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Liver Abscess-Etiology

Liver Abscess | Medical Science Optional Notes for UPSC

  • Pyogenic Liver Abscess (80% of cases):
    • Predominantly caused by polymicrobial infections, with E. coli being the most common causative organism.
    • K. pneumoniae is the second most common pathogen.
    • Other bacteria contributing to the infection include Enterococci, Streptococci, Staphylococcus aureus, Proteus vulgaris, and anaerobes.
  • Non-Pyogenic Liver Abscess:
  • Fungal Infection (<10% of cases): Candida species are the predominant causative agents.
  • Amebic Liver Abscess (<10% of cases): Entamoeba histolytica is the primary organism responsible for the infection.

Liver abscess-Clinical presentation

  • Classic Triad of Pyogenic Liver Abscess:
    • Fever (with or without chills and rigors).
    • Malaise.
    • Right upper quadrant pain.
  • Other Symptoms:
    • Anorexia and weight loss.
    • Nausea and vomiting.
    • Symptoms of diaphragmatic irritation.
  • Physical Examination:
    • Jaundice.
    • Tender hepatomegaly.
    • Intercostal tenderness.
    • Epigastric tenderness.
    • Decreased breath sounds in the right lower lobe of the lung.
    • Features of sepsis.
  • Note: The symptoms of pyogenic liver abscess are often non-specific, including fever, weight loss, and others.

Question for Liver Abscess
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Which organism is the most common causative agent in pyogenic liver abscess?
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Liver abscess-investigations

Laboratory Tests

  • Complete Blood Count:
    • Neutrophilic leukocytosis.
    • Normocytic normochromic anemia.
  • Liver Function Tests and Enzymes:
    • Increased alkaline phosphatase (90%).
    • Elevated AST and ALT.
    • Hypoalbuminemia.
    • Hyperbilirubinemia.
  • Inflammatory Markers:
    • Increased ESR and CRP.
  • Blood Culture:
    • Positive in approximately 50% of cases.

Imaging

  • Abdominal imaging is confirmatory for pyogenic liver abscess.
  • Abdominal Ultrasound (US):
    • Solitary/multiple, poorly demarcated, fluid-filled, round hypoechoic lesion(s) within the hepatic parenchyma with surrounding edema and hyperemia.
  • Abdominal CT Scan:
    • Similar findings to abdominal ultrasound; peripheral rim enhancement is observed with IV contrast administration.

Percutaneous Aspiration and Culture of the Aspirate

  • Both diagnostic and therapeutic (refer to the "Treatment" section below).
  • Performed under US or CT guidance.
  • Aspirated material is cultured to determine the organism and its antibiotic-susceptibility profile.

Liver abscess-Differential diagnosis

Pyogenic Liver Abscesses Need Differentiation from Other Space-Occupying Lesions of the Liver:

  • Amebic Liver Abscess: Amebic liver abscess is one of the conditions requiring differentiation.
  • Hepatic Echinococcosis (Hydatid Cyst of the Liver): Hepatic echinococcosis, specifically hydatid cysts of the liver, is another entity that needs to be distinguished.
  • Hepatic Cysts: Simple hepatic cysts should be considered in the differential diagnosis.
  • Benign Liver Tumors: Various benign liver tumors may present as space-occupying lesions and need to be differentiated.
  • Hepatocellular Carcinoma: Hepatocellular carcinoma is a malignant liver tumor that requires consideration in the differential diagnosis.
  • Liver Metastases: Metastatic lesions in the liver, originating from other primary sites, should also be distinguished from pyogenic liver abscesses.

