18- Pyogenic liver abscess Flashcards
3 common causes of pyogenic liver abscesses
- post peritonitis
- biliary infection
- arterial hematogenous seeding in systemic infection
rf for pyogenic liver abscesses
diabetes mellitus hepatobiliary (gall stones, malignant obstruction) or pancreatic disease liver transplant regular use of proton pump inhibitor Geographic and host factors
what is portal vein pyemia
collection of pus in the portal venous system due to inflammation; this often follows bowel leakage and peritonitis and eventually leads to pyogenic liver abscesses
T/F a mnonmicrobial liver abscess due to strep or staph species should cuase investigation for an additional source of infection esp infective endocarditis
T
most pyogenic liver abscesses etiologies are
polymicrobial
- mixed enteric facultative and anaerobic species
- E coli and K pneumonia
- Streptococcus milleri group (including S. anginosus,
S. constellatus, and S. intermedius) is an important
cause of liver abscess. When implicated, it should prompt a search for
simultaneous metastatic infections at other locations
• Staphylococcus aureus, Streptococcus pyogenes, and other gram-positive
cocci are recognized pathogens in specific circumstances; in a report of liver abscesses in patients who underwent transarterial
embolization for hepatocellular carcinoma, they accounted for 60 percent of
pathogens
manifestation of pyogenic liver abscess
fever, abdominal pain
does the absence of right upper quadrant pain exclude liver abscess
no
1/2 of pts with abscess have hepatomegaly, RUQ tenderness or jaundice
dx of pyogenic liver abscess
US
CT
MRI
primary ddx for liver abscess on imaging is
amebic liver abscess due to E histolytica
NOTE you cant tell pyogenic from amebic with imaging only
- Not so common is Tuberculous abscesses which manifest as multiple small abscesses (military TB)
- Echinococcus hyatid cysts can be differentiated by imaging and serology
- Candida: microabscesses occur in hematologic malignancy during recovery of neutrophic count
- Bartonella, fasciola and endemic fungal infections are small and nodular
tx of pyogenic liver abscess
drainage (with CT guide, or US; open surgical - if you need to perform sugery too, laparoscopic, ERCP - useful for pts who previously had biliary procedures ) - the approach to abscess drainage depends on size and number of abscesses and antibiotic therapy (covering streptococci, enteric gram negative bacilli, anaerobes)- 3+ gen cephalosporin, B lactamase inhibitor
Metronidazole to cover E histolytica
amebiasis is due to
protozoa entamoeba histolytica
most infection of E histolytica are asymtpmatic
True, common manifestations are amebic dysentry and extraintestinal disease (amebic liver abscesses, pulmonary, cardiac, brain)
Amebic liver abscess is the most common
extraintestinal manifestation of amebiasis
Amebae establish hepatic infection by
ascending the portal venous system
clincal of pts with amebic liver abscess
- 1-2 weeks of right upper quadrant pain
- cough, sweating, malaise, weight loss, anorexia
- 50% have hepatosplenomegaly
tx for amebic liver abscesses
Uses a tissue agents and a luminal agent.
Tissue agents: metronidazole or tinidazole
Luminal agents: it is used to eliminate intraluminal cysts even with stool microscopy for amebic liver abscesses is negative (eg paromomycin, diiodohydroxyquin, diloxanide)
hydatid cyst disease is caused by
echinococcus tapeworm (metacestode)
- E granulosus (worldwide- grazing areas), E multilocularis (northern hemisphere)
- E vogeli E oligarthus (central and south america)
echinococcus granulosus infection sx
- primary phase is always asymptomatic
- infections are acquired in childhood but do
not cause clinical manifestations until adulthood
latent period can last 50 years
clinical presentation of E granulosis infection depends on
the site of the cysts and their size (small calcified cysts can remain asymptomatic. But symptoms due to mass effect can also occus)
- cysts grow at 1-5 cm/year
hyatid cysts are only in the liver
false
E. granulosus infection of the liver frequently
produces no symptoms.
The right lobe is affected in 60 to 85 percent of
cases.
Significant symptoms are unusual before the
cyst has reached at least 10 cm in diameter.
If the cysts become large, hepatomegaly with or
without associated right upper quadrant pain,
nausea, and vomiting can result.
e multilocularis is usually (sx or not?)
symptomatic, non specific
if left untreated 90% of pts will die in 10 years
dx of hyatid cysts
imaging and serology
T/F serology for E multilocularis is more sensitive and specific than for E granulosis
T
gharbi US classification
stage 1: homogeneously hypoechogenic cystic
thin-walled lesion
– stage 2: septated cystic lesion
– stage 3: cystic lesion with daughter lesions
– stage 4: pseudo-tumor lesion
– stage 5: calcified or partially calcified lesion
(inactive cyst)
tx options for hydatid cysts
- surgical excision
- PAIR (puncture, aspiration, injection, reaspiration)
- chemotx with anti helminthic agent
- watch and wait for inactive and silent cyst
The most common types of visceral abscesses (abscess within an intra-abdominal organ) are
pyogenic liver abscesses
T/F Some , abscesses arise from surgical or penetrating wounds,
including injury from migration of an ingested foreign body
T
Complications of pyogenic liver abscesses
Abscess rupture (rare; RF for rupture are diameter >6cm with cirrhosis- most ruptures are perihepatic or pleural)
RF for mortality in amebic abscesses
- bilirubin >3.5
- albumin <2
- large volume of abscess cavity
- multiple abscesses
- encephalopathy
RF for developing pulmonary amebiasis
malnutrition
chronic alcoholism
atrial septal defect (L to R shunt)
most common symptoms of pulmonary cystic echinococcus
cough, chest pain, dyspnea
- Majority are asymptomatic in teens despite size
Principle manifestations of cyst rupture
fever and acute hypersensitivity reactions (anaphylaxis)
