Liver abscesses and hydatid disease

LIVER ABSCESSES AND

HYDATID DISEASEDr. Muhammad Zoha Farooq

Resident Surgical Oncology

Clinical Scenerio

• 50 years old, diabetic hypertensive farmer from

Gujranwala presented to ER with abdominal pain more

localized in right UQ , jaundice and urticaria. Patient gives

Hx for on and off fever since 1 month. His BP is 130/90.

Pulse 88. Temperature 37 C. On examination there is

enlarged liver, no fluid thrill/ shifting dullness. Gut sounds

are audible.

• What is the differential diagnosis?

• What investigations will you order?

• What is initial management?

What is Abscess?

• Defined as a collection of pus (dead cells and neutrophils)

• An inflammatory process in response to either an

infectious process or other foreign materials

• Liver abscess may be single or multiple

• Can be of different sizes

• May contain foul smelling pus or reddish brown paste.

Incedence and Epidemiology

• Liver – organ most subject to the development of

abscesses

• 13% of total intraabdominal abscesses

• 48% of all visceral abscess

• Mortality - 5-30% of cases

• most common causes of death include sepsis, multiorgan failure,

and hepatic failure

• Equal Male to female ratio. Males have poorer prognosis

Types of Liver Abscess

• There are three major forms of liver abscess, classified by

etiology:

• Pyogenic liver abscess, which is most often polymicrobial,

accounts for 80% of hepatic abscess cases in the United States.

• Amoebic liver abscess due to Entamoeba histolytica accounts for

10% of cases.

• Fungal abscess, most often due to Candida species, accounts for

less than 10% of cases.

Pyogenic Liver Abscess

Pyogenic Liver Abscess

• A pyogenic liver abscess is a type of liver abscess caused

by bacteria, can be single or multiple.

• The right lobe is affected twice as often as the left; 5%

have bilateral involvement.

• No cause found in 15% cases. Most are secondary to

infection originating in the abdomen. Bacterial

endocarditis and dental infection are other causes.

• More common in the immunocompromised and in people

with Liver cirrhosis

Etiology of Pyogenic Liver Abscess

• Disorders or bacterial infection of following origins may

invade liver to cause abscess:

• Biliary disease (most common) e.g.: stones, cholangiocarcinoma,

infection

• Colonic disease. e.g.: diverticulitis, appendicitis, Crohn's disease

• Pancreatitis

• Infection of blood

• Intra-abdominal sepsis

• Endocarditic, Dental infection (with streptococci)

• Traumatic, Iatrogenic

Common Causative Agents

• Most common species invloved are

• E coli 2/3rd

• Streptococcus fecalis

• Pseudomonas

• Klebsiella pneumoniae

• Proteus vulgaris

• Bacteroides

• Staphylococcus and Streptococcus ( Endocarditits)

Amoebic Liver Abscess

• Amoebic liver abscess or amebiasis is a type of liver

abscess caused by Entamoeba Histolytica (Protozoa).

• E. histolytica causes amoebic colitis and dysentery but

liver abscess is the most common extra-intestinal

manifestation of infection

• Route of entry via oro-fecal roue by ingestion of

contaminated food or water. Amoebae invade intestinal

mucosa and can gain access to the portal venous system

Amoebic Liver Abscess

• A large necrotic area which is liquefied into thick reddish-

brown pus (Anchovy sauce pus) due to liquefied necrosis,

thrombosis of blood vessels, lysis of liver cells

• It affects the right lobe in 80%.

• This type is common in overcrowded areas with poor

sanitation and in alcoholics.

Amoebic Liver Abscess

Fungal Liver Abscess

• Fungal abscesses is a less common type,

• Primarily due to Candida albicans

• Occur in individuals with

1. Prolonged exposure to Antimicrobials

2. hematologic malignancies

3. solid-organ transplants

4. congenital and acquired immunodeficiency.

Clinical Presentation

1. Fever with Chills

2. Abdominal pain

3. Anorexia

4. Weight loss

5. Nausea, Vomiting

6. Right shoulder pain / irritable cough

7. Cough and Dyspnea

8. Hepatomegaly

9. Tenderness

10. Rebound tenderness

11. Jaundice (late) 1/3

People At Risk

• Age: Advanced age, particularly in people older than 70 years.

• Health: Having a long-term disease, (cancer, diabetes,

tuberculosis) or splenectomy, a weak immune system, AIDS.

• Taking Drugs: Such as steroids, chemotherapy, prolong use

of antibiotics (fungal abscess).

• Lifestyle: Drinking too much alcohol, too often. Living in over

crowding area, poor sanitation

• Nutrition: Being malnourished (having poor nutrition).

• Activity: Traveling to places where ameobiasis is common.

Eating foods and drinking liquids that are sold in the street may

further increase risk.

