Hepatobiliary Infections Flashcards
DDx of hepatic infections
Acute viral hepatitis
Hepatic abscess
Infections with liver dysfunction (viral, bacterial, parasitic, fungal)
Possible presentations of liver disease and their relevant disease
Fatigue, pruritus, vague RUQ pain - non-specific
Jaundice - acute hepatitis, biliary obstruction, advanced CLD
Abdominal pain, fever - acute cholangitis, cholecystitis, liver abscess
Spider naevi, palmar erythema, gynaecomastia, testicular atrophy - CLD, cirrhosis
Wasting - malnutrition from cirrhosis, HCC
Encephalopathy, ascites, acute GI bleed, coagulopathy - advanced liver disease (decompensated)
Typical patterns of liver dysfunction
Hepatocellular integrity - AST, ALT
Cholestasis - ALP, GGT, Bilirubin
Liver function - albumin
Pyogenic liver abscess - definition, organisms
= focal purulent bacterial collection in the liver
Usual organisms:
- POLYMICROBIAL
- Gram -ve: Klebsiella (K1, K2), E. coli
- Gram +ve: Streptococci, Enterococci
- Anaerobes: Bacteroides, Peptostreptococcus
Pyogenic liver abscess - presentations
Usually middle-aged (50-60)
Rapid onset High swinging fever Single or multiple abscess (right>left) RUQ pain Septic emboli (to the eyes)
Pyogenic liver abscess - risk factors, routes of infection
Risk factors: cholangitis, diverticulitis, bowel surgery, DM
Routes of infection:
- biliary tree most common (gallstones, tumour –> cholestasis, bacteria ascends)
- hepatic artery: systemic bacteremia
- portal vein: pancreatitis, intra-abdominal sepsis
- direct extension: subphrenic or perinephric abscess
- trauma
- cryptogenic
Pyogenic liver abscess - Ix and Tx
- USG abdomen to look for SOL
- USG guided ASPIRATION OF PUS for gram stain and culture
- BLOOD culture (rmb to take early before antibiotics)
Treatment:
- percutaneous DRAINAGE with pigtail insertion (a few days)
- triple ANTIBIOTICS: ampicillin, cefuroxime, metronidazole for 4-6 weeks
Amoebic liver abscess - definition, organism
= focal collection of non-purulent fluid in liver due to Entamoeba histolytica infection
- uncommon in HK, usually have travel history
Amoebic liver abscess - presentations
Males>Females
Gradual onset LG fever, LOW Hepatomegaly with tenderness (80%) Usually single abscess, right lobe (May have wheeze, crackles, hx of dysentery, diarrhoea, cough)
Amoebic liver abscess - risk factors, pathogenesis
Risk factors: steroid use
Ingestion of amoebic cysts (contaminated water/ food) –> cause liver cell and neutrophil apoptosis
==> non-purulent “anchovy paste” abscess
Recall life cycle in body (excystation in intestinal lumen –> migrate to colon, bind to colonic epithelium and multiply –> exit in stool (cysts) or invade mucosa and systemically invade (trophozoites)
Amoebic liver abscess - Ix and Tx
SEROLOGY (>95% +ve)
ASPIRATED PUS for microscopy (wet mount) and culture (exclude bacterial)
STOOL: wet mount for amoebic cysts and trophozoites (40% +ve)
Treatment:
- metronidazole 7-10 days, followed by paromomycin/ diloxanide (prevent relapse)
- drainage if large
Complications of liver abscess
Rare
- pulmonary: empyema, lung abscess, hepatobronchial fistula
- peritonitis
- pericardial rupture
Systemic infections with liver involvement and other differentials of hepatic infection
Bacterial:
- extra pulmonary TB
- zoonotic e.g. brucellosis, Q fever, leptospirosis, rickettsiosis
- syphilis, legionellosis
Parasites:
- protozoa e.g. malaria, leischmaniasis, toxoplasmosis
- helminths e.g. schistosomiasis, liver flukes
Disseminated disease in immunocompromised:
- candidiasis, aspergillosis, mucormycosis
DDx of acute obstruction of biliary tree
Cholelithiasis
- cholangitis
- cholecystitis
Parasitic infection
- clonorchis sinensis (liver fluke)
- hydatid disease (ecchinococcus sp)
Other non-infective causes e.g. tumour
Acute cholecystitis - definition, cause, symptoms
= inflammation of gallbladder resulting from obstruction of cystic duct, often by a stone
- may be acalculous
Symptoms:
- fever, minimal jaundice
- RUQ pain
