Nelsons Chapter 386 - Liver Abscess Flashcards

1
Q

Liver abscess have 1 of 2 infectious etiologies?

A
  1. Pyogenic - involving bacteria

2. Parasitic - amebiasis, ascariasis, toxocariasis

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2
Q

Pyogenic liver abscess are uncommon in children but reported in all ages
How bacteria can invade the liver?

A

Hematogenously through:

  1. Hepatic artery
  2. Biliary tract
  3. Portal vein
  4. By contiguous infection
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3
Q

Pyogenic liver abscess of Uknown source are classified as?

A
  • crypto genie
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4
Q

Children with increased risk of liver abscess?

A

Children with:

  • chronic granulomatous dse (CGD)
  • hyper-immunoglobulin E (hyper-IgE) syndrome
  • malignancies
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5
Q

Clinical sx/s of pyogenic liver abscess?

A

Nonspecific

  • fever
  • child
  • malaise
  • fatigue
  • nausea
  • abdominal pain (w/ or w/o RUQ tenderness)
  • hepatomegaly
  • jaundice is uncommon
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6
Q

Lab findings for pyogenic liver abscess?

A
  • elevated inflammatory markers
  • hypoalbuminemia
  • elevated hepatic functioning test
  • leukocytosis
  • UTZ or
  • CT scan
  • CXR
    Elevation of the right hemidiaphragm with right pleural effusion
  • solitary lesions of right hepatic lobe most common
    Solitary abscess can appear in any hepatic lobe or as multiple disseminated lesions (disseminated candidiasis, bartonellosis, rarely brucellosis)
  • culture
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7
Q

Culture of pyogenic liver abscess often yield mixed pop’n

A
  • staphylococcus aureus
  • streptococcus spp.
  • enteric gram negative organisms
    (Escherichia coli, Klebsiella pneumoniae, serratia)
  • anaerobic organisms
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8
Q

Treatment for pyogenic liver abscess?

A

broad spectrum empiric antimicrobial treatment
- piperacillin-tazobactam
- ampicillin - sulbatam or
- metronidazole + 3rd gen cephalosporin
- vancomycin
Maybe added to cover methicillin resistant S. aureus
- therapy can be modified based on culture sensitivities

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9
Q

Treatment duration of pyogenic liver abscess?

A
  • not standardized
  • based on:
    resolution of fever,
    clinical, and
    inflammatory marker improvement
    serial UTZ monitoring
  • 4 to 6 wks therapy
    First 2wks parentally
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10
Q

Depending on the size and extent of the lesions ___________ may be added to obtain samples for cultures and to shorten illness duration.

A
  • percutaneous or surgical drainage
  • percutaneous options include single-pass needle or catheter aspiration or insertion of a continuously draining catheter
  • percutaneous drainage should be attempted first for large lesions (> = 5-7cm in dm)
  • for smaller lesions initial approach is antibiotic therapy.
    Resolution is monitored by trending inflammatory markers and/or serial imaging
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11
Q
  • most common extraintestinal manifestation of Entamoeba histolytica infection
  • more common in endemic areas
  • presentation can be delayed by months to year
  • more common among adults 18-55yo
  • male predominant
A

Amebic Liver Abscess (ALA)

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12
Q

Pathophysio of ALA?

A
  • amoebic trophozoites invade colonic mucosa -> reach liver through the portal circulation.
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13
Q

CM of ALA

A
  • fever
  • right upper quadrant pain
  • anorexia
  • weight loss
  • may not have an associated colitis
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14
Q

Lab findings in ALA

A
  • leukocytosis with eosinophilia
  • inc. alk phos.
  • UTZ or CT -> abscess
  • confirmed by serum ELISA
  • most specific and sensitive: stool assays PCR > stool antigen detection > microscopy (least sensitive cause cant easily distinguish E dispar, E. moshkovskii)
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15
Q

Tx of ALA

A
- nitroimidazole / metronidazole 
    7-10days 
    To kill trophozoites 
Followed by
- paromomycin 
    7days 
    Luminal agent
    To kill colonic cyst  
- for large abscess (>= 5-7cm in dm) my benefit from percutaneous aspiration in addition to medical therapy.
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