Laboratory Studies

1. CBC

1. Increased WBC, usually Neutrophilic Leukocytosis.

2. Raised erythrocyte sedimentation rate (ESR).

3. Mild normochromic normocytic anaemia.

2. Liver function studies

1. Hypoalbuminemia

2. Elevation of alkaline phosphatase

3. Elevations of transaminase and bilirubin levels (variable)

Laboratory Studies

3. Blood cultures are positive in roughly 50% of cases.

4. Stool DR: Stools can contain cysts or trophozoites of

E. histolytica.

5. Serology should be carried out if E. histolytica is

suspected.

6. Culture of abscess fluid should be the goal in

establishing microbiologic diagnosis. Usually done

through Percutaneous needle aspiration (under CT or

Ultrasound Guidance)

Imaging Studies

1. Chest X-Ray: May show raised right hemi-diaphragm on.

2. Ultrasonography

a) Can show abscess

b) Allow guided percutaneous aspiration and drainage and biliary

tree examination.

3. CT scanning

a) Can show the abscess,

b) Allow guided aspiration and drainage

c) Show other intra-abdominal abscesses or a possible cause

such as diverticular disease, appendicitis, etc.

d) Good for the detection of small abscesses.

4. MRI

Imaging

CXR Sono

CT SCAN

Medical Managment

• Antibiotics• Pyogenic liver abscess: Broad spectrum antibiotics should be

started before waiting for culture results.

• Usually start treatment with tri-therapy included the use of penicillin,

amino-glycoside and metronidazole.

• A third-generation cephalosporin can be considered in the elderly

or if renal function is impaired.

• Antibiotic therapy can be modified once culture results are

available.

• Treatment may be needed for up to 12 weeks and should be

guided by the clinical picture and radiological monitoring.

Medical Managment

• Amoebic liver abscess:

• Metronidazole is the treatment of choice. 95% of patients with

amoebic liver abscess recover with this alone. Most patients show

a response to treatment within 72-96 hours.

• Diloxanide furoate should be prescribed for 10 days to eliminate

intestinal amoebae after the abscess has been successfully

treated.

• Antifungal agents such as amphotericin B are used if fungal

abscess is suspected.

Surgical Mangment and Drainage

• Most patients with pyogenic liver abscess or with very large

amoebic abscesses, may not recover with antibiotics alone

need drainage guided by ultrasonography or CT.

• Percutaneous aspiration can be carried out for small

abscesses although

• Catheter drainage carried out for larger abscesses.

• Open surgery may be necessary if

• Abscess ruptured

• Signs of peritonitis,

• Abscess 5 cm

Percutaneous Aspiration and Catheter

Drainage

Complications

1. Return of Abscess

2. Widespread infection in abdomen.

3. Overwhelming sepsis.

4. Rupture of the abscess into adjacent structures

(pleural, peritoneal and pericardial spaces).

5. Secondary infection of amoebic liver abscesses.

Prognosis

• Pyogenic liver abscess

• Mortality rate is 5-30%.

• Condition such as Diabetes Mellitus, immunodeficiency,

malignancy, affect prognosis.

• Amoebic liver abscess

• Mortality rates have fallen to 1-3%.

HYDATID DISEASE OF

LIVER

Etiology

Life Cycle

Clinical Features

• Can involve any organ.

• liver (63%), lungs (25%), muscles (5%), bones (3%), kidneys (2%), brain (1%), and spleen (1%).

• The clinical presentation of a hydatid cyst is largely asymptomatic until complications occur.

• The most common presenting symptoms are abdominal pain, dyspepsia, and vomiting.

• The most frequent sign is hepatomegaly/palpable mass.

• Jaundice and fever are each present in about 8% of patients.

• Bacterial superinfection of a hydatid cyst can occur and present like a pyogenic abscess.

• Rupture of the cyst into the biliary tree.

• Free ruptures can result in disseminated echinococcosis and a potentially fatal anaphylactic reaction.

Laboratory Studies

• Leukocytosis

• Eosinophilia is present in 25%

• Hypogammaglobinemia is present in 30%.

• Serodiagnostic techniques

• Indirect hemagglutination test and the enzyme-linked immunosorbent assay (ELISA) have a sensitivity of 80% overall (90% in hepatic echinococcosis, 40% in pulmonary echinococcosis) and are the initial screening tests of choice.

• Immunodiffusion and immunoelectrophoresis demonstrate antibodies to antigen 5 and provide specific confirmation of reactivity.

• The ELISA test is useful in follow-up to detect recurrence.

Imaging - SONO

• currently the primary

diagnostic technique

and has diagnostic

accuracy of 90%.

• This scan is of a

multiloculated cyst.

Gharbi’s Classification

• Type I : pure cystic fluid Collection (spherical-oval, thick-walled)

• Type II : fluid Collection with membrane separation

• Type III : Fluid collection with septa

• TypeIV: heterogeneous (hypoechoic-hyperechoic-intermediate) pattern

• Type V: completely calcified (Reflecting) walls

CT Scan

• More sensitive than

sono, 95-100%.

