Classifieds for every web site!
| View Our Guestbook | Sign Our Guestbook | Search Our Web Site |
| Chat Room | Discussion Forums | Free Classified Ads |
SURGICAL WEBSITES BREAST DISEASE LIVER ABSCESS Anatomy of liver SURGICAL WEBSITES KIDNEY SURGERY POSTGRADUATE SURGERY LINKS
BREAST DISEASE Breast cancer Breast lump Breast awareness Breast calcifications Breast cysts Breast pain Duct ectasia Fat necrosis Fibroadenoma Hyperplasia Intraductal papilloma Phyllodes tumour Sclerosing adenosis
LIVER ABSCESS Anatomy of liver Physiology of liver Method of examination of liver Haematology of liver disease. Amoebic liver abscess .Pyogenic liver abscess. Percutaneous needle aspiration of liver abscess. Case study. Result Result continued Discussion
CHOLECYSTECTOMY Introduction Historical Review Anatomy of Gallbladder Physiology of Gallbladder Physiologic effects of pneumoperitoneum Pathology of Gallbladder Investigations Pre- operative preparation of laparoscopic cholecystectomy Contraindications Treatment modalities for gallstones. Anaesthesia
INGUINAL HERNIA HOW SURGICAL OPERATION IS DONE THYROID EXAMINATION MANAGEMENT OF SEVERELY INJURED PATIENT SEPSIS AND MULTIPLE ORGAN FAILURE CHEST TRAUMA BRONCHOGENIC CARCINOMA TETANUS AND ANAEROBIC INFECTIONS
PYOGENIC LIVER ABSCESS PYOGENIC LIVER ABSCESS
In our part of the world pyogenic liver abscess is less common than the amoebic liver abscess. It is relatively common to amoebic liver abscess in the developed part of the world. In the United States, pyogenic liver abscess is more frequently seen than amoebic liver abscess 66.
Pyogenic infections used to be due to portal infection, often in young people secondary to acute appendicitis. This is less frequent, because of earlier diagnosis and treatment. Abscess secondary to obstruction and infection of biliary tree and affecting an older age group have however continued to increase. Immunosuppression as in AIDS, intensive chemotherapy or transplant recipients is increasing the number of liver abscesses due to opportunistic organisms 67.
Earlier diagnosis has increase due to scanning and cholangiographic techniques. Failures are usually due to clinician not considering the diagnosis.
CLASSIFICATION
Portal pyaemia
Pelvic or gastrointestinal infection may result in portal pylephlebitis or in septic emboli. This may follow appendicitis, empyaema of the gallbladder, diverticulitis, regional enteritis, Yersinia ileitis perforated gastric or colonic ulcers, leaking anastomosis, pancreatitis and infected haemorrhoids.
Neonatal umbilical vein sepsis may spread at the portal vein with subsequent liver abscesses.
Biliary
The biliary tree is the commonest source of infection. Septic cholangitis can complicate any form of biliary obstruction, especially if partial. The abscesses are often multiple. Abscess may occur due to reflux of intestinal contents following biliary/ enteric anastomosis 68. In a study by Tazawa and colleagues biliary diseases and malignancies were more frequently observed in the solitary cases than multiple cases. E. coli was more frequently cultured from the abscesses in the multiple cases 69. Liver abscess has been reported in association with Choledochal cyst 70.
Direct infection
Solitary liver abscess may follow a penetrating wound or direct spread from an adjacent septic focus such as perinephric abscess. It may follow secondary infection of an amoebic abscess, metastasis, cyst or intra hepatic haematoma. Automobile accidents or other blunt trauma can cause intrahepatic haematoma which can get infected leading to hepatic abscess formation 71. Patients receiving transarterial embolization for hepatocellular carcinoma can develop liver abscess 72. Iatrogenic causes include liver biopsy, percutaneous biliary drainage or hepatic artery injury or perfusion.
Miscellaneous
It may affect patients with haematological diseases such as leukaemia who are receiving chemotherapy. In a study of Ravichandran et al seventeen patients underwent surgery for alcohol-induced chronic pancreatitis. Three patients later presented with pyogenic liver 73. Pyogenic liver abscess could be a presentation of hepatopancreatobiliary malignant disease at the preterminal stage, and carries a grave prognosis. Pyogenic liver abscess in patients with non hepato-pancreatobiliary malignant disease has a better chance of favourable outcome. Oriental cholangiohepatitis is a condition marked by intrahepatic strictures and extensive formation of pigmented stones leading to recurrent biliary sepsis and hepatic abscesses. It is a common condition in Southeast Asia and is seen with increasing frequency in Western populations due to Asian immigration 74.
