Nasir khan

A liver abscess is a pus-filled cavity within the liver

Types Amoebic liver abscess

Pyogenic liver abscess

Amoebic liver abscess

Caused by ent histolytica
Carried from bowel to liver in portal venous system More common in adult male

Abscess are usually large single and present in right

upper lobe

Pathophysiology
fecal-oral route excystation in the small bowel and invasion of the colon by

the trophozoites. Invasive disease begins with the adherence of E histolytica to colonic mucins, epithelial cells, and leukocytes. Adherence of the trophozoite is mediated by a galactoseinhibitable adherence lectin.

Cont ..
After adherence, trophozoites : invade the colonic epithelium to produce the ulcerative lesions typical of intestinal amebiasis . lyse the target cells by using lectin to bind to the target cells' membranes and using the parasite's ionophore like protein to induce a leak of ions (i.e, Na+, K+, Ca+) from the target cell cytoplasm. An extracellular cysteine kinase causes proteolytic

destruction of the tissue, producing flask-shaped ulcers

Cont ..
Spread of amebiasis to the liver occurs via the

portal blood. Trophozoites ascend the portal veins to produce liver abscesses filled with acellular proteinaceous debris. This material has the appearance of anchovy paste. The trophozoites of E histolytica lyse the hepatocytes and the neutrophils.

Cont.. Amebic liver abscess is the most common form of extraintestinal amebiasis.
It results from spread of the organisms from

the intestinal submucosa to the liver via the portal system. Approximately 40% of patients who have amebic liver abscess do not have a history of prior bowel symptoms. 5% of patients with symptomatic intestinal amebiasis and is 10 times as frequent in men as in women.

Cont ..
presents with fever and a constant, dull, upper right

abdominal or epigastrium pain. Involvement of the diaphragmatic surface of the liver may lead to right-sided pleuritic pain or referred shoulder pain. : occur in 10-35% of patients and include nausea, vomiting, abdominal distention, diarrhea, and constipation. May present with vague abdominal discomfort, weight loss, and anemia.

Associated GI symptoms

Pain and fever

Initially dull in right hypochindrium later becomes

sharp and stabing. Referred to tip of right or left shoulder and may increase by dep inspiration or coughing Fever initialy high later remittent or intermittent rigors may occur

Examination
Ill looking ,toxic and febrile
Enlarged tender liver liver is palpable and severely

tender Jaundice is usually absent Local edema of chest or abdominal wall may present Compression test pain on firm pressure with findertips on intercostel space over a limited area is common and valuable in localizing the puss

complications
Basal pneumonia of right side
Rupture into plueral space Hepathobronchial fistula may cause productive cough

containing necrotic material and may contain amoeba Rupture into peritoneum present as acute abdomen Rupture into pericardum

Pyogenic liver abscess

Thy are uncommon but important because they are

potentialy curable inevitably fatal if untreated Mortality is 20 to 40% and failure to diagnose is the most common cause Older patient and those with multiple abscess also have high mortality rates

Causes
Billiary obstruction cholingitis
Hematogenous

portal vein mesenteric infection hepatic artery bacteraemia Truama penetrating or non penetrating Infection of liver tumor or cyst

Organisms
E coli most common
Strep fecalis Proteus vulgaris

Anaerobes such as bacteriods

S aures occasionally

Clinical feature
Are similar to amebic liver abscess

Investigation
CBC showing leucocytosis with predominance of neutrophils LFT s serum bilrubin is raised in 50% of cases serum alkaline

phosphatase raise in 90% of cases and serum ALT in 48% of cases and serum albumin is often low Stool D R may show amoeba X ray chest showing right side of diaphram raised and may be right side consolidation and pleural effusion Ultrasound is investigation of first choice CT scan and MRI may b required Indirect hemaglutination test for detection of antibodies is positve in 95% of patient diagnostic aspiraton of fluid sent for gram stainaing and culture

Treatment of amebic liver abscess

Metronidazole 800 mg 8 hourly orally for 10 days 90% of patient respond within 72 hours with reduce pain and fever Diloxanide furate tab entamizole DS 500 mg 3 times daily for 10 days to eliminate intestinal infections Aspiration of liver abscess

Indication of aspiration
Failure to response clinically in 3 to 5 days
Threat of imminent rupture Need to rule out pyogenic abscess

Left lobe abscess

Large abcess more than 10 cm

Procedure
A wide bore needle is inserted into area of maximum

tendreness or into 8th or 9th intercostal space in midaxillary line All available fluid should be removed Ultrasound guided procedure may be performed

Treatment of pyogenic liver abscess

Prolonged antibiotic and drainage of abscess Associated billiary obstruction and cholingitis

required biliary drainage preferably endoscopicaly 3rd generation cephalosporinsuch as cefataxime inj. claforan 1 gm 8 hourly plus metronidazole inj. flagyl 500 gm 8 hourly If cost is problem then use Ampicillin inj. penbtrin 500 gm 6 hourly Gentamicin inj. gentacin 80 gm 8 hourly Metronidazole

Aspiration
Aspiration is required if
abscess is large in size or does not respond to antibiotics