liver abscess complete

1. Dr. (Maj) Ajay Kandpal
MD MEDICINE, DNB MEDICINE
DM PG (Gastro enterology) STANLEY
MEDICAL COLLEGE
CHENNAI, INDIA
kandykilroy@gmail.com

2.  Epidemiology
 Etiology & Pathogenesis
 Clinical features
 Imaging
 Mgt
 Recent advances
 Approach

3.  Sleisenger texbook of Gastroenterology
 WHO guidelines
 AIIMS publication
 Radiology update on liver abscess

4.  Liver abscess is a localized collection of
necrotic inflammatory pus-filled mass in the
liver.

5.  Liver abscess has long been recognized since
the age of Hippocrates (400 BC).
 In 1883, Koch described the amoebae as a
cause of liver abscess, and the first published
review was in 1936 by Bright.
 In 1938, Ochsner and Debakey published the
largest series of pyogenic and amebic liver
abscesses in the literature.

6. Age-related demographics
 Liver abscess was more common in the fourth
and fifth decades of life, primarily due to
complications of appendicitis.
 Currently, frequency curves display a small
peak in the neonatal period due to umbilical
vein catheterization and sepsis, then gradual
rise at the sixth decade of life due to
underlying immune deficiency, severe
malnutrition, or trauma.

7. Sex-related demographics
 Liver abscesses once showed a predilection
for males in the fourth to sixth decade of life
giving a male-to-female ratio of 2:1;
 10:1 ???
 Some authors now say no sexual predilection
currently exists

8. Based on cause :
a) Pyogenic abscess – 80%.
b) Parasitic abscess :
Parasitic protozoa: Entamoeba histolytica10%.
Parasitic helminthes: Hepatic abscess is rarely
associated with it.
c) Fungal abscess – uncommon, most often due to
yeasts (Candida species) and
immunosuppression.

9. Based on the duration of symptoms
 Acute (Less than a month)
 Chronic (Greater than a month)

11. Based on Associated conditions
 Primary Liver Abscess: if patient was
previously healthy
 Secondary Liver Abscess: When associated
with any systemic diseases or risk factors
that could compromise the immune system
such as HIV, infection, Neoplasm etc

12.  Pyogenic liver abscess and parasitic abscess
are common
 Onset and endemecity
 Amebic liver abscess is more prevalent in
individuals with immunosuppression while
pyogenic abscess severity is dependent on
the bacterial source and the underlying
condition of the patient

13. Abscesses involve:
 ~70% of the right hepatic lobe
 20% of the left lobe
 5% of the caudate lobes
 5% of bilateral involvement
The right hepatic lobe is affected more often
than the left hepatic lobe by a factor of 2:1.

14.  More common in Right lobe
 WHY?

15.  Left lobe receives blood from
– Inferior mesenteric
– Splenic veins
 Right lobe receives blood from
– Superior mesenteric
– Portal veins
 Streaming effect in portal circulation is
causative.

16. For pyogenic liver abscess
 Crohn’s disease
 Abdominal or gastrointestinal infection
 Recent abdominal surgery
 Diabetes
For amebic liver abscess
 Poor nutritional status
 Immunosuppression
 Travel to regions where amebic infections are common
 Alcoholism
 Advanced age

19.  Amebic liver abscesses are caused by
Entamoeba histolytica.
 Fungal abscesses are commonly due to
Candida albicans primarily and Aspergillus
species.

20.  Biliary tract is the most common source of
liver abscess and accounts for about 40% of
all cases. It can occur from bile flow
obstruction by biliary stone, benign or
malignancy tumors, postoperative stricture
or congenital
 Hematogenous (via hepatic artery) route
accounts for 20% of cases and results from
seeding of the pathogens into the liver.
Appendicitis and pylephlebitis are the
predominant causes.

