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 :

- 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

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