Download MBBS Surgery Presentations 33 Liver Infections Lecture Notes

Download MBBS (Bachelor of Medicine, Bachelor of Surgery) 1st Year, 2nd Year, 3rd Year and Final year Surgery 33 Liver Infections PPT-Powerpoint Presentations and lecture notes


Liver Infections

Dept Of Surgery

? Liver parenchyma is constantly exposed to a low level of enteric

bacteria through the portal blood flow

? However, liver infections are rare

? Liver is the largest repository of the reticuloendothelial system

and is therefore able to cope with this constant barrage.

? When the inoculum exceeds the capacity for control, infection

and abscess occur

? Pyogenic hepatic abscesses constitute over 80% of liver abscesses,

the rest primarily being amoebic in nature
Pyogenic Liver Abscess

Causes

? Transportation of virulent organisms through portal

system from the GI tract

? Trauma
? Spread of infection from the biliary tract (35% cases)
? Blood-borne infection via the hepatic artery
? Extension from a contiguous disease process


Organisms

? The most common organisms cultured from

pyogenic hepatic abscesses are:

? Gram-negative aerobic rods (most commonly Klebsiella and

Escherichia coli)

? Gram-negative anaerobes (Bacteroides fragilis)

? Gram-positive aerobes (Enterococcus, microaerophilic

Streptococcus)
Clinical presentation

? Right upper quadrant abdominal pain
? Fever
? Jaundice
? Nausea/vomiting
? Diarrhoea
? Weight loss
? Progressive fatigue

Lab Abnormalities

? Elevated white blood cell count

? Low haemoglobin

? High alkaline phosphatase

? Transaminase levels can be slightly elevated


Radiological Investigations

? Ultrasonography: sensitivity is 85% to 90%

? Computed tomography (CT) scan: sensitivity is

approximately 95%

? Magnetic resonance imaging

? Chest X ray: may display an elevated right hemi

diaphragm, pleural effusion, or extra luminal air fluid level

Plain abdominal x-ray demonstrating an abnormal col ection of air in the RUQ

consistent with pyogenic hepatic abscess




Treatment

? First, the abscess must be managed, most often with a

drainage procedure.

? Antimicrobial therapy is essential in the treatment of

pyogenic abscesses.

? Second, the initiating process must be identified and

managed to ensure that recurrence is avoided.

Guiding principle for surgical management prevail:

Diagnosis, drug(s), and drainage.
? Once the diagnosis of a single or multiple liver abscess is made,

broad-spectrum parenteral antibiotics should be started.

? Antibiotics alone is given in:

? multiple small abscesses
? low risk of abscess rupture
? lack of toxemia

Clinical response is gauged by defervescence , fall in

leukocytosis , and resolution of symptoms

? Imaging with ultrasonography or CT can be used to assess

resolution of abscess(es).

? Lack of improvement after a reasonable course (10 to 14 days)

indicates failure of treatment.

? Oral antibiotics should be continued for at least 4 weeks after

discontinuance of parenteral antibiotics.

? Worsening of fever, leukocytosis, and symptoms at any time also

indicates failure of treatment and immediately qualifies the

patient for a more aggressive treatment regimen involving a

drainage procedure
? Percutaneous aspiration
Aspirated fluid should be sent for aerobic and anaerobic cultures

? Percutaneous catheter drainage :

? In whom aspiration fails
? Coagulopathy
? Lack of a safe or appropriate access route
? Multiple macroscopic abscesses

In 10% to 15% of cases, percutaneous drainage fails and

intraoperative drainage is required.

? Operative drainage

Indications:

? patients who require laparotomy for the underlying problem

? those in whom percutaneous catheter drainage fails

? patients with contraindications to percutaneous drainage
? Management of Underlying disease

? Sphincterotomy , biliary-enteric bypass, or resection of

liver for ductal obstruction

? Cholecystectomy

? Evacuation of the hematoma (hepatic trauma)

Amoebic Liver Abscess


Pathogenesis

? Cysts containing the parasite are transmitted via the fecal and oral

route.

? Trophozoites are released in the intestinal tract after ingestion of

cysts and then reside primarily in the large bowel.

? Amoebic abscesses in the liver form when the amoebic

trophozoites invade through the colonic mucosa and spread via

venules or lymphatics from the colon to the liver.

? E. histolytica may live within the lumen of the colon and may or

may not be invasive.

? liver is the most common extra intestinal site of amoebic invasion

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

shows peripheral edema (black arrows) with extension into the intercostal

space (white arrow)

Treatment

? Metronidazole remains the drug of choice

? Effective for intestinal as well as extraintestinal

amebiasis

? Dose regimen is 750 mg three times daily for 10 days.