21.  Cryptogenic abscesses account for about 20%
and there is increased incidence in patients
with diabetes or metastatic cancer.
 Blunt or penetrating trauma can inoculate
organisms directly into the liver parenchyma,
resulting in pyogenic liver abscess.
 Biliary tract or hematogenous route usually
causes small multiple abscesses.
 Direct infiltration and penetrating injuries
tend to cause a large abscess

22.  The liver receives blood from both systemic
and portal circulations.
 Increased susceptibility due to increased
exposure to infections would be expected.
 Multiple processes have been associated with
the development of hepatic abscesses.
 However, Kupffer cells lining the hepatic
sinusoids clear pathogens so efficiently that
infection rarely occurs

23.  But when pathogens exceed the capacity of
the Kupffer cells, they destroy hepatic
tissue.
 Producing a Necrotic filled cavity, with the
infectious organism, liquefied liver cells and
leukocytes, which walls off from the rest of
the liver forming a liver abscess

24.  Kupffer cells

26. Epidemiology:
 Found worldwide, especially in tropical areas,
 There is no animal reservoir.
Mode of transmission:
 Ingestion of cysts.
 Anal-oral transmission due to sexual practice is
also a consideration.

27.  Pathology: Two-stage life cycle.
The trophozoite (ameba stage) is motile.
The cyst stage is nonmotile.
Trophozoites are found in the intestinal and
extraintestinal lesions.
Cysts predominate in the stools, with some
trophozoites present.

28.  Amebic dysentery: Colonization of cecum &
colon by Entamoeba histolytica is common.
 Localized necrosis results in "teardrop" or
“flask shaped” ulcerations. Invasion into the
portal submucosa is progressive after
penetration of the submucosa.
 Liver abscess:
 Penetration of the diaphragm can lead to
lung disease.
 Most liver disease not preceded by dysentery

34.  E. dispar?
 Why only 10% of amebiasis go into ALA

35.  Pre antibiotic era
 Post antibioic era

36. There is usually a history of:
 Right upper quadrant pain in 80% of cases,
may extend to the left side or referred to
right shoulder especially in amebic abscess.
 Fever (100.4 F either continuous or spiking)
with prominent evening rise
 Chills and rigors
 Profuse sweating
 Nausea with or without vomiting
 Loss of appetite
 Unexplained weight loss
 Dark urine

37.  Diarrhea is present in about 25% of the cases.
 Clay-colored stools
 Dry painful Cough or hiccups (due to hepatic
friction rub associated with diaphragmatic
irritation or inflammation of Glisson capsule)
 Pleuritic chest pain

39.  Toxic /restless
 Pale
 Jaundiced (in about 25% of cases and usually
with biliary tract disease or presence of
multiple abscesses or Liver damage)
 Febrile

40.  There could be tenderness on the right
hypochondrium, epigastrium or intercostal
spaces overlying the liver.
 An epigastric mass (may be found on left-lobe)
 Upward enlargement of the liver which may
cause bulging of the right chest wall with raised
upper level of liver dullness on percussion.
 Dyspnea
 Right pleural effusion, or pulmonary
consolidation
 Decreased breath sounds or crepitations at the
right lung base zones

41.  Multiple abscess 15%
 Left lobe abscess: 35% , wih half having
concomitant rt lobe abscess(Long duration,
less fever, palpable mass)
 Compressive lesion
 Posteriorly loc rt lobe abscess(ascites, pedal
edema, dilated veins)

42. Often delayed, though depends on the combination
of:
 history
 clinical presentation,
 investigation findings,
 radiologic imaging and
 the culture of abscess

43.  CBC
 neutrophilic Leukocytosis,
 anemia of chronic disease
 LFT
 Raised ALP and hypoalbunemia;
 Mild transaminitis
 Blood cultures are positive in identifying the
bacterial agent in roughly 50% of cases.

44.  Microscopic stool examinations for
trophozoites and cysts are performed in 3 to
6 stool samples for concentration and
specificity and are positive in 25% cases.
 WHO recommends that intestinal amoebiasis
should be diagnosed with specific stool E.
histolytica testing (such as cultures, serology,
antigen testing, and Enzyme immunoassay,
hemagglutination tests or PCR) rather than
microscopy for ova and cysts.

