Nelsons Chapter 386 - Liver Abscess Flashcards
Liver abscess have 1 of 2 infectious etiologies?
- Pyogenic - involving bacteria
2. Parasitic - amebiasis, ascariasis, toxocariasis
Pyogenic liver abscess are uncommon in children but reported in all ages
How bacteria can invade the liver?
Hematogenously through:
- Hepatic artery
- Biliary tract
- Portal vein
- By contiguous infection
Pyogenic liver abscess of Uknown source are classified as?
- crypto genie
Children with increased risk of liver abscess?
Children with:
- chronic granulomatous dse (CGD)
- hyper-immunoglobulin E (hyper-IgE) syndrome
- malignancies
Clinical sx/s of pyogenic liver abscess?
Nonspecific
- fever
- child
- malaise
- fatigue
- nausea
- abdominal pain (w/ or w/o RUQ tenderness)
- hepatomegaly
- jaundice is uncommon
Lab findings for pyogenic liver abscess?
- 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
Culture of pyogenic liver abscess often yield mixed pop’n
- staphylococcus aureus
- streptococcus spp.
- enteric gram negative organisms
(Escherichia coli, Klebsiella pneumoniae, serratia) - anaerobic organisms
Treatment for pyogenic liver abscess?
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
Treatment duration of pyogenic liver abscess?
- not standardized
- based on:
resolution of fever,
clinical, and
inflammatory marker improvement
serial UTZ monitoring - 4 to 6 wks therapy
First 2wks parentally
Depending on the size and extent of the lesions ___________ may be added to obtain samples for cultures and to shorten illness duration.
- 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
- 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
Amebic Liver Abscess (ALA)
Pathophysio of ALA?
- amoebic trophozoites invade colonic mucosa -> reach liver through the portal circulation.
CM of ALA
- fever
- right upper quadrant pain
- anorexia
- weight loss
- may not have an associated colitis
Lab findings in ALA
- 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)
Tx of ALA
- 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.