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Liver Abcess Dr.dr. H. Chudahman Manan SpPD-KGEH
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CLASSIFICATIONSPYOGENICGram PositiveGram NegativeAnaerobic(Polymicrobial)
AMEBIC
CANDIDA
TB (rare)
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EPIDEMIOLOGYPyogenic AbscessesBacterialMost common M > F 3:1
EntamoebaM > F 7:140-50 million amoeba infections/year worldwideAge ExtremesEndemic Areas most susceptibleCountry of origin or Travel
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RISK FACTORSPYOGENICDMCancerLiver Transplant
ENTAMOEBAPregnancySteroidsCancerEndemic area travel (short or long term)EtOH?
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PATHOPHYS.PYOGENIC:PeritonitisTo liver via portal circulation
Direct SpreadBiliary infections
Hematogenous SeedingLook for bacteremia!
Sites: R lobe most commonBlood supply
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PATHOPHYS.ENTAMOEBA:Fecal-Oral transmission into GI TractTo liver via portal circulation
Can also spread to other extraintestinal sitesHeartBrainLungs
- CLINICAL MANIFESTATIONSSYMPTOMSFever (90%)RUQ pain (50-75%)Constitutional SxDiarrhea (
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WORKUPCBC (leukocytosis)
LFTs AlkPhos elevated (67-90%)AST/ALT elevated (50%)TBili elevated (50%)
Blood CulturesBacteremia (50%)E Histolytica AbEchinococcus Ab
Imaging- US, CT, MRICan not differentiate types of abscess
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ULTRASOUND
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CT/MRIFluid Collection w/ surrounding stranding, edema, and inflammation
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DIAGNOSTIC PROCEDURE***IMAGING-GUIDED DRAINAGE******SEND FOR CULTURE***
- WHAT MAY GROWPOLYMICROBIAL (including anaerobes)GRAM NEGATIVES (think gut bugs)E. HistolyticaMoney is in the serum Ab (95%)Less yield with wet-mount of abscess or fecal microscopy (
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TREATMENTTO DRAIN OR NOT TO DRAIN:5cm- catheterAlso: Surgery, ERCP
Amoeba: drainage not usually requiredExceptions:Verge of ruptureAbx not workingImminent need to exclude other dx
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TREATMENT-ABXPyogenic: Gram Neg + Anaerobe cov.UnasynZosyn3rd gen Ceph (Rocephin) + FlagylPCN Allergy: FQ + Flagyl, Carbapenem
Course: 4-6 weeksIV duration depends on f/u imagingSuitable PO Abx: Augmentin OR FQ + Flagyl
Amoeba: Flagyl 500-750mg TID 7-10daysThen follow with lumenal antiamebicUsually Paromomycin TID 10d
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PROGNOSIS & NATURAL HISTORYMortality 2-12%Often due to comorbidities, not necessarily abscess itself
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SummaryThink Pyogenic (usually gram neg/anaerobe) or E.HistolyticaBroad Spectrum Abx at firstImage Image ImageImaging-Guided Culture +/- JP DrainTreat for 4-6 weeks
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