45.  Serology is the best method of confirming
the diagnosis of liver abscess.
 Indirect hemagglutination and gel diffusion
precipitation are the most commonly used
tests with 85–95% sensitivity and specificity
detecting antibodies to E. histolytica.

46.  The amebic abscess has Necrotic central
portion that contains a thick, reddish brown,
pus-like material.
 This material has been likened to anchovy
paste or chocolate sauce.

48. The radiographic general rule of liver abscess:
 Bacterial and fungal abscesses are often
multiple, whereas
 Amoebic abscesses are often single though
spread through the diaphragm and into the
chest.

49.  Gas within the abscess cavity,
 Gas in biliary tree (pneumobilia) or
 Gas beneath the diaphragm (elevating the
diaphragm)
 right pleural effusion

50.  Chest radiograph which may show:
 Basilar atelectasis
 Right hemidiaphragm elevation
 Right pleural effusion is present
 Both Computed tomography (CT) and
ultrasonography remain the radiologic modalities of
choice as screening procedures (80-90% sensitive
but non-specific in differentiating pyogenic and
amebic abscesses), although can be used as
techniques for guiding percutaneous aspiration and
drainage.

51.  Intrahepatic abscesses larger than 2 cm
 Hypoechoic round or oval lesions (still with
some internal echoes however), and
irregularly shaped well defined borders
 Limitation in abscesses located in the dome
of the liver and liquefied necrotic area does
not enhance

54.  Round or oval shaped lesion
 Absence of prominent abscess wall
 Hypoechogenicity compared to liver
 Fine low level internal echos
 Distal sonic enhancement
 Contiguity with diaphragm

55.  USG features
 Wheel within a wheel
 Bull’s eye
 Uniformly hypoechoic
 Echogenic

56.  CT scan is superior in detecting abscess (es) as
small as 0.5 cm and reveals the abscess as:
 Lobar involvement
 Solid appearance (mimicking a hepatic tumour)
 Contain gas in 20% of lesions
 Association with thrombophlebitis

58.  Amebic abscess.
(a) Contrast-enhanced CT scan demonstrates a
large, lobulated,well-defined cystic mass in
the right hepatic lobe. Note the enhanced,
thickened wall of the lesion (arrows).
(b) Transverse sonograms show a well-defined
oval subdiaphragmatic mass with increased
through transmission. There are uniform low-
level internal echoes

62.  Delayed-phase contrast enhanced CT scan shows a large,
hypo attenuating lesion in the right hepatic lobe with thin
peripheral enhancement and surrounded by other smaller
hypo attenuating areas (arrows). These smaller abscesses
cluster or aggregate in a pattern that suggests coalescence
into a single large cavity. Pyogenic micro abscesses.
 Arterial phase contrast-enhanced CT scan shows multiple
small hypo attenuating nodules representing pyogenic
micro abscesses scattered throughout the liver. Note the
faint peripheral enhancement (arrow) and perilesional
edema (arrowhead). Faint rim enhancement and
perilesional edema help differentiating them from hepatic
cyst. CLUSTER SIGN

64.  Contrast imaging characterizes lesion, measures the
size of the necrotic area, and depict internal
septations for management purposes.
 Contrast-aided magnetic resonance imaging may
soon become an accurate method for diagnosing
hepatic abscesses as its characteristics findings
include:

65.  T1: hypointense centrally though may be
slightly hyperintense in fungal abscess
 T2: tends to have hyperintense signal
 T1+C (Gd): enhancement of the capsule,
although this may be absent in
immunocompromised patients and multiple
septations may be visible
 DWI: tends to have high signal within the
abscess cavity
 ADC: tends to have low signal within the
abscess cavity

68.  Bull eye morphology
 Uniformly hypoechoic pattern. Multiple
hypoechoic hepatic lesions are present in this
young patient with acute myelogenous
leukemia

69.  Candidiasis. Contrast-enhanced CT scan of
the liver shows multiple hypo attenuating
micro abscesses less than 1 cm in diameter
disseminated throughout the hepatic
parenchyma.
 Axial T1-weighted MR image reveals
relatively hyperintense lesions less than 1 cm
in diameter in the liver (arrows).

