Pyogenic_Hepatic_Abscesses

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Pyogenic Hepatic Abscesses:

Pyogenic Hepatic Abscesses Vic V. Vernenkar,D.O. St. Barnabas Hospital Bronx, N.Y.

Introduction:

Introduction Described since age of Hippocrates In 1883 Koch described the amoeba as a cause of liver abscess. In 1938 Debakey published largest series in the lierature. Over last 2 decades,percutaneous drainage has becaome a therapeutic option.

Frequency:

Frequency Uncommon, prevalence in autopsy series 0.29-1.47%. Incidence in the US is 8-15 per 100,000. Male to female ratio is 2:1 in recent studies. 4 th -6 th decades of life.

Etiology:

Etiology Biliary disease accounts for 21-30%, with extrahepatic obstruction leading to ascending cholangitis and abscess. Also CBD stones, benign and malignant tumors, biliary enteric anastamoses.

Etiology:

Etiology Infection via portal system Infectious process originates in abdomen, reaches liver by embolization of portal system. Appendicitis, diverticulitis, IBD, proctitis

Etiology:

Etiology Hematogenous. Via hepatic artery. From systemic septicemia. No cause in 50% of cases, but increased in diabetics and metastatic cancer.

Pathophysiology:

Pathophysiology Access to liver by direct extension from nearby organs. Through portal vein and hepatic artery. Hepatic clearance of bacteria via portal system is a normal phenomena, but organism proliferation, tissue invasion and abscess can occur with biliary obstruction, poor perfusion, microembolization.

Microbiology:

Microbiology Most contain more than one organism, with source biliary or enteric. Blood cultures positive in 33-65%. E.Coli 33%. Klebsiella 18%. Bacteroides 24%. Streptococcal 37%.

Clinical:

Clinical Fever, right upper quadrant pain (80%). Right shoulder pain, pleuritic chest pain. Fever 87-100%. Anorexia, weight loss, mental confusion. Physical exam shows RUQ tenderness, hepatomegaly, liver mass, jaundice.

Indications For Open Drainage:

Indications For Open Drainage Abscess not amenable to percutaneous drainage Co-existing intra-abdominal disease that requires operative management. Failure of antibiotic therapy. Failure of percutaneous aspiration or drainage.

Relative Contraindications:

Relative Contraindications Age older than 70. Multiple abscesses. Polymicrobial infection. Presence of associated malignancy or immunosupressive disease. Multiple medical problems.

Workup:

Workup Lab studies include CBC: anemia in 50-80%, leukocytosis in 75-96%. LFTs: elevated alkaline phosphatase 95-100%, elevated AST, ALT 40-60%. Elevated bilirubin in 28-73%. Decreased albumin in 71-87%.

Imaging Studies:

Imaging Studies Chest film abnormal in 50%. Abdominal film can show intrahepatic air, air-fluid levels, pneumobilia. Ultrasound 80-100% sensitive, round hypoechoic mass consistent with abscess. CT scan is study of choice, abscesses are non enhancing with contrast.

Medical Therapy:

Medical Therapy Most dramatic change has been CT guided percutaneous drainage. Previously, open surgical procedures had a mortality rate as high as 70%. Current approach has three steps.

Medical Therapy:

Medical Therapy Initiation of antibiotic therapy. Diagnostic aspiration and drainage of abscess. Surgical drainage in selected patients.

Antibiotic Therapy:

Antibiotic Therapy Diagnostic aspiration should be employed prior to antibiotic therapy. Coverage should include aerobic gram negatives, streptococcus, anerobic, including bacteroides. Flagyl and clindamycin is usually good.

Percutaneous Drainage:

Percutaneous Drainage CT or US guided placement of a catheter. Drain is removed once abscess cavity collapses. Success 80-87%. Consider open drainage if fails, or patient worsens over 72 hrs.

Complications of Percutaneous Drainage:

Complications of Percutaneous Drainage Perforation of a viscous. Pneumothorax. Bleeding. Leakage of pus into the abdomen. Immunocompromised patients with multiple abscesses are best treated with high dose antibiotics rather than open or percutaneous drainage.

Surgical Therapy:

Surgical Therapy Five indications as previously discussed. Presence of peritoneal signs mandates emergent exploration. Transthoracic, extraperitoneal, transperitoneal. Transperitoneal is preferred as intra-abdominal pathology can be dealt with.

Complications:

Complications Result from rupture of abscess into adjacent organs or cavities. These include both pleuropulmonary and intrabdominal types. Pleuropulmonary are themost common 15-20%, include effusions, empyema, bronch-hepatic fistula. Intraabdominal include subphrenic abscess, rupture into peritoneal cavity, stomach, colon, vena cava, or kidney.

Outcome andPrognosis:

Outcome andPrognosis Untreated, pyogenic abscess has a 100% mortality rate. Now with early drainage and antibiotics, mortality ranges 15-20%. The four poor prognostic factors are, age over 70, multiple abscesses, polymicrobial infection, presence of associated malignancy or immunosupression.

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