Liver abscess-Treatment

  • Treatment Approach for Pyogenic Liver Abscesses: Pyogenic liver abscesses are typically managed with a combination of intravenous (IV) antibiotics and percutaneous drainage. Surgical drainage may be necessary in some cases.
  • Antibiotics:
    • Antibiotics are recommended for all cases.
    • Broad-spectrum IV antibiotics include ampicillin + sulbactam, piperacillin + tazobactam, or a 3rd generation cephalosporin + metronidazole until antibiotic susceptibility is known.
  • Drainage of the Abscess Cavity:
    • Percutaneous drainage or needle aspiration is indicated for nearly all pyogenic liver abscess cases.
    • For solitary abscess:
      • Small abscesses (<5 cm) may be managed with percutaneous needle aspiration.
      • Large abscesses (>5 cm) may require percutaneous drainage with intracavitary catheter placement.
      • If percutaneous drainage/aspiration is unsuccessful, a second attempt can be made before considering surgical drainage.
  • Indications for Surgical Drainage (Open/Laparoscopic):
    • Multiple or loculated abscesses.
    • Deep-seated abscess not amenable to percutaneous drainage.
    • Ruptured abscess.
    • Thick viscous pus that cannot be drained percutaneously.
    • Underlying diseases requiring surgical intervention (e.g., choledocholithiasis, appendicitis, etc.).
  • Contraindications: Coagulopathy (e.g., international normalized ratio (INR) > 1.5; thrombocytopenia due to sepsis).
  • Considerations: The underlying etiology (e.g., choledocholithiasis, biliary stricture) should be addressed to prevent recurrent pyogenic liver abscesses.

Liver Abscess | Medical Science Optional Notes for UPSC

Question for Liver Abscess
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What is the primary investigative tool for diagnosing amoebic liver abscess?
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Liver abscess-Complications

Complications of Liver Abscess:

  • Rupture: Rupture can lead to various complications.
  • Into the Abdomen (Peritonitis): Rupture into the abdomen can result in peritonitis.
  • Into the Chest (Empyema): Rupture into the chest may lead to empyema.
  • Into the Retroperitoneum (Retroperitoneal Abscess): Rupture into the retroperitoneum can cause the formation of a retroperitoneal abscess.
  • Sepsis: Systemic infection (sepsis) is a potential complication.
  • Pneumonia: Pneumonia can occur as a consequence.
  • Pleural Effusion: Pleural effusion is another possible complication.

Poor Prognostic Factors:

  • Certain factors indicate a less favorable prognosis.
  • Pyogenic Abscess with Sepsis: Presence of sepsis in pyogenic abscess.
  • Advanced Age (>70 Years): Older age, specifically over 70 years.
  • Multiple Abscesses: The presence of multiple abscesses.
  • Polymicrobial Infection; Anaerobic Infection: Infection involving multiple organisms or anaerobic bacteria.
  • Immunosuppression (e.g., Malignancy, Diabetes): Weakened immune system due to conditions like malignancy or diabetes.
  • Need for Surgical Drainage: The necessity for surgical drainage is also considered a poor prognostic factor.

Pathogenesis of Amoebic liver abscess

Liver Abscess | Medical Science Optional Notes for UPSC

Clinical features of Amoebic liver abscess

Intestinal Amebiasis (Dysentery):

  • Loose stools with mucus and bright red blood.
  • Symptoms include painful defecation, tenesmus, abdominal pain, cramps, weight loss, and anorexia.
  • Fever occurs in 10-30% of cases, with possible systemic symptoms like fatigue.
  • High risk of recurrence, often through self-inoculation (hand to mouth).
  • A chronic form resembling inflammatory bowel disease is also possible.

Extraintestinal Amebiasis:

  • Symptoms typically have an acute onset; subacute courses are rare.
  • In 95% of cases, manifests as amebic liver abscess, usually a solitary abscess in the right lobe.
  • Fever is present in 85-90% of cases (compared to amebic dysentery).
  • Right upper quadrant pain or pressure sensation is common.
  • Chest pain and pleuralgia may also occur.
  • Diarrhea precedes only about a third of all cases of amebic liver abscess.
  • In 5% of cases, abscesses may occur in other organs, especially the lungs, and in rare cases, the brain, with accompanying organ-specific symptoms.
  • Diarrhea precedes only about a third of all cases of amebic liver abscess.

