy sauce pus5) Chest X-Ray Raised fixed diaphragm Right lateral abscess6) USG (most useful) : Round lesion7) CT : Irregular edge8) Serology: ELISA

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

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

Thank You