L31 Hepatobiliary infection

Question 1

The patient presented with RUQ pain, fever, but is not jaundiced. No other abdominal physical signs.
Possible DDx?

Answer 1

Liver abscess

• unlikely acute hepatitis (no jaundice, liver enzymes AST normal/slightly raised/ ALP high)
• exclude gallstone disease

Other ddx

• acute cholangitis (but no jaundice in this case, less likely)
• acute cholecystitis

Question 2

Investigations for suspected liver abscess?

Answer 2

1. USG of the abdomen with aspiration and percutaneous drainage of pus
2. Pus for microscopy, culture, Gram stain

Question 3

How can liver abscess be classified? (2)

What are their definitions? (2)

Answer 3

1. Pyogenic (bacterial) liver abscess
   - A focal, purulent bacterial collection in the liver
2. Amoebic abscess
   - A focal, non-purulent fluid collection in the liver

Question 4

Name the causative organisms of pyogenic liver abscess. (6)

Answer 4

GN: Klebsiella, E.coli
GP: Enterococcus, Streptococcus
An: Bacteroides, peptostreptococcus

Question 5

Name the causative organism that causes Amoebic abscess.

Answer 5

Entamoeba histolytica

Question 6

What are the differences in onset and fever between pyogenic and amoebic abscess?

Answer 6

Onset:
Rapid in pyogenic, gradual in amoebic

Fever:
High-swinging fever in pyogenic, low grade in amoebic

Question 7

Which of the following about Amoebic liver abscess is incorrect?
A. It can cause the formation of septic emboli which may enter the eyes
B. Usually single abscess
C. Abscess usually at the right lobe of the liver
D. It causes LOW and dysentery
E. It causes cough, wheeze
F. It causes hepatomegaly with tenderness

Answer 7

A
Should be a pyogenic abscess!

B: pyogenic abscess can be single/multiple
C: Right lobe > Left lobe > Caudate lobe

Question 8

Name the 4 risk factors for patients to have pyogenic abscess.

Answer 8

1. Cholangitis
2. DM
3. Diverticulitis
4. Bowel surgery

Question 9

List the 5 route of infection of pyogenic abscess.

Answer 9

1. MC: Biliary tree: gallstone, tumor
2. Hepatic artery: systemic bacteremia
3. Portal vein: pancreatitis/ intraabdominal sepsis
4. Direct extension: subphrenic abscess
5. Trauma

Question 10

What is the risk factor for amoebic abscess? (1)

Describe the pathogenesis + the texture of the abscess

Answer 10

Use of steroids

Pathogenesis:
- Ingestion of amoebic cyst > death of liver cells and neutrophils > non-purulent “anchovy paste” abscess

Question 11

Investigations for patients with Amoebic abscess.

Answer 11

1. Serology +ve in >95% of amoebic abscess
2. Aspirated pus: microscopy and culture
3. Stool OCP: for amoebic cysts and trophozoites (40% +ve)

Question 12

Treatment for each kind of abscess. (4)

Answer 12

Pyogenic abscess

1. Percutaneous drainage by pigtail
2. Triple Abx: Ampicillin (enterococcus), Cefuroxime (GN), Metronidazole for 4-6/52

Amoebic abscess

1. Drainage if large
2. Metronidazole 7-10 days, then paromomycin

Question 13

Which of the following are possible complications for liver abscess?

A. Consolidation
B. Pleural effusion/ empyema
C. Hepatobronchial fistula
D. Peritonitis
E. Pericardial rupture

Answer 13

All of the above

+ lung abscess

Question 14

Other than bacterial and amoebic infections, viral causes hepatic infections too.
The liver can also be infected due to systemic infections such as by bacterial and by parasites.
List 2 examples of bacterial infections.

Answer 14

1. Mycobacterial: extrapulmonary TB, disseminated M.avium
2. Zoonotic: brucellosis, Q fever, Rickettsiosis, Leptospirosis
3. Syphillis, Legionellosis

Question 15

Other than bacterial and amoebic infections, viral causes hepatic infections too.
The liver can also be infected due to systemic infections such as by bacterial and by parasites.
List 2 examples of parasitic infections.

Answer 15

1. Protozoa
   - Malaria
   - Toxoplasmosis
   - Leishimaniasis
2. Helminths
   - Liver fluke
   - Schistosomiasis
   - Strongyloides

Question 16

List 2 examples of liver infections due to disseminated disease in immunocompromised.

Answer 16

1. Candidiasis
2. Aspergillosis
3. Mucormycosis

Question 17

Name the usual organisms causing Acute cholecystitis. (5)

Answer 17

Gut flora

1. GN: Klebsiella, E Coli
2. GP: Enterococcus, Streptococcus
3. AN: Clostridium perfringens

Question 18

Name the usual organisms causing Acute cholangitis. (7)

Answer 18

Gut flora

1. GN: Klebsiella, E.coli
2. GP: Enterococcus, Streptococcus
3. AN: C.perfringens
4. Pseudomonas (if stent)
5. Clonorchis Sinensis

Question 19

Which of the following is incorrect?
A. Both acute cholangitis and cholecystitis require USG for investigation
B. Acute cholangitis requires blood culture and bile for microscopy and culture for investigations.
C. ERCP is done for biliary drainage in both diseases
D. Triple antibiotics are used in both diseases
E. Acute cholangitis may require laparoscopic cholecystectomy.

Answer 19

E

• Should be acute cholecystitis

Question 20

Clonorchis sinensis infection is due to the ingestion of infected ______________.
Presentations can be asymptomatic, while chronic infection will cause? (3)

Answer 20

freshwater fish;

1. recurrent cholangitis
2. pancreatitis
3. risk of cholangiocarcinoma

Question 21

How can Clonorchis sinensis be diagnosed? (2)

Answer 21

1. Stool OCP for eggs/ Flukes in bile

2. USG of liver and intrahepatic ducts

Question 22

Treatment for Clonorchis sinensis infection?

Answer 22

Praziquantel