PYOGENIC LIVER ABSCESS

1938: 20 s and 30 s - acute appendicitis

Now : 60 s - biliary tract disease or cryptogenic

Pathogenesis :

- Liver exposed- portal venous bacterial load

clear this bacterial loads-usual circumstances

- Hepatic abscess-inoculum of bacteria- exceeds

-the liver ability to clear it.

Potential route :

1. Biliary tree

2. Portal vein

3. Hepatic artery

4. Direct extension

5. Trauma

Biliary tree :

-Most common

-Biliary obstruction

-Ascending suppurative cholangitis

-Related to stone disease or malignancy

Portal venous system :

-drain the gastrointestinal tract

-ascending portal vein infection

-diverticulitis,appendicitis, pancreatitis .

Hepatic artery :

-Endocarditis , pneumonia, osteomyelitis

-Bacteremie and infection

Direct extension :

-Suppurative cholecystitis, subphrenic abscess,

perinephric abscess, perforation of intestine

Trauma :

-penetrating and blunt trauma

Commonly-no cause found

Pathologic and Microbiology :

-¾ right lobe of liver

-20% left lobe

-5% caudate lobe

-Bilobar-uncommon

-50% solitary

-Size : millimeters-centimeters in diameter

-Appear tan and are fluctuant

-Can cause adhession

-Most common Escherichia coli and

Klebsiella pneumoniae

-Anaerobic organism 40% to 60%

Clinical features :

-Classic description

- fever

- jaundice

- right upper quadrant pain

- tenderness

-Fever and right upper quadrant tenderness40% to 70%

-Jaundice - 25%

-Chest findings- 25%

-Hepatomegaly 50%

-Leucocytosis 70% to 90%

-Chest radiograph-50%

-Ultrasuond and CT - mainstays

-Ultra sound 80% to 90%

-CT - 95% to 100%

Differential diagnosis :

1. Amebic abscess

2. Echinococcal cyst

Treatment :

-before antibiotics and drainage uniformly fatal

-Combination gram negative + gram positive +

anaerobe.

-antibiotics-2 or more weeks

-Percutaneous drainage

-Surgery if percutaneous drainage fails

Amebic abscess :

Pathogenesis

-E.histolitica ---Protozoon-thropozoite or cyst

-Ingestion -cyst- fecal-oral route

-Human are the pricipal host

-Contaminated water and vegetable

-Once ingested cyst not degraded in stomach

pass intestinetropozoite release- passed on to the colon.

In the colon - invade mucosa- desease.

-Trophozoite -liver portal venous system.

Pathology

-Result liquefaction liver tissue

-Anchovy sauce and odorless

-Glisson capsule resistant

-Mainly in the right liver

Clinical Feature

-20s – 40s years

-Travel to endemic area

-Fever, chills, anorexia, right upper quadrant pain,

tenderness and hepatomegaly

-abdominal pain-constant, dull, right upper quadrant

-1/3 diarrhea

-1/3 active amebic colotis

-mild to moderate leukocytosis without eosinophilia

-Anemia is common

-70% do not have detectable amebae in their stool

-Circulating anti amebae antibodies-90%-95%

-Plain chest radiographsbabnormal50% :

- elevated right diaphragm

- pleural effusion

- atelectasis

-Abdominal ultrasound- 90%

-CT more sensitive

Differential Diagnosis

a. pyogenic abscess

b. hydatid cyat

c. viral hepatitis

d. cholangitis

e cholecystitis

f. appendicitis

Management

-Mainstay treatment -metronidazole---

750mg orally three times perday for ten days

curative in over 90%

-Therapeutic needle aspiration

-Operative- rupture