abcess and fatty liver

8/19/2019 Abcess and Fatty Liver

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KONSEP TERKINIKONSEP TERKINI

NON-ALCOHOLIC STEATO HEPATITISNON-ALCOHOLIC STEATO HEPATITIS(NASH)(NASH)

Bagian Ilmu Penyakit Dalam

RSUD Dr. Adhyatma

Semarang


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• Ludwig (198! "#n Al$#h#li$ Steat#

%e&atiti' (NASH)• I'tilah Lain ) Diabetic Hepatitis

- Fatty Liver Hepatitis

- Alcohol Like Liver Disease• I'tilah 'ekarang Non Alcoholic Fatty Liver

Disease (NAFLD).

•NAFLD (Primer! haru' di*edakan dari'teat#'i' dengan atau tan&a he&atiti'aki*at kau'a lain (NAFLD Sekunder!.


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NAFLDNAFLD

Steat#'i'

+i*r#'i'

Steat# %e&atiti'

,irrh#'i'

-


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Im&lika'i linik "A+LDIm&lika'i linik "A+LD

• Di Amerika meru&akan &enyakit hati

menahun yang *anyak ditemukan

dalam &raktek 'ehari)hari.• au'a ter'ering dari kenaikan

tran'amina'e .

• Da&at *erkem*ang men/adi 'ir#'i' hatidan kar'in#ma he&at#'eluler.


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0&idemi#l#gi0&idemi#l#gi

• +akt#r Ri'ik#

2*e'ita' (3)45! D6 7i&e (1)45!

%i&erli&idemia ()95!

%y&erten'i#n


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Pat#gene'i'Pat#gene'i'• :7w# %it; %ythe'i' (Day < =ame' 1998!

First Hit: Steatosis

Second Hit: Steato Hepatitis

[ Steatotic Liver ]

Fibrosis

irr!osis


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Harisson S"A"# d$$ %&&%


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>am*aran linik dan La*#rat#rium>am*aran linik dan La*#rat#rium

• A'im&t#matik• %e&at#megali

• S>P7 < S>27

• >amma)>7 dan +#'?ata'e alkali

• %ial*uminemia

• @aktu &r#tr#m*in meman/ang

Sir#'i'


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Penemuan %i't#l#giPenemuan %i't#l#gi

• Steat#'i'

• 6ied In?lammat#ry ,ell In?iltrati#n

• %e&at#$yte Ball##ning and "e$r#'i'

• >ly$#gen "u$lei

• +i*r#'i'


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Harisson S"A"# d$$ %&&%


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7era&i7era&i• Belum ada #*at yang da&at mengurangi atau

mem&er*aiki kelainan hi't#l#gi

• 6em&er*aiki k#ndi'i yang *erhu*ungan dengan"A+LD Penurunan *erat *adan

Penanganan dia*ete'

Penanganan hi&erli&idemia

• 6#dalita' +armak#tera&i yang men/an/ikan Citamin 0

Ur'#de#y$h#li$ a$id

Betaine

7hia#lidinedi#ne tr#glita#ne

6et?#rmin

>em?i*r#il


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Ringka'anRingka'an

• "A+LD mem&unyai im&lika'i klinik yaitu da&at*erkem*ang men/adi 'ir#'i'

• Re'i'ten'i in'ulin dan 'tre'' #idati?mem&unyai &eranan &enting dalam &at#gene'i'

"A+LD• Bi#&'i hati teta& meru&akan m#dalita' yang

&aling 'en'iti? untuk in?#rma'i diagn#'i' dan&r#gn#'i'

• Peng#*atan yang e?ekti? *elum ada walau&un*e*era&a ?armak#tera&i men/an/ikan

• 7ran'&lanta'i hati meru&akan tera&i alternati?untuk 'tadium akhir "A+LD


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Petun/uk Prakti'Petun/uk Prakti'

• Pa'ien dengan #*'era'i kenaikan AL7 tan&a&etanda iru' dan riwayat #*at :he&at#t#k'ik;'erta di'ertai #*e'ita'EF) D6 ti&e EF)Di'li&idemia &erlu di&ikirkan "A+LD.

• 7era&i meli&uti mengata'i k#ndi'i yangmenyertai 'erta ?armak#tera&i yang ter*uktiaman 'e&erti UD,A dan Citamin 0.

• Penggunaan #*at untuk mengata'i re'i'ten'i

In'ulin dan anti #k'idan lain ma'ih memerlukan'tudi lan/utan.


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Lier A*'$e'' in ,hildrenLier A*'$e'' in ,hildren

and G#ung Adult'and G#ung Adult'

Presented by

Zulfachmi Wahab, MD-FINASIM


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Intr#du$ti#nIntr#du$ti#n

Tw characters!

" #mmn in de$el%in& cuntries'

" (ni)ue set f %redis%sin& factrs'


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Predisposin' ca(ses o) LiverPredisposin' ca(ses o) Liver

abscessesabscesses


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These include!

" Parasitic Infestations.

" Genetic Disorders.

" Skin infections.

" Protein Calorie malnutrition.

" Abdominal infections.

" Post trauma.


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Parasitic n!estationsParasitic n!estations

" Parasitic infestatins are thu&ht t %redis%se t %y&enicli$er abscesses'

" These include! Ascariasis'

Schistsmiasis

Fasciliasis

Trichuris

Necatr'

Ancylstma'

T*cara'


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"enetic Disorders"enetic Disorders

" + Pa%illn-efer$e syndrme!

Autsmal recessi$e disease' Palm%lantar .eratderma '

Peridntitis'

Py&enic li$er abscess


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" / #hrnic 0rannulmatus Disease!

