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  • MANAGEMENT LIVER ABSCESS

    dr. Samuel Sampetoding, SpB-KBD

    Department of Surgery Faculty of Medicine, Universitas Hasanuddin,

    Wahidin Sudirohusodo Hospital, Makassar

  • LIVER ABSCESS?

     is an encapsulated collection of suppurative

    material within the liver parenchyma,

    infected by bacterial, fungal, and/or

    parasite

    pyogenic liver

    abscess

    (PLA)

    amebic liver

    abscess

    (ALA)

    Beal E. Schackelford's Surgery of the Alimentary Tract Vol.2 (2019). 1430-1445

    Figure 1. Liver Abscess Huston CD. Sleisenger and Fordtran's Gastrointestinal and Liver Disease (2016)|133

  • LIVER ABSCESS?

    Abses Hepar

    Pyogenik

    (PLA)

    Abses Hepar

    Amoebik

    (ALA)

    Beal E. Schackelford's Surgery of the Alimentary Tract Vol.2 (2019). 1430-1445

    10th century

    20th century

    over the past 100 years has

    seen fairly dramatic changes

    in demographics, etiology,

    diagnosis, and treatment.

    ↑ immunosuppression

    ↑ Liver Abscess

    incidence

    2.3 - 275.4 cases per 100.000

  • TYPES OF ABSCESS

    Fig. 1. The gray areas. Depicts a comparison of the sub-groups of HA and also delineates the areas of overlap between them. Journal of

    Clinical and Translational Hepatology 2016 vol. 4 | 158–168

  • ETIOPATHOGENESIS

    Fig. 2. Routes of infection. Journal of Clinical and Translational Hepatology 2016 vol. 4 | 158–168

    PLA ALA Pathogen:

    • Escherichia coli

    • Klebsiella pneumonia  DM

    • Streptococcus constellatus 

    immunocompetent

    Pathogen:

    • Entamoeba hystolitica

    • Related to nutritional

    status & poor sanitation

    Beal E. Schackelford's Surgery of the Alimentary Tract Vol.2 (2019). 1430-1445

  • Infectious Abscess

    Figure 2. Organisms isolated from all positive cultures.

    Serraino et al. Medicine (2018) 97:19

  • ETIOPATHOGENESIS

    Beal E. Schackelford's Surgery of the Alimentary Tract Vol.2 (2019). 1430-1445

    Tabel 1 Etiology of PLA

  • RISK FACTORS Table 1. Risk factors for development of hepatic abscess (HA) and

    increased mortality from HA

    Increased risk of

    developing HA

    Increased mortality

    from HA

    Diabetes mellitus Malignancy

    Liver cirrhosis Diabetes mellitus

    Immune-compromised

    state Liver cirrhosis

    Use of PPI Male gender

    Advanced age19 Multiorgan failure16

    Male gender*16 Sepsis

    Infection with mixed

    organisms

    HA rupture

    Abscess size > 5 cm

    Respiratory distress

    Hypotension

    Jaundice

    Extrahepatic involvement16

    *Diabetes mellitus, liver cirrhosis and male gender are risk factors for both

    development and increased mortality of HA.

    Journal of Clinical and Translational

    Hepatology 2016 vol. 4 | 158–168

  • CLINICAL PRESENTATION

    Beal E. Schackelford's Surgery of the Alimentary Tract Vol.2 (2019). 1430-1445

    1

    Early presentation  non spesific

     predormal symptomps: weight

    loss, fever, fatigue, malaise, anorexia, and myalgia.

    2

    Classic triad 

    • right upper quadrant pain

    • fever or chills

    • generalized malaise

    3 Others 

    • hepatomegaly • jaundice

    1 Asymptomatic >>>

    2

    Sub-acute 

    • mild diarrhea to severy dystery

    • abdominal pain

    3 Others 

    • high grade fever • RUQ pain

    • History of gastroenteritis

    • Jaundice (uncommon)

    PLA ALA

  • CLINICAL PRESENTATION

    Beal E. Schackelford's Surgery of the Alimentary Tract Vol.2 (2019). 1430-1445

    Tabel 2 Clinical Presentation of PLA

  • DIAGNOSIS (PLA)

    Beal E. Schackelford's Surgery of the Alimentary Tract Vol.2 (2019). 1430-1445

    it's non-spesific • WBC↑

    • Hypoalbuminemia

    • Transaminase &

    alkaline phospate ↑ • Bilirubin ↑

    Lab

    Table 3 Laboratorium of PLA

  • DIAGNOSIS

    Beal E. Schackelford's Surgery of the Alimentary Tract Vol.2 (2019). 1430-1445

    • elevated right

    diaphgrama

    • air fluid level w/ gas

    forming

    subdiaphragmatica

    • pleular effusion

    • athelectasis

    CXR

    2

    USG

    3

    • hypoechoic and

    varying degrees of

    internal echogenicity

    • low opacity, reveal rim

    and internal

    septations

    enhancement

    CT

    Scan

    3

    MRI

    4

    • hyperintense on T2-

    weighted images and

    hypointense on

    noncontrast T1-

    weighed images, by

    gadolinium

    demonstrate similar

    enhancement on CT

    RADIOLOGIC

  • DIAGNOSIS

    Journal of Clinical and Translational Hepatology 2016

    vol. 4 | 158–168

    3 .

