Liver abscess

 Liver Abscess 

    Collection of pus in the liver parenchyma is called liver abscess . Liver is the organ commonly involved in the development abscesses . It may be solitary or multiple .Amoebic abscesses are single and pyogenic abscesses are multiple .

Fig : liver Abscess 

Types of liver abscess 

(a) Amoebic liver abscess 

(b) Pyogenic liver abscess 

(a) Amoebic liver abscess 

        Amoebic liver abscess are caused by Entamoeba histolytic infection . It occurs particularly in endemic areas and often without history of recent diarrhea . It is usually found in the right lobe of liver . 

Pathogenesis 

       The vegetative trophozoite form of amoebae in the colon invade the colonic mucosa forming flask- shaped ulcer from where they are carried to the liver in the portal venous system. Amoebae multiply and block small intrahepatic portal radicals resulting in infraction necrosis of the adjacent liver parenchyma , and form liver abscess . 

Clinical features C/F 

Early symptoms : Anaemia , loss of weight ,malaise .

Abdominal discomfort, nausea,vomiting 

Enlarged tender liver .

Swinging temperature and sweating, jaundice .

Cough and pain in the right shoulder . 

Features of right sided pleural effusion. 

Investigations 

Blood 🩸: polymorph nuclear leucocytosis 

X-ray abdomen including chest .

Ultra sonogram of Hepatobiliary system to determine size and site of abscess. 

Serum bilirubin : raised 

Serum transaminases: raised 

Serum alkaline phosphatase : raised 

Needle aspiration of pus : Anchovy sauce appearance. 

Specially for amoebiasis 

          Stool for R/M/E : to see motile trophozoite 

         Sigmoidoscopy: to see typical flask -shaped ulcers 

          Serological : - Immunofluorescence test 

                                 - Haemaglutination inhibition test 

                                 - complement fixation test 

Treatment 

  General measures : 

                                    • waters sanitation 

                                    • personal Hygiene 

   Drugs 

  (a) Metronidazole 800 mg orally or 500 mg IV *8 -hourly for 5-10 days 

        Tinidazole 2gm orally *OD*3 day 

       Or ,

   Ordinazole 2 gm orally for 3 days 

   ( b) Dialoxanide furoate 500mg or paromomycin 500mg * 8 hourly for 10 days after above treatment to eliminate luminal cysts .

 ** Ultrasound guidance aspiration of pus if abscess is 

large 

threatens to burst or rupture

not responding to drug therapy  

Complications : 

      * Rupture of abscess 

      * Liver failure 

      * Renal failure 

(b) pyogenic liver abscess 

        Pyogenic liver abscess are becoming uncommon due to improved diagnostic facilities and early use of antibiotics. Incidence is higher in old age, immunocompromissed patient . 

Causes of pyogenic liver abscess 

Biliary obstruction 

Haemotogenous

         Portal vein : mesenteric infections 

         Hepatic artery: bacteraemia 

   3. Trauma : penetrating injury 

                       Non penetrating injury 

    4. Secondary infection of liver tumour or cysts .

common organisms 

Escherichia coli ( commonest)

Streptococcus fecalis 

Proteus vulgaris 

Staphylococcus 

Clinical features 

Fever ,sometimes associated with rigors 

Weight loss

Abdominal pain usually right upper quadrant, radiates to right shoulder 

Mild jaundice 

Signs of right sided pleural effusion , pleural rub .

Tender hepatomegaly 

Investigations 

Blood 🩸: TC , DC ,Hb%ESR . Polymorph nuclear leucocytosis

X- ray abdomen and chest :

                    Tented right dome of diaphragm 

                    Right pleural effusion 

Ultra sonogram of Hepatobiliary system 

Serum alkaline phosphatease : raised 

Blood culture (30% positive)

Serum transaminases : raised 

Serum bilirubin : raised 

Treatment 

Antibiotic - Ampicillin +Gentamicin +Metronidazole 

                      - Third generation cephalosporin     

          + Metronidazole 

Aspiration or drainage of pus under ultrasonic guidance .

A surgical drainage may needed.