" Primary immundeficiency disease'

" #an be cm%licated with life threatenin& infectinsincludin& li$er abscesses'

" Fe$er is the mst cmmn %resentin& sym%tm'

" These abscesses are ften recurrent, multi%le anddifficult t treat'


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" Mean a&e f first abscesses is ften mid teens'

" #mmnest micr-r&anism is sta%hylccus thu&h &ram ne&ati$e rds, ncardia and fun&alinfectins are als re%rted'

" 1ften sur&ical resectin is better than %ercutaneus

draina&e'


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" 2 Infectins and li$er abscess has been re%rted inchildren with deficiencies in #+ cm%lement'


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Skin in!ectionsSkin in!ections

" S.in infectins are cmmn in children' These%r$ide a surce f bacteremia and inculatin finfectin in li$er and a resultant %y&enic li$er

abscess'

" Predminant r&anism is Sta%hylcccus aureus'


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Protein #alorie $alnutritionProtein #alorie $alnutrition

" There is a c-relatin between li$er abscesses andmalnutritin in children' i$er abscesses in childrenare rare in de$el%ed cuntries whereas they are

cmmn in de$el%in& cuntries'


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Post trau$aPost trau$a

" Trauma %redis%ses t li$er abscesses bth by directin4ury t li$er r by %r$idin& habitat fr %rliferatinf r&anisms elsewhere'


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*icrobio+o', o) Liver*icrobio+o', o) Liver

abscessesabscesses


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" Sta%hylcccus is the leadin& cause'

" Anaerbes ! u% t 256 f r&anisms'

" 0ram ne&ati$e rds li.e 7' cli and .lebsiella'


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" (nusual infectins !

Fun&al he%atic micrabscesses'

Tubercular li$er abscesses'

Ty%hid fe$er can be assciated he%atic abscesses'

#at scratch disease'

8rucella li$er abscesses'


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Location and nu$ber o! LiverLocation and nu$ber o! Liver

abscessesabscesses " 9+ Mainly! ri&ht lbe f li$er

" eft lbe abscesses are fre)uently assciated with

cm%licatins li.e ru%ture int %eritneum and%ericardium'

" eft sided li$er abscesses re)uire draina&e far mre ften 9:;6 cases when cm%ared t ri&ht sidedlesins'


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" 9/ Mainly! slitary '

" With multi%le li$er abscesses, mrtality may bealmst twice that in slitary cases'


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+inica+ Presentation+inica+ Presentation


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" Fe$er ften with chills' " Abdminal %ain s%ecially in ri&ht u%%er )uadrant'

" Tender he%atme&aly

" Anre*ia, nausea and $mitin&'

" (ne*%lained anemia' " Afebrile %resentatins still can ha%%en'

" 1n the ther hand, li$er abscesses may %resent as

fulminant se%sis r acute abdmen'


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Investi'ationsInvesti'ations


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" #8#! Anemia, leuccytsis and raised 7S


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ImagingImaging

" " May shw!

> 7le$atin f ri&hthemidia%hra&m

> 8luntin& f Fluid le$els belwdia%hra&m in casef &as frmin&r&anisms


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"


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"


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"


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%esolution and !ollo& up o!%esolution and !ollo& up o!

abscess on i$a'in' abscess on i$a'in' (?S is the best fr fllw u%'

The abscess ca$ity ta.es many mnths t finally resl$e

and la&s behind clinical reslutin by mnths'


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7reatment7reatment


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edical therapy edical therapy

" A cmbinatin f anti-sta%hylcccal dru& li.ecl*acillin, an anti-anerbic and an amin&lycsider ce%hals%rin fr &ram ne&ati$e bacilli is a &d

initial chice, and mdified accrdin& t results fcultures'

" Thera%eutic draina&e is needed in :5-56 f cases'

Medical antibitic c$er is additinally re)uired fr a%erid f 2-B wee.s'


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%ole o! aspiration%ole o! aspiration

As%iratin is indicated in slitary, unilcular lesins'Multilculated li$er abscesses can be mana&ed witha&&ressi$e %ercutaneus techni)ues that include

disru%tin f lculatins and %lacement f lar&e brecatheters'


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" Failure is mstly due t technical causes li.e

9a Ina%%r%riate a%%rach int a nn- de%endant%rtin f ca$ity'

9b Failure t rec&ni3e and res%nd t se%tatin'

9c Premature withdrawal f drains' #atheters shuld be withdrawn nce there is ne&li&ible9C+5 ml %usdrain %er day and when %atient is a%yre*ic'


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%ole o! sur'ery %ole o! sur'ery

" Sur&ical draina&e is fr !

" 9a Patients with failed %ercutaneus draina&e'

" 9b Patients wh need additinal mana&ement fr anunderlyin& abdminal %rblem'

" 9c Patients with multi%le macrsc%ic abscesses'

" 9d Patients n sterids'" 9e Patients with ascites'


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*orbidit, and *orta+it,*orbidit, and *orta+it,


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#o$plications #o$plications " Pleur-%ulmnary cm%licatins! %leural effusin,

em%yema, %neumnitis, and he%at%leural r he%at- brnchial fistula'

" Intra%eritneal ru%ture f abscess, %eritnitis andascites'

" Intra%ericardial ru%ture and %ericardial effusin'

" Se%tic shc. '

" @embilia and aundice'

" Perfratins int a hllw $iscus li.e cln, stmachand dudenum'


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ortality ortality

" Facility f ra%id dia&nsis with ima&in&,%ercutaneus draina&e, and better antibitics ha$eim%r$ed sur$i$al'

" With mdern mana&ement ! mrtality less than +;6


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abcess and fatty liver

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