Tuberculosis can also give rise to liver abscess 75. The gp91phax-deficient chronic granulomatous disease is found to be associated with liver abscess. Bacteraemia from involved periodontal tissues and a possible impaired immune response could indicate an increased risk of pyogenic liver abscess among children with Papillon-Lefevre syndrome 76. Kumar et al has reported association of pyogenic abscess with patients of aplastic amaemia receiving long-term steroid therapy, measles in recent past and other important features reported was association with moderate to severe malnutrition 77. Skin infections may predispose to pyogenic liver abscess in the presence of intra-abdominal pathology like fistulous disease or in the presence of steroid therapy 78. Some workers have reported other associated factors in relation to liver abscess which are biliary ascariasis along with cholecystitis and pancreatitis 79 and pyogenic cholangitis secondary to ascariasis 80. In a prospective study by Grois and et al, hepatic abscesses is found as a common complication of intensive chemotherapy of acute myeloid leukemia 81.
Meticulous search should be done for a cause for pyogenic liver abscess when it occurs in an otherwise healthy adult 82. Patients with hepatic transplant are at increased risk of developing abscess in post-transplant phase and may require re-operation 83.
Cryptogenic
About one half have no obvious predisposing cause. This is especially so in elderly. If a liver abscess is thought to be cryptogenic, a thorough dental exam is recommended. 84. It is also found to be associated with malnutrition, poor hygiene, hepatic dysfunction and possible suppression of amoebistatic substance 85. Cholangiocarcinoma presenting as liver abscess has a dismal prognosis. Concomitant hepato-lithiasis worsened the infectious process and can adversely affect the survival 86.
BACTERIOLOGY
The commonest infecting organisms are Gram negative E coli, are found in two thirds. Streptococcus faecalis, Klebsiella and Proteus vulgaris are also frequent. Recurrent pyogenic cholangitis may be due to Salmonella typhi. Anaerobic organisms have become increasingly important, and include bacteroides, aerobacteria, actinomyces and anaerobic and microaerophilic streptococci. Liver abscess due to anaerobic organisms has been reported in association with unsuspected carcinoma of colon without liver metastasis 87. Streptococcus milleri Lancefield group F, which is neither a true anaerobe nor microaerobe, is a very common cause. Staphylococci are found in nearly half especially in those who have received chemotherapy, when they are usually resistant. Freidländer’s bacillus, Pseudomonas and Clostridium welchii may also be found. Rare causes include Yersinia enterocolitica, septicaemic melioidosis and Pasteurella multocida. Infection is often multiple.
The abscess may be sterile, but this is usually due to lack of adequate, particularly anaerobic culture techniques or due to previous antibiotics use. Tuberculous abscesses are common in the patients suffering from acquired immuno-deficiency syndrome 88.
PATHOLOGY
The enlarged liver may contain multiple yellow abscesses 1cm in diameter or a single abscess encased in fibrous tissue.
When there is an associated pylephlebitis, the portal vein and its branches may contain pus and blood clots. The abscesses are particularly in the right lobe. There may be peri-hepatitis and adhesion formation.
In bacteroides infection, the pus has a foul odour and the abscess wall is ill defined.
When bile ducts spread infection, multiple foci correspond to the bile duct system.
A chronic solitary liver abscess may persist for as long as 2 years before death or diagnosis.
There may be small pyaemic abscess else where, such as in lungs kidney brain and spleen. Direct extension from liver lead to subphrenic or pleuro-pulmonary suppuration. Extension to the peritoneum or rupture of a sinus pointing under the skin is rare. A small amount of ascites is present in about a third of patients.
Histologically areas remote from the abscess show infection in the portal tract surrounding disintegrating liver cells being infiltrated by polymorphs.
CLINICAL FEATURES
In the pre-antibiotic era, the picture was of spiking fever and right upper quadrant pain, often with prostration and shock. The presentation is, with malaise, fever and abdominal pain increased by movements. It is particularly likely to be occult in elderly.