    4.

    Figure 3. Ultrasound (US). A. US demonstrates a hypoechoic abscess with heterogeneous echogenicity centrally consistent with

    septations and internal debris (blue arrow). B. Color Doppler US demonstrates peripheral hypervascularity surrounding the abscess

    cavity.

  • DIAGNOSIS

    Journal of Clinical and Translational Hepatology

    2016 vol. 4 | 158–168 4.

    Figure 4 Dynamic contrast-enhanced computed tomography (CT). A. Late arterial phase CT demonstrates hypervascular, peripheral enhancement of the abscess seen in Figure 4 (blue arrow). B. Portal venous phase CT demonstrates conspicuity of internally enhancing septations (blue star), likely representing intervening hepatic

    parenchyma. Note the multilocular nature of the abscess, which has implications for potential treatments (blue arrows).

  • DIAGNOSIS

    Journal of Clinical and Translational Hepatology 2016 vol. 4 | 158–

    168

    4.

    Figure 5. Magnetic resonance imaging (MRI).

    A. T2-weighted image demonstrates multiple (at least six) small hyperintense abscess cavities

    in the right hepatic lobe (blue arrows). Note the hyperintense, edematous hepatic

    parenchyma (blue star). B. Noncontrast T1- weighted fat-sat image demonstrates varying

    degrees of T1 hyperintensity in the abscess cavities consistent with proteinaceous debris.

    C. Postcontrast T1- weighted fat-sat image demonstrates peripheral or rim enhancement

    around each of the abscesses.

  • TREATMENT

    4.

    Fig. 10. Treatment strategies*. *Adapted from Hope WW, Vrochides DV, Newcomb WL, Mayo-Smith WW, Iannitti DA. Optimal treatment of hepatic abscess. Am Surg

    2008;74:178-182.

    Journal of Clinical and Translational Hepatology 2016 vol. 4 | 158–168

  • DRUG THERAPY FOR PLA

    4. Beal E. Schackelford's Surgery of the Alimentary Tract Vol.2 (2019). 1430-1445

    1 Effective for small abscesses, < 3–5 cm in diameter and smaller abscesses in

    difficult anatomical positions

    2 Soon as blood obtained for identification of organisms, usually

    accomplished a third-generation cephalosporin plus metronidazole or

    piperacillin/tazobactam

    3 Recommendation: empiric coverage for gram-negative bacilli, gram-

    positive cocci, as well as anaerobic

    • 3 weeks IV followed 1–2 months PO, or

    • 2–3 weeks IV followed 1–2 weeks PO

    4 Treatment duration depends on response, as determined by repeat US, and

    resolution of fever and leukocytosis

  • DRUG THERAPY FOR ALA

    4. Beal E. Schackelford's Surgery of the Alimentary Tract Vol.2 (2019). 1430-1445

    1 Effective for uncomplicated amebic hepatic abscess

    2

    3

    Both amebic colitis and liver abscess—nitroimidazole derivatives (e.g., metronidazole)

    Amebic colitis—luminal agents such as paromomycin, diloxanide furoate,

    iodoquino

  • PERCUTANEOUS DRAINAGE

    4. Beal E. Schackelford's Surgery of the Alimentary Tract Vol.2 (2019). 1430-1445

    1 PD is most common first-line treatment by 16-18 Ga needle aspiration or insertion of 8-14 F pigtail catheter drain under US or CT guidance

    2 Benefits: minimally invasive procedure, no need for GA, lower risk of

    adhesion formation, contamination, and lower cost in comparing with surgical

    3 Failures: multiloculated, catheter blockage by viscous fluid and necrotic

    tissue, hypoalbuminemia significant risk

    4 Complications: haemorrhage and biliary fistula

    5 PD indication for ALA: deterioration in clinical condition despite adequate

    treatment, bacterial superinfection, abscess with high risk of rupture

  • CURRENT UNIT PROTOCOL FOR THE MANAGMENT OF DRAINS PLACED

    Liver abscess: contemporary presentation and management in a Western population 23rd February 2018, Volume 131 Number 1470

  • SURGICAL

    4. Beal E. Schackelford's Surgery of the Alimentary Tract Vol