Abses Hati

Sigit Widyatmoko
Fakultas Kedokteran
Universitas Muhammadiyah Surakarta

Pyogenic
Abscess

Introduction
Described since age of Hippocrates
In 1883 Koch described the
amoeba as a cause of liver
abscess.
In 1938 Debakey published largest
series in the literature.
Over last 2 decades, percutaneous
drainage has become a
therapeutic option.

Frequency
Uncommon, prevalence in autopsy
series 0.29-1.47%.
Incidence in the US is 8-15 per
100,000.
Male to female ratio is 2:1 in
recent studies.
4th-6th decades of life.

Etiology
Biliary disease accounts for 2130%, with extrahepatic obstruction
leading to ascending cholangitis
and abscess. Also CBD stones,
benign and malignant tumors,
biliary enteric anastamoses.

Etiology
Biliary disease accounts for 2130%, with extrahepatic obstruction
leading to ascending cholangitis
and abscess. Also CBD stones,
benign and malignant tumors,
biliary enteric anastamoses.

Etiology
Infection via portal system:
infectious process originates in
abdomen, reaches liver by
embolization of portal system.
Ex.: appendicitis, diverticulitis, IBD,
proctitis

Etiology
Hematogenous: via hepatic artery,
from systemic septicemia.
No cause in 50% of cases, but
increased in diabetics and
metastatic cancer.

Pathophysiology
Access to liver by direct extension from
nearby organs.
Through portal vein and hepatic artery.
Hepatic clearance of bacteria via portal
system is a normal phenomena, but
organism proliferation, tissue invasion
and abscess can occur with biliary
obstruction, poor perfusion,
microembolization.

Microbiology
Most contain more than one
organism, with source biliary or
enteric.
Blood cultures positive in 33-65%:
E.Coli 33%.
Klebsiella 18%.
Bacteroides 24%.
Streptococcal 37%.

Clinical
Fever, right upper quadrant pain
(80%).
Right shoulder pain, pleuritic chest
pain.
Fever 87-100%.
Anorexia, weight loss, mental
confusion.
Physical exam shows RUQ
tenderness, hepatomegaly, liver
mass, jaundice.

Workup
Lab studies include CBC: anemia in
50-80%, leukocytosis in 75-96%.
LFTs: elevated alkaline
phosphatase 95-100%, elevated
AST, ALT 40-60%.
Elevated bilirubin in 28-73%.
Decreased albumin in 71-87%.

Medical Therapy
Most dramatic change has been CT
guided percutaneous drainage.
Previously, open surgical
procedures had a mortality rate as
high as 70%.
Current approach has three steps.

Medical Therapy
Initiation of antibiotic therapy.
Diagnostic aspiration and drainage
of abscess.
Surgical drainage in selected
patients.

Antibiotic Therapy
Diagnostic aspiration should be
employed prior to antibiotic
therapy.
Coverage should include aerobic
gram negatives, streptococcus,
anerobic, including bacteroides.
Flagyl and clindamycin is usually
good.

Percutaneous Drainage
CT or US guided placement of a
catheter.
Drain is removed once abscess
cavity collapses.
Success 80-87%.
Consider open drainage if fails, or
patient worsens over 72 hrs.

Complications of
Percutaneous Drainage

Perforation of a viscous.
Pneumothorax.
Bleeding.
Leakage of pus into the abdomen.
Immunocompromised patients with
multiple abscesses are best
treated with high dose antibiotics
rather than open or percutaneous
drainage.

Indications For Open

Drainage
Abscess not amenable to
percutaneous drainage
Co-existing intra-abdominal
disease that requires operative
management.
Failure of antibiotic therapy.
Failure of percutaneous aspiration
or drainage.

Complications
Result from rupture of abscess into
adjacent organs or cavities. These
include both pleuropulmonary and
intrabdominal types.
Pleuropulmonary are themost common
15-20%, include effusions, empyema,
bronch-hepatic fistula.
Intraabdominal include subphrenic
abscess, rupture into peritoneal cavity,
stomach, colon, vena cava, or kidney.

Amoebic
Abscess

Introduction
Frequency
Pyogenic(80%): E. coli, K.P
Paracytic(10%): Entamaeba histolytica
Others(10%): candida
-Host immune: Kupffer cell
-Age: 6th-7th decades
-Sex: equal

Clinical Syndromes
Acute phase with prominent symptoms of
< 10 days duration
Febrile and RUQ pain, may be dull or
pleuritic, radiate to the shoulder
Point tenderness over the liver
Right sided pleural effusion are common
Jaundice is rare

Diagnostic Tests

FBE
Aneamia, leukocytosis, eosinophilia

LFTs
Jaundice, hypoalbuminaemia
Elevated AST (acute) and ALP (chronic)

Stool sample
Low sensitivity (only 30% of patients have
concomitant intestinal amoebiasis)

Investigation

Serologic testing: Enzyme immunoassay for

antibodies to E hystolitica
Absence of antibodies after one week of
symptoms almost exclusive of Amoebic liver
abscess
Cannot distinguish between carriage and acute
infection

Treatment

Medical
1. Eradication of invasive trophozoites
Metronidazole 750mg tds (or tinidazole) for
seven days
Clinical recovery usually within 3 days
2. Eradication of colonic carriage with a luminal
amebicidal agent
Paramomycin 500mg tds for seven days, other
agents:
Diloxanide furoate 500mg tds for twenty days
Iodoquinol
10% relapse rate without intestinal eradication

Surgical
1. Aspiration of cyst

To confirm diagnosis (vs pyogenic)

If no response to antibiotic therapy after 5-7d
High risk of rupture (diameter > 5cm, abscess
wall < 10mm)
Left lobe abscess (high rate or rupture at
smaller size into peritoneum or pericardium)

2. Open drainage
Failed percutaneous aspiration
Ruptured cyst with generalized peritonitis

Complications
Liver abscess rupture
Pleuro-pulmonary disease
Bronchopulmonary fistula
Subphrenic abscess
Intraperitoneal rupture
Pericardial rupture
Secondary infection - pyogenic abscess
(usually S. aureus)

Prognosis
Most cases resolve within 7 days of
treatment
Mortality is uncommon but can occur
with abscess rupture

Alhamdulillahi robbil
alamiin