Liver Abscess | Medical Science Optional Notes for UPSC

Question for Liver Abscess
Try yourself:
Which organism is the most common causative agent of pyogenic liver abscess?
View Solution

Management of Amoebic liver abscess

  • Diagnosis:
    • Liver function tests may exhibit mild abnormalities, with uncommon occurrences of hyperbilirubinemia.
    • CT scans, more than ultrasounds, are the primary investigative tools.
    • Confirmation of diagnosis involves serological tests (enzyme immunoassay) for antiamoebic antibodies.
    • Cultures of amoebic abscesses usually yield negative results.
  • Treatment:
    • Invasive amebiasis is addressed with a nitroimidazole such as metronidazole or tinidazole, followed by a luminal amebicide like paromomycin.
    • Indications for percutaneous aspiration in amebic liver abscess include:
    • Large abscesses (>5 cm).
    • Lack of response to medical therapy within 5 days.
    • Suspected superinfection.
    • Abscesses of the left lobe of the liver at risk for rupture into the pericardium.
  • Malecot Catheter:
    • Utilized in draining amoebic liver abscesses.
    • It is a self-retaining urinary catheter with an umbrella or flower tip.
    • The catheter contains sulfur, making it radioopaque.

Liver Abscess | Medical Science Optional Notes for UPSC

Pyogenic vs amoebic liver abscess

Liver Abscess | Medical Science Optional Notes for UPSC

Liver abscess-Repeats

Q1: What is an abscess? Describe the method of draining a deep abscess by Hilton's method. (1995)

Q2: Describe the clinical features of amoebic abscess liver and its management. (1995)

Q3: Discuss pathogenesis and lab diagnosis of amoebic liver abscess. (1998) 

Q4: What are the causes of liver abscess? Discuss their clinical presentation. How will you investigate and manage? (2006)

Q5: Enumerate the complications of liver abscess. How would you manage a 40-year old diabetic with suspected liver abscess in left lobe of liver? (2011)

Q6: What are the mode of infection, clinical presentation and complications of amoebic liver abscess? Briefly outline the management of patients with amoebic liver abscess including surgical intervention. (2013)

The document Liver Abscess | Medical Science Optional Notes for UPSC is a part of the UPSC Course Medical Science Optional Notes for UPSC.
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FAQs on Liver Abscess - Medical Science Optional Notes for UPSC

1. What is the etiology of liver abscess?
Ans. The etiology of liver abscess can be either pyogenic or amoebic. Pyogenic liver abscess is usually caused by bacteria such as Escherichia coli and Klebsiella pneumoniae, while amoebic liver abscess is caused by the parasite Entamoeba histolytica.
2. What are the clinical presentations of liver abscess?
Ans. The clinical presentations of liver abscess can vary but commonly include fever, abdominal pain, jaundice, weight loss, and fatigue. Other symptoms may include nausea, vomiting, and an enlarged liver.
3. What investigations are conducted for liver abscess?
Ans. The investigations conducted for liver abscess may include blood tests to assess liver function, complete blood count, and inflammatory markers. Imaging techniques such as ultrasound, computed tomography (CT) scan, or magnetic resonance imaging (MRI) may be used to visualize the abscess.
4. What are the differences between pyogenic and amoebic liver abscess?
Ans. Pyogenic liver abscess is usually caused by bacteria, while amoebic liver abscess is caused by a parasite. Pyogenic abscess is commonly associated with a history of underlying infections, such as biliary tract infections or abdominal surgery. Amoebic abscess is often associated with a history of travel to endemic areas and is more prevalent in developing countries.
5. Can liver abscess recur?
Ans. Yes, liver abscess can recur in some cases. Factors such as underlying liver disease, incomplete treatment, or reinfection can contribute to the recurrence of liver abscess. It is important to identify and address the underlying cause to prevent recurrence.
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