bacteria through the portal blood flow
? However, liver infections are rare
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? Liver is the largest repository of the reticuloendothelial system
and is therefore able to cope with this constant barrage.
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? When the inoculum exceeds the capacity for control, infectionand abscess occur
? Pyogenic hepatic abscesses constitute over 80% of liver abscesses,
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the rest primarily being amoebic in nature
Pyogenic Liver Abscess
Causes
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? Transportation of virulent organisms through portal
system from the GI tract
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? Trauma? Spread of infection from the biliary tract (35% cases)
? Blood-borne infection via the hepatic artery
? Extension from a contiguous disease process
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Organisms
? The most common organisms cultured from
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pyogenic hepatic abscesses are:? Gram-negative aerobic rods (most commonly Klebsiella and
Escherichia coli)
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? Gram-negative anaerobes (Bacteroides fragilis)
? Gram-positive aerobes (Enterococcus, microaerophilic
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Streptococcus)Clinical presentation
? Right upper quadrant abdominal pain
? Fever
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? Jaundice? Nausea/vomiting
? Diarrhoea
? Weight loss
? Progressive fatigue
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Lab Abnormalities
? Elevated white blood cell count
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? Low haemoglobin? High alkaline phosphatase
? Transaminase levels can be slightly elevated
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Radiological Investigations
? Ultrasonography: sensitivity is 85% to 90%
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? Computed tomography (CT) scan: sensitivity is
approximately 95%
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? Magnetic resonance imaging? Chest X ray: may display an elevated right hemi
diaphragm, pleural effusion, or extra luminal air fluid level
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Plain abdominal x-ray demonstrating an abnormal col ection of air in the RUQ
consistent with pyogenic hepatic abscess
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Treatment
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? First, the abscess must be managed, most often with adrainage procedure.
? Antimicrobial therapy is essential in the treatment of
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pyogenic abscesses.
? Second, the initiating process must be identified and
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managed to ensure that recurrence is avoided.Guiding principle for surgical management prevail:
Diagnosis, drug(s), and drainage.
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? Once the diagnosis of a single or multiple liver abscess is made,broad-spectrum parenteral antibiotics should be started.
? Antibiotics alone is given in:
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? multiple small abscesses
? low risk of abscess rupture
? lack of toxemia
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Clinical response is gauged by defervescence , fall inleukocytosis , and resolution of symptoms
? Imaging with ultrasonography or CT can be used to assess
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resolution of abscess(es).
? Lack of improvement after a reasonable course (10 to 14 days)
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indicates failure of treatment.? Oral antibiotics should be continued for at least 4 weeks after
discontinuance of parenteral antibiotics.
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? Worsening of fever, leukocytosis, and symptoms at any time also
indicates failure of treatment and immediately qualifies the
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patient for a more aggressive treatment regimen involving adrainage procedure
? Percutaneous aspiration
Aspirated fluid should be sent for aerobic and anaerobic cultures
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? Percutaneous catheter drainage :
? In whom aspiration fails
? Coagulopathy
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? Lack of a safe or appropriate access route? Multiple macroscopic abscesses
In 10% to 15% of cases, percutaneous drainage fails and
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intraoperative drainage is required.? Operative drainage
Indications:
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? patients who require laparotomy for the underlying problem
? those in whom percutaneous catheter drainage fails
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? patients with contraindications to percutaneous drainage? Management of Underlying disease
? Sphincterotomy , biliary-enteric bypass, or resection of
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liver for ductal obstruction? Cholecystectomy
? Evacuation of the hematoma (hepatic trauma)
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Amoebic Liver Abscess
Pathogenesis
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? Cysts containing the parasite are transmitted via the fecal and oral
route.
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? Trophozoites are released in the intestinal tract after ingestion ofcysts and then reside primarily in the large bowel.
? Amoebic abscesses in the liver form when the amoebic
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trophozoites invade through the colonic mucosa and spread via
venules or lymphatics from the colon to the liver.
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? E. histolytica may live within the lumen of the colon and may ormay not be invasive.
? liver is the most common extra intestinal site of amoebic invasion
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USG showing: peripheral location, rounded shape with poor rim and internal echoes
CT scan of amebic abscess,peripheral y located,round, rim is nonenhancing but
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shows peripheral edema (black arrows) with extension into the intercostal
space (white arrow)
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Treatment? Metronidazole remains the drug of choice
? Effective for intestinal as well as extraintestinal
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amebiasis
? Dose regimen is 750 mg three times daily for 10 days.