? Chloroquine may be added if defervescence does not

occur in 72 hours or if the patient is acutely ill
Percutaneous aspiration of amoebic abscesses

? bacterial suprainfection is suspected

? pyogenic liver abscess is suspected

? abscess is large and left sided (segments 2 and 3) so that the

risk of rupture into the pericardium is significant.

Laparotomy is indicated for ruptured amebic abscesses into

the pericardium

Rupture into the pleura or pericardium may be treated with

amoebicides and pleuracentesis or pericardiocentesis as

necessary

If laparotomy is performed, a midline incision should be used

Amoebic versus Pyogenic Liver Abscess

? No reliable clinical features exist that are specific for

amoebic versus pyogenic hepatic abscesses

?
? Younger age, recent travel to areas of endemic

amebiasis, diarrhoea, and marked abdominal pain

raise the clinical suspicion of amoebic abscess

? Indirect haem agglutination is the most sensitive and

specific laboratory test
Hydatid Cyst

? Echinococcal species cause hydatid cyst in liver.
? 4 species which can infect humans ?

1. E. granulosus
2. E. multilocularis
3. E. oligrathus
4. E. vogeli


Hydatid cyst

? E. granulosus - most common type infesting

humans. Forms single cyts. Can also infest

lung, peritoneum etc.

? E. multilocularis ? most dangerous. Cause

multiple cysts like locally advanced malignancy.

? E. oligrathus and vogeli are rare. They are

found in south america.

Life cycle
Hydatid cyst

? Humans are accidental hosts.
? Carnivorous or flesh eating animals are

definitive hosts like dogs, wolves.

? Herbivorous animals are intermediate hosts.
? Humans who keep pets are more prone.
? Oro-fecal route or direct inoculation while

pets lick mouth.

Hydatid cyst

? Echinococcus reach liver through entero-

hepatic circulation.

? In liver, oncosphere forms hydatid cyst.
? Three layers ?
1. Outermost or ectocyst- parenchymal reaction.
2. Laminated ? fibrous layer for protection.
3. Germinal layer ? forms daughter cysts.


Hydatid cyst layers

Hydatid cyst

? Complete calcification around it indicates

dead cyst.

? For viability ? intrahydatid cyst pressure

>35cm H2O

? Most common site ? right lobe segment VI

and VI I.

? 1st apperance ? 3weeks later.


Hydatid cyst

Symptoms and signs

? Feeling of lump.
? Dull aching pain RHC.
? Obstructive jaundice.
? Breathlessness or asthma.
? Palpable hepatomegaly with globular lump.
Complications

? Compression ? can stretch glisson capsule and

compress CBD, portal vein, vena cava.

? Cyst infection ? liver abscess formation.
? Rupture into biliry tract ? cholangitis,

cystobiliary fistula.

? Rupture into pleura /brochial tree.
? Peritoneal rupture.
? Rupture into pericardium, duodenum etc.

Lab tests

? DLC shows Eosinophilia.
? Raised bilirubin, Alkaline phosphatase and

GGT ? cystobiliary fistula

? USG abdomen
? CECT abdomen
? Serology ? ELISA , immunoelectrophoresis,

blotting.


Imaging

USG imaging
Imaging signs

? Water-lily sign
? Hydatid sand
? Honey coomb/rosette/spoke wheel

appearance

? Calcification.
? Daughter cysts, brood capsules or

proctoscolicse in cyst.

Treatment

? If <5cm and asymptomatic, serial USG

monitoring 2-3 monthly. Give albendazole 10-

15mg/kg body wt for 4-6 weeks.
PAIR

? PAIR ? percutaneous aspiration, injection and

reaspiration .

? We can inject 20% hypertonic saline, 10%

povidone, 0.5% cetrimide, absolute alcohol as

scolicidal agent.

? Indications ?

? subcapsuler and single cyst.

? Unfit for surgery

? Size >6cm.

Surgery

? Main treatment and best results

? Indications ?

1. Young patients.

2. Multiple cysts.

3. Deep seated

4. Causing obstruction

? Types of suregry ?

1. Radical

2. Conservative
Conservative surgery

? External tube drainage
? Capsulorrhaphy
? Capitonnage
? Omentoplasty
? Internal collapse
? Marsupialization

Radical surgery

? Pericystectomy
? Hepatic resection ? anatomic and non

anatomic.
Pre and post op management

? Give albendazole 400mg 3 weeks before

surgery

? Give albendazole 400mg 4 to 6 weeks post

surgery.

? For E. multiloccularis, post-op albendazole

400mg for 2 years.

This post was last modified on 08 April 2022