Treatment

• The treatment of choice is surgery.

• Available Options:• Medical

• Per-cutaneous

• Endoscopic

• Surgical

Medical Treatment

• Small Cysts , asymptomatic cysts and patients unsuitable

for surgical resection.

• ALbendazole- Relies on diffusion through the cyst

membrane

• Mebendazole

• 400mg BID in cycles of 28 days with 2 weeks period off

between the cycles.

• Usually 3 cycles are sufficient.

PERCUTANEOUS DRAINAGE OF

HYDATID CYST (PAIR)• This technique, performed using either ultrasound or CT

guidance

• involves aspiration of the contents via a special cannula,

followed by injection of a scolicidal and then reaspiration.

• The cysts should be larger than 5 cm in diameter and type

I or II according to the Gharbi ultrasound classification of

liver cysts

• PAIR can be performed on type III cysts as well.

Indications For PAIR

•Patients with:• lesion ≥ 5 cm in diameter (TYPE 1)

• Cysts with detachment of membranes (TYPE2) and/or with daughter cysts (TYPE 3),

• Multiple cysts if accessible to puncture

• Infected cysts

•Also• Pregnant women

• Children >3 years old

• Patients who fail to respond to chemotherapy alone

• Patients in whom surgery is contraindicated

• Patient who refuse surgery

• Patients who relapse after surgery

Contraindications For PAIR

• Non-cooperative patients and inaccessible or risky

location of the cyst in the liver.

• Cyst in spine, brain and/or heart.

• Inactive or calcified lesion.

• Cysts communicating with the biliary tree.

• Cysts open into the abdominal cavity, bronchi and urinary

tract.

PAIR step by Step

•PAIR Protocol (Minimum Requirements):1. Prophylaxis with albendazole

2. Puncture and parasitological examination (if possible) or fast

test for antigen detection in cyst fluid

3. Aspiration of cystic fluid (10-15 cc)

4. Test for bilirubin in cyst fluid

5. If bilirubin present: →→ →→ stop procedure

6. If no bilirubin present: →→ →→ aspirate all cystic fluid

7. Injection of 95 % ethanol solution or hypertonic saline (1/3 of

the amount of aspirated fluid)

8. Re aspiration of protoscolicide solution after 15 minutes

Surgical Treatment

• Indications:

1. Large liver cysts with multiple daughter cysts

2. superficially located single liver cysts that may rupture

(traumatically or spontaneously)

3. liver cysts with biliary tree communication

4. pressure effects on vital organs or structures

5. infected cysts.

Surgical Treatment

• Contraindications:

1. extremes of age

2. Pregnancy

3. severe preexisting medical conditions

4. multiple cysts in multiple organs

5. cysts that are difficult to access

6. dead cysts

7. calcified cysts

8. very small cysts are contraindications.

Principles of Hydatid Surgery

• 1) Total removal of all infective components of the cysts

• 2) The avoidance of spillage of cyst contents at time of

surgery

• 3) Management of communication between cyst and

adjacent structures

• 4) Management of the residual cavity

• 5) Minimize risks of operation

• All the surgical procedures can be divided into two large

groups, conservative group and radical group

Conservative Technique ( Open

Cystectomy)• conservative technique

• aspiration of the cyst,

• instillation of scolicidal agents

• evacuation of the cyst contents and leaving the pericyst.

• The residual pericyst is managed by marsupialization,

which consists of suturing the edges of opened pericyst

with the skin,

• capitonnage (suture obliteration)

Radical Surgical Procedures

• Pericystectomy

• Lobectomy

• Hepatectomy .

• Radical procedures have lower rate of recurrences but

many authors consider them inappropriate, claiming that

intraoperative risks are too high for a benign disease

LAPAROSCOPIC MANAGEMENT OF

HYDATID CYSTS • A special instrument has been developed for the removal

of the hydatid cyst with the laparoscope called the

perforator-grinder-aspirator apparatus.

• The instrument penetrates the cyst, grinds the particulate

matter and sucks it all out.

• The advantage of this instrument over that of conventional

suction apparatus is that it does not gets blocked by the

daughter cysts and laminated membranes..

Follow Up

• Chemotherapy:

• Postoperative treatment with benzimidazoles for 1 month

who have undergone complete resection or PAIR

successfully.

• Continued for 3-6 months for patients, incompletely

resected cyst, spillage during surgery or PAIR.

Follow Up

• Laboratory tests:

• Patients on benzimidazoles should have a CBC count and

liver enzyme evaluation performed at biweekly intervals

for 3 months and then every 4 weeks to monitor for

toxicity.

• ELISA or indirect hemagglutination tests are usually

performed at 3-, 6-, 12-, and 24-month intervals as

screening for recurrence of resected disease or

aggravation of existing disease.

Follow UP

• Imaging:

• Ultrasonography

• CT scan

• at the same intervals as the laboratory tests or as

clinically indicated

THANK YOU