Liver amebic and pyogenic abscess, hydatid cyst, surgical management, sabiston textbook

1. • Liver abscess; Hydatid Cyst
• M530
• Gunchmaa.N, Ludevdorj.N

4. Pyogenic Abscess

5. Epidemiology
• Patients in their 50s or 60s
• Often related to biliary tract disease
• Cryptogenic in nature (uncertain in origin)

6. Pathogenesis
• An inoculum of bacteria exceeds the livers ability to clear it.
• Tissue invasion
• Neutrophil infiltration
• Abscess formation

7. Biliary tree
• Stone or malignant disease
• Biliary obstruction
• Bile stasis
• Bacterial colonization
• Ascends to liver
• Ascending suppurative cholangitis

8. Portal vein
• Ascending portal vein infection – pyelophlebitis
• Diverticulitis, appendicitis, pancreatitis, IBD etc
• Malignant disease

9. Hepatic artery
• Any systemic infection
• Altered immune response
• Direct infection extension

10. Other causes
• Necrotic liver:
• Trauma
• Hepatic artery embolization
• Thermal ablative procedures

11. Pathology
• 75% right hemiliver
• 20% left hemiliver
• 5% caudate lobe
• Mostly solitary
• 1 mm – 4 cm
• Multiloculated or in single cavity

12. Microbiology
• Either polymicrobial or single organism
• Escherichia coli
• Klebsiella pneumoniae
• Staphylococcus aureus
• Enterococcus sp.

13. Clinical features
• Fever
• Chills
• Jaundice
• RUQ pain
• Tenderness to
palpation
• Hepatomegaly
• Acute or
chronic

14. Complication
• If diaphragm is involved, cough or dyspnea
• Peritonitis secondary to rupture
• Rupture into pleural space or pericardium
• Endogenous endophthalmitis (Klebsiella)

15. Lab findings
• Leukocytosis
• Anemia
• LFT abnormality
• ALP elevated /80%/
• Total bilirubin elevated /20-50%/
• Transaminases increase /60%/
• Hypoalbuminemia, increased PT

16. Radiology
• Chest X-ray
Atelectasis
Right pleural effusion
Elevated right
hemidiaphragm
• Plain abdominal X-ray
- Air fluid levels
- Portal venous gas

17. Radiology
• Ultrasound – round or oval, less echogenic than surrounding liver
• CT – lesions are of lower attenuation than surrounding liver, multiple
small abscesses
• Both are useful in diagnosing intra-abdominal diseases

19. Differential diagnosis
• Amebic abscess
• Echinococcal cyst

20. Treatment
• Immediate broad spectrum IV antibiotics /2 weeks</
• Combination of ampicillin, aminoglycosides, metronidazole
• Aspiration, send for culture.
• Percutaneous catheter drainage
• Contraindications: ascites, coagulopathy, proximity to vital structures
• If larger than 5 cm, surgery is better
• Liver resection if destruction is severe

21. Amebic Abscess

22. Epidemiology
• Largely a disease in tropical or developing countries
• Less than 50% are symptomatic
• Mostly Hispanic men
• 20-40 age
• Socioeconomic status
• Alcohol consumption
• Immunosuppression
• Travel history

23. Pathogenesis
• E.histolytica is a protozoan that exists as trophozoite or cyst
• Fecal-oral route
• When ingested, cysts aren’t degraded in stomach
• Trophozoite released
• Invades colon mucosa
• Enzymatic cellular hydrolysis

24. Pathogenesis
• Localized necrosis
• Cavity forms
• It contains proteinaceous debris
• Surrounded by rim of trophozoites
• Rapid IgA release

25. Pathology
• Cavity full of blood, liquefied liver tissue
• The fluid is odorless
• Glisson capsule resistant to hydrolysis
• Early stage, ill-defined
• Right hemiliver

26. Clinical features
• Last from days to 4 weeks
• Fever
• Chills
• RUQ pain and tenderness
• Hepatomegaly
• Constant, dull abdominal pain
• Diarrhea
• Anorexia
• Jaundice

27. Clinical features
• Acute <10 days
• High fevers, chills, abdominal tenderness
• Multiple lesions usually
• Chronic > 2 weeks
• Single right-sided lesion
• Response is similar in both groups

28. Lab findings
• Mild to moderate leukocytosis with no eosinophilia
• Anemia
• LFT abnormality
• Elevated PT-INR
• Enzyme immunoassay
• Detection kit

29. Radiology
• Plain chest x-ray: elevated right hemidiaphragm, pleural effusion,
atelectasis
• Ultrasound: Round lesions, liver capsule, without significant rim
echoes. Contents are hypoechogenic, nonhomogenous
• CT: more sensitive
• Nuclear studies: to differentiate from pyogenic abscess. No
leukocytes, does not light up

31. Differential
diagnosis
• Viral hepatitis
• Echinococcal disease
• Cholangitis
• Cholecystitis
• Appendicitis
• Liver tumor
• Pyogenic abscess

32. Treatment
• Metronidazole 750 mg orally, three times daily, 10 days
• Emetine hydrochloride
• Chloroquine
• After liver abscess is treated, iodoquinol, paromomycin, diloxanide
furoate to treat carrier state
• If failure of metronidazole in 3-5 days, diagnostic aspiration
• Larger than 5 cm, in left side – aspiration
• Radiologic resolution 3-9 months

33. Hydatid Cyst

34. • Hydatid disease or echinococcosis is a zoonosis that is common
worldwide because the dog is a definitive host.
• Human contract the disease from dogs, but there is no human to
human transmission

35. • 3 species that cause hydatid cyst:
• Echinococcus granulosus
• Echinococcus multilocularis
• Echinococcus ligartus
• Humans are end stage to the parasite.

36. • In the human duodenum, the parasitic embryo releases an
oncosphere containing hooklets that penetrate the mucosa, allowing
access to the bloodstream.
• In the blood, it can reaches the liver or lungs, where the parasite
develops its larval stage

37. • 3 weeks after infection, a visible hydatid cyst develops, which then
slowly grows in a spherical manner.

38. • The cyst wall itself has 2 layers, an outer gelatinous membrane
(ectocyst) and an inner germinal membrane (endocyst).
• Brood capsules are small, intracystic cellular masses in which future
worm heads develop into scoleces. In a definitive host, the scoleces
develops into an adult tapeworm.

39. Hydatid cysts can die with:
• degeneration of the membranes
• Development of cystic vacuoles
• Calcification of the wall
• Calcification of a hydatid cyst, however, doesn’t always imply that the
cyst is dead

40. • Hydatic cysts are diagnosed in equal numbers of en and woman at an
average age of about 45 years.
• Approximately 75% of hydatid cysts are located in the right liver and
are solitary

41. • The clinical presentation of a hydatid cyst is largely asymptomatic
until complications occur.
• Dyspepsia
• Abdominal pain
• Vomiting
• Hepatomegaly are the most common symptoms.

42. • Jaundice and fever are each present in approximately 8% of patients.
• Bacterial super infection of a hydatid cyst can occur and be
manifested like a pyogenic abscess

43. • Rupture of the cyst into the biliary tree or bronchial tree or free
rupture into the peritoneal , pleural, or pericardial cavities can occur.

44. Diagnosis
• Serologic tests are available to evaluate antibody response, but all are
plagued by low sensitivity and