Abscess of liver

ABSCESS OF LIVER

Level of competence 4

2 types :Right lobe (65%)Both lobes (30%)Left lobe (5%)

Right lobe (65%)Both lobes (30%)Left lobe (5%)

ETIOLOGIES

AmebicBile is lethal to amebas, thus infection of gall bladder & bile

duct do not occur

PATHOPYSIOLOGY

AMEBICBile is lethal to amebas → infection of

gallbladder or bile duct do not occur

Pathophysiology• Ingestion contaminated water or

food containing E. histolytica cysts - infective cyst form of the parasite survives passage through the stomach and small intestine.

• Excystation occurs in the bowel lumen, where motile and potentially invasive trophozoites are formed.

• In most infections the trophozoites aggregate in the intestinal mucin layer and form new cysts, resulting in a self-limited and asymptomatic infection.

In some cases, adherence to and lysis of the colonic epithelium, mediatedby the galactose and N-acetyl-D-galactosamine (Gal/GalNAc)–specific lectin, initiates invasion of the colon → neutrophils responding to the invasion contribute to cellular damage.

Once the intestinal epithelium is invaded, extraintestinal spread to the peritoneum, liver, and other sites may follow.

CLINICAL MANIFESTATIONPYOGENIC AMEBIC

Nonspesific, fever (absent in 30%), chills, RUQ pain (45%), malaise, weight lose

More severe RUQ pain, fever 90% cases

Dominate by underlying disease : appendicitis, diverticulitis, biliary disease

Recent travel to endemic area, but maybe remote

Comorbid common : DM, malignancy, alcholism, cardiovascular, chronic renal disease

Previous colonic amebiasis (only 5-15%), concurrent hepatic abcess & amebic dysenteri are unusual

Eosinophilia, high bilirubin, blood culture + 50%, aspirates + bacteria 75-90%

Most aspiration does not yield an organism (tropozoite < 20%); odorless, serologic + only invasive amebiasis, negative asymptomatic carrier, gel diffusion precipitin (best test)

Laboratory & Diagnostic

• Routine lab not diagnostic for both abcess : WBC (↑), anemia (normocytic normochromic), sed rate (↑)

• LFT nonspesific : 90% high AP, AST/ALT ↑ but to a lesser degree, low albumin (<2mg%) poor prognostic

• CXR : 50-80% abnormal (RLL atelectasis, R pleural eff, R hemidiaphragm elevation)

• U/S initial test of choice : noninvasive, high sensitivity 80-90%; to distinguish cyst from solid lesion/visualizing biliary tree

• CT (IV contrast) : smaller abcess, asses peritoneal cavity

ASPIRATE• Pyogenic (multipel

abcess, coexistent biliary disease, intraabdominal inflammatory process)

• Non amebic

• Amebic aspiration : pyogenic can’t be roled out, respond to amebic therapy has not occurred within 24-48 hours, abcess is large (size greater than 5 cm) & painful

• Surgical drainage of amebic abcess : located in left lobe, respon therapy is not dramatic in 4-5 days

TREATMENT• Antibiotic : aminoglicoside/

cephalosporin (gram -), clindamycin/metronidazole (anaerobes), penicillin/ampicillin (enterococci)

• Surgery percutaneus drainage : conservative measure fail, to treat primary intraabdominal lesion

76% cure rate, 60% either alone

• Metronidazole drug active against extraintestinal form of amebiasis : 750mg TID x 10 days

• Eradicates intestinal form : iodoquinol 650mg TID x 20 days

• Consider aspiration if failing therapy

PYOGENIC PYOGENIC

AMEBIC AMEBIC

CoMPLICATION & PROGNOSISPYOGENIC AMEBIC

Untreated 100% mortality Rapid clinical improvement is observed in less than 1 week with antiamebic drug therapy alone

Ruptur into peritoneal cavity : subphrenic, perihepatic, subhepatic abscesses or peritonitis; metastatic ruptur emboli (lung, brain)

similar

Left lobe abscess : cardiac tamponade, pericarditis

Abscess in dome of liver or complicated by bronchopleural fistula

Depends on rapidity diagnosis & underlying illness

Generally do well with treatment

Morbidity high (50%), mortality 5-10% (prompt recognation & adequate AB) higher in multipel abscesses

Morbidity 4.5%, mortality 2.2%

Independent risk factors predicting a higher mortality

– Bilirubin level greater than 3.5 mg/dL– Encephalopathy– Volume of abscess cavity greater than 500 mL at presentation– Serum albumin less than 2 g/dL– Hemoglobin less than 8 g/dL– Multiple abscesses