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A liver abscess is a pus-filled cavity within the liver
Types
Amoebic liver abscess Pyogenic liver abscess
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Amoebic liver abscess Caused by ent histolytica
Carried from bowel to liver in portal venous system
More common in adult maleAbscess are usually large single and present in right
upper lobe
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Cont ..
After adherence, trophozoites :-
invadethe colonic epithelium to produce the ulcerativelesions typical of intestinal amebiasis .
lysethe target cells by using lectin to bind to the targetcells' membranes and using the parasite's ionophorelike
protein to induce a leak of ions(i.e, Na+, K+, Ca+) fromthe target cell cytoplasm.
An extracellular cysteine kinasecauses proteolyticdestruction of the tissue, producing flask-shaped ulcers
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Cont ..
Spread of amebiasis to the liver occurs via the
portal blood.Trophozoites ascend the portal veins to
produce liver abscesses filled with acellular
proteinaceous debris. This material has theappearance of anchovy paste.
The trophozoites of E histolyticalyse the
hepatocytes and the neutrophils.
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Cont..
Amebic liver abscessis the most common
form of extraintestinal amebiasis. It results from spread of the organisms from
the intestinal submucosa to the liver via the
portal system.Approximately 40% of patients who have
amebic liver abscess do nothave a history ofprior bowel symptoms.
5% of patients with symptomatic intestinalamebiasis and is 10 times as frequent in men asin women.
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Cont .. presents with fever and a constant, dull, upper right
abdominal or epigastrium pain.
Involvement of the diaphragmatic surface of the liver
may lead to right-sided pleuritic pain or referredshoulder pain.
Associated GI symptoms : - occur in 10-35% of patients and include nausea,
vomiting, abdominal distention, diarrhea, andconstipation.
May present with vague abdominal discomfort, weightloss, and anemia.
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Pain and fever Initially dull in right hypochindrium later becomes
sharp and stabing.
Referred to tip of right or left shoulder and mayincrease by dep inspiration or coughing
Fever initialy high later remittent or intermittent rigorsmay occur
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Examination Ill looking ,toxic and febrile
Enlarged tender liver liver is palpable and severely
tenderJaundice is usually absent
Local edema of chest or abdominal wall may present
Compression test pain on firm pressure with
findertips on intercostel space over a limited area iscommon and valuable in localizing the puss
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Pyogenic liver abscess Thy are uncommon but important because they are
potentialy curable inevitably fatal if untreated
Mortality is 20 to 40% and failure to diagnose is themost common cause
Older patient and those with multiple abscess alsohave high mortality rates
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Causes Billiary obstruction cholingitis
Hematogenous
portal vein mesenteric infection hepatic artery bacteraemia
Truama penetrating or non penetrating
Infection of liver tumor or cyst
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Organisms E coli most common
Strep fecalis
Proteus vulgarisAnaerobes such as bacteriods
S aures occasionally
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Clinical featureAre similar to amebic liver abscess
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Treatment of amebic liver abscessMetronidazole 800 mg 8 hourly orally for 10 days
90% of patient respond within 72 hours with reducepain and fever
Diloxanide furate tab entamizole DS 500 mg 3 timesdaily for 10 days to eliminate intestinal infections
Aspiration of liver abscess
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Indication of aspiration Failure to response clinically in 3 to 5 days
Threat of imminent rupture
Need to rule out pyogenic abscess Left lobe abscess
Large abcess more than 10 cm
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Procedure
A wide bore needle is inserted into area of maximumtendreness or into 8thor 9thintercostal space inmidaxillary line
All available fluid should be removed
Ultrasound guided procedure may be performed
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Treatment of pyogenic liver
abscess Prolonged antibiotic and drainage of abscess
Associated billiary obstruction and cholingitisrequired biliary drainage preferably endoscopicaly
3rdgeneration cephalosporinsuch as cefataxime inj.claforan 1 gm 8 hourly plus metronidazole inj. flagyl500 gm 8 hourly
If cost is problem then use
Ampicillin inj. penbtrin 500 gm 6 hourly Gentamicin inj. gentacin 80 gm 8 hourly
Metronidazole
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AspirationAspiration is required if
abscess is large in size or
does not respond to antibiotics