The onset may be insidious and the duration at least one month before diagnosis. Multiple abscesses are associated with more acute systemic features and the cause is more often identified. The single abscess is more insidious and often ‘cryptogenic’. If there is sub-diaphragmatic irritation or pleuro-pulmonary spread of infection, the patient may complain of right shoulder pain and irritating cough. The liver is enlarged and tender, and percussion may accentuate pain over the lower rib cage.
The spleen is palpable in chronic cases. Detectable ascites is rare. Jaundice is late unless there is suppurative cholangitis.
Recovery may be followed by portal hypertension due to thrombosis of the portal vein.
INVESTIGATION
Jaundice is usually mild except inn the cholangitic types. It is more common than with amoebic abscess.
Serum alkaline phosphatase is usually raised. The ESR is very high. Polymorphonuclear leucocytosis is usual.
Blood cultures may show the causative organisms in 50% of the patients.
Fluoroscopic examination
This may show a high, immobile, right diaphragm, with alteration in contour and a pleural effusion. A penetrated film may show a fluid level, indicating gas- producing organisms.
Localisation of the abscess
Ultrasound is a useful routine and distinguishes a solid from a fluid filled lesion. False negatives can be due to lesions near the dome of the liver and to micro-abscesses. Multiple small abscesses aggregate suggesting the beginning of the coalescence into single larger abscess (cluster sign).
Endoscopic or percutaneous cholangiography may be used to diagnose cholangitic abscesses.
Aspirated material is positive in 90%. It should be cultured aerobically, anaerobically and in carbon dioxide enriched media for streptococcus milleri. Aspiration is usually done under ultrasound or CT direction.
TREATMENT
Prevention is by early treatment of acute biliary and abdominal infections and the adequate drainage, usually percutaneous, of intra-abdominal purulent collections under adequate antibiotic cover.
Antibiotics are rarely effective alone, and should not postpone mandatory drainage. The course should be intravenous and the choice dependent on the causative organism.
Once a single abscess is localised, it must be drained. If amoebiasis is suspected, metronidazole should be given before aspiration 88. Otherwise, the treatment of choice is aspiration, which can be repeated. Sometimes a percutaneously inserted pigtail catheter is necessary for drainage. With multiple abscesses, the largest is aspirated and the smaller lesions usually resolve with chemotherapy. Occasionally, percutaneous drainage of each is necessary. Percutaneous needle aspiration in combination with systemic antibiotics is safe and effective in treating liver abscess, it should be considered as a first line alternative to catheter drainage, especially for multiple abscesses. Cu et al have reported that fifty percent of there patients suffering from pyogenic abscess may require repeated aspiration89.
High-dose antibiotic alone, given for at least 6 months, may be successful particularly if the infection is streptococcal. Intraarterial antibiotic therapy is an additional mode of treatment for patients with persistent pyogenic abscess which fails to respond with conventional methods 90. The gas-forming liver abscess may be a disease of wide spectrum of severity and may run a fulminating course. Strong antibiotics with early adequate drainage are mandatory. Surgery should not be delayed if necessary 91.
Open surgical drainage is rarely indicated. Biliary obstruction must be relieved. This is usually done by ERCP, papillotomy and stone removal. If necessary a biliary endo-prosthesis is inserted.
COMPLICATIONS:
Liver abscess can be further complicated by septic pulmonary emboli which can lead superadded pulmonary complications and is very difficult to diagnose if the patient is presenting late 92.
PROGNOSIS
The advent of needle aspiration and antibiotic therapy has lowered the mortality to 16%. The prognosis is better for a unilocular abscess in the right lobe where survival in 90%. The out come for multiple abscesses throughout the liver, especially if biliary, is very poor only 20% survive.
The prognosis is made worse by delay in diagnosis, continued fever, and multiple infections shown by blood culture, hyperbilirubinaemia, associated diseases, hypoalbuminaemia, pleural effusion and old age. Pyogenic liver abscess could be a presentation of hepatopancreatobiliary malignant disease at the preterminal stage, and carries a grave prognosis. Pyogenic liver abscess in patients with nonhepatopancreatobiliary malignant disease has a better chance of favourable outcome 93.
Washington, DC Registry
Last modified: Monday, 29-Nov-2004 06:56:18 EST |