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? Chloroquine may be added if defervescence does notoccur in 72 hours or if the patient is acutely ill
Percutaneous aspiration of amoebic abscesses
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? bacterial suprainfection is suspected? pyogenic liver abscess is suspected
? abscess is large and left sided (segments 2 and 3) so that the
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risk of rupture into the pericardium is significant.
Laparotomy is indicated for ruptured amebic abscesses into
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the pericardiumRupture into the pleura or pericardium may be treated with
amoebicides and pleuracentesis or pericardiocentesis as
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necessary
If laparotomy is performed, a midline incision should be used
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Amoebic versus Pyogenic Liver Abscess? No reliable clinical features exist that are specific for
amoebic versus pyogenic hepatic abscesses
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?
? Younger age, recent travel to areas of endemic
amebiasis, diarrhoea, and marked abdominal pain
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raise the clinical suspicion of amoebic abscess
? Indirect haem agglutination is the most sensitive and
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specific laboratory testHydatid Cyst
? Echinococcal species cause hydatid cyst in liver.
? 4 species which can infect humans ?
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1. E. granulosus
2. E. multilocularis
3. E. oligrathus
4. E. vogeli
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Hydatid cyst
? E. granulosus - most common type infesting
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humans. Forms single cyts. Can also infest
lung, peritoneum etc.
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? E. multilocularis ? most dangerous. Causemultiple cysts like locally advanced malignancy.
? E. oligrathus and vogeli are rare. They are
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found in south america.
Life cycle
Hydatid cyst
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? Humans are accidental hosts.
? Carnivorous or flesh eating animals are
definitive hosts like dogs, wolves.
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? Herbivorous animals are intermediate hosts.
? Humans who keep pets are more prone.
? Oro-fecal route or direct inoculation while
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pets lick mouth.Hydatid cyst
? Echinococcus reach liver through entero-
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hepatic circulation.
? In liver, oncosphere forms hydatid cyst.
? Three layers ?
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1. Outermost or ectocyst- parenchymal reaction.2. Laminated ? fibrous layer for protection.
3. Germinal layer ? forms daughter cysts.
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Hydatid cyst layersHydatid cyst
? Complete calcification around it indicates
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dead cyst.
? For viability ? intrahydatid cyst pressure
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>35cm H2O? Most common site ? right lobe segment VI
and VI I.
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? 1st apperance ? 3weeks later.
Hydatid cyst
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Symptoms and signs
? Feeling of lump.
? Dull aching pain RHC.
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? Obstructive jaundice.? Breathlessness or asthma.
? Palpable hepatomegaly with globular lump.
Complications
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? Compression ? can stretch glisson capsule andcompress CBD, portal vein, vena cava.
? Cyst infection ? liver abscess formation.
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? Rupture into biliry tract ? cholangitis,cystobiliary fistula.
? Rupture into pleura /brochial tree.
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? Peritoneal rupture.? Rupture into pericardium, duodenum etc.
Lab tests
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? DLC shows Eosinophilia.? Raised bilirubin, Alkaline phosphatase and
GGT ? cystobiliary fistula
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? USG abdomen? CECT abdomen
? Serology ? ELISA , immunoelectrophoresis,
blotting.
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Imaging
USG imaging
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Imaging signs? Water-lily sign
? Hydatid sand
? Honey coomb/rosette/spoke wheel
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appearance
? Calcification.
? Daughter cysts, brood capsules or
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proctoscolicse in cyst.
Treatment
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? If <5cm and asymptomatic, serial USGmonitoring 2-3 monthly. Give albendazole 10-
15mg/kg body wt for 4-6 weeks.
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PAIR? PAIR ? percutaneous aspiration, injection and
reaspiration .
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? We can inject 20% hypertonic saline, 10%
povidone, 0.5% cetrimide, absolute alcohol as
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scolicidal agent.? Indications ?
? subcapsuler and single cyst.
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? Unfit for surgery
? Size >6cm.
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Surgery? Main treatment and best results
? Indications ?
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1. Young patients.
2. Multiple cysts.
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3. Deep seated4. Causing obstruction
? Types of suregry ?
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1. Radical
2. Conservative
Conservative surgery
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? External tube drainage
? Capsulorrhaphy
? Capitonnage
? Omentoplasty
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? Internal collapse? Marsupialization
Radical surgery
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? Pericystectomy? Hepatic resection ? anatomic and non
anatomic.
Pre and post op management
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? Give albendazole 400mg 3 weeks before
surgery
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? Give albendazole 400mg 4 to 6 weeks postsurgery.
? For E. multiloccularis, post-op albendazole
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400mg for 2 years.