72.  Magnetic resonance
cholangiopancreatography (MRC) shows a
voluminous and heterogeneous collection.

77.  Due to delayed onset of treatment, 10–20%
cases of liver abscess rupture and
disseminate into the peritoneum,
pericardium and the brain.
 7–11% complication occurs at the inferior
surface of the liver; where the ruptured
abscess disseminates into the intraperitoneal
cavity leading to peritonitis and peritonitis.

78.  4–7% complication is at the dome of the liver
which could disseminate through the
diaphragm into the pericardium and cause
empyema, pleural effusion, bronchopleural
fistula, pericarditis, Endocarditis.
 1-2% cases develop Brain abscess and
Endophthalmitis especially when an abscess
is associated with Klebsiella pneumoniae.
 Liver failure can also occur

80.  Trauma to the abdomen
 Glucose-6-Phosphate Dehydrogenase Deficiency
 Acute Gastritis
 Intestinal Obstruction
 Biliary Obstruction
 Acute Cholecystitis
 Acute Pancreatitis
 Liver cysts
 Liver metastasis (especially necrotic metastases)
 Bacterial Pneumonia (because of the chest
radiographicfinding)

82.  Institute appropriate antibiotics,
 Drain the pus
 Deal with any underlying source of infection.

83.  This is usually sufficient in treating patients
with good clinical condition and those with
solitary or micro (less than 2 cm) abscess.
 Before identification of the causative
organism, a wide spectrum antibiotic is/are
commenced to treat aerobic and anaerobic
bacilli.

84.  MEDICAL:
Metronidazole 750 mg three times a day for 7 to
10 days is the treatment of choice successful in
95% of cases.

86.  Aspiration of the abscess rarely is needed
 Large abscess having impending rupture
/Compression sign,
 Those who appear to be superinfected.
 Thin rim of liver tissue around the abscess (<10 mm)
 Sero-negative abscesses
 Failure in the improvement following noninvasive
treatment after 4 to 5 days

87.  Abscesses of the left lobe of the liver at risk
for rupture into the pericardium should be
treated with aspiration and drainage

88.  Antibiotics could consist of Cephalosporin,
Aminoglycoside, Metronidazole Or Penicillin .
 Metronidazole (Flagyl) remains the first choice

89.  When the causative organism(s) is/are
identified, the choice of antibiotics is
determined and the antibiotic regimen is
modified to match the patient's sensitivities

91.  Treatment of intestinal carriage
 Luminal amebicidal agent
 Paromomycin
– 25-30 mg/kg/d orally for 7 days in three
divided doses
 Iodoquinol
 Diloxanide furoate

92.  Diloxanide furoate is the drug of choice for
asymptomatic patients with E. histolytica
cysts in the faeces and also given as a 10-day
course for chronic infections.
 Use of amebicidal drugs is indicated in
amebic liver abscess.
 Antifungal drugs may be commenced after
drainage of a fungal abscess.

93.  DRAINAGE
Though not recommended in very small
uncomplicated abscesses (less than 2 cm), it is
the mainstay of the treatment, accomplished
either percutaneously or Open Laparotomy

95. Drainage Options
 Percutaneous
Needle aspiration
Catheter drainage
 Surgical drainage
Open
Laproscopic

96. Percutaneous needle aspiration
 Under CT or USG guidance, needle aspiration
of cavity material can be performed.
 Needle aspiration enables rapid recovery of
material for microbiologic and pathologic
evaluation.
 Large percentage requires second or third
aspirations to achieve success

97. Advantages include
 reduced costs, recovery time,
 it eliminates the need for general anesthesia
This also allows for gradual, controlled
drainage

98. Percutaneous catheter drainage
 A catheter is placed under ultrasonographic
or CT guidance via the Seldinger or trocar
techniques.
 The catheter is flushed daily until output is
less than 10 mL/day or cavity collapse is
documented by serial CT

99. Contraindications to catheter drainage include
 coagulopathy;
 a difficult access path to the cavity;
 peritonitis; and/or
 a complicated, multiloculated, thickwalled
abscess with viscous pus

100. Open laparotomy is the standard care indicated in:
 Multiple abscesses
 Abscess (es) at risk of rupture and complications
 Abscess that is not amenable to percutaneous
drainage because of its location
 Coexistence of intra-abdominal pathology that
requires operative management
 Failure to respond to conservative methods after 72
hours
 Persistent fever (lasting longer than 2 weeks)
 Failure of percutaneous aspiration and drainage
 Abscesses > 5 cm

101.  Surgical drainage
Indications of surgical drainage include:
 Failure of non operative treatment
 Intraperitoneal rupture
 the presence of a complicated, multiloculated,
 thick-walled abscess with viscous pus
 treatment of underlying intra-abdominal
processes,
 peritonitis;
 existence of a known abdominal surgical
pathology (eg, diverticular abscess)

102.  Approaches
 Open
 A transperitoneal approach
– allows for abscess drainage and
– abdominal exploration to identify previously
undetected abscesses and the location of an
etiologic source
 Transpleural approach
– For high posterior lesions,
– easier access to the abscess,
– the identification of multiple lesions or a
concurrent intra-abdominal pathology is lost

103.  The clinical and radiographic progress of the
patient should guide the length of therapy.
 Intravenous medication should be
administered for 14 days, and then replaced
with oral medications to complete a 4-6
week course following adequate drainage.
 Multiple abscesses require up to 12 weeks of
therapy.
 A 10-day course of Diloxanide furoate should
be given at the completion of metronidazole
to destroy any amoebae in the gut.

104. Follow up will include:
 Patients prolonged parenteral medications
that may continue after discharge.
 Monitoring of vital organ functions and
complete blood count will be needed.
 Imaging studies especially in patients with
suboptimal clinical response

105. Long-Term Monitoring
 Weekly serial computed tomography (CT) or
ultrasound examinations to document
adequate drainage of the abscess cavity.
 Maintain drains until the output is less than
10 mL/day
 Monitor fever curves.
 Persistent fever after 2 weeks of therapy
may indicate the need for more aggressive
drainage.

106.  For patients with an underlying malignancy,
definitive treatment, such as surgical removal of
the mass, should be pursued if at all possible.
 Patients on prolonged parenteral antibiotics
monitoring of RFTs and TLC may be needed

107.  With better diagnostic techniques and early
treatment Prognosis is good as abscess
resolves completely within 8 months to 2
years.
 Co-morbidities could alter the prognosis.
 Recurrence is common if pathogen(s)-causing
abscess are not completely eradicated.
 With treatment, (despite co-morbidities)
mortality is less than 15%. But without
treatment, the mortality rate approaches
100%.

108. Indicators of a poor prognosis
 Males
 age > 60 years
 immunosuppression
 blood urea nitrogen > 20 mg/dL,
 serum creatinine > 2 mg/dL,
 total bilirubin > 3.5 mg/dL,
 Hypoalbuminemia (serum albumin level of <2
g/dL),
 chest involvement, cerebral involvement,
encephalopathy and multiple abscesses.

109.  The most common causes of death include
sepsis, multi-organ failure and hepatic
failure. Also mortality has increased
significantly with laparotomy

110.  Prompt treatment of abdominal and other
infections will reduce the risk of developing liver
abscess
 Control of pathogens can be achieved by
educating and exercising proper sanitary
measures and avoiding faecal contamination of
food and water
 Boiling is the only effective means of eradicating
cyst in water.
 Travelers to area with suboptimal sanitation and
hygiene should avoid drinking local water
including ice cubes frequently used for cocktails

111.  Hepatic abscesses are uncommon conditions
that present diagnostic and therapeutic
challenges to physicians. If left untreated,
these lesions are invariably fatal.
 Prevention is aimed at proper sanitation,
personal hygiene, safe food and water.

112.  RF?
 Clinical features
 Can I exclude the DDs
 Imaging assistance
 Am I on right track??
 How should I follow my patient

113.  E. dispar
 Post antibiotic era
 Advances in imaging
 Advances in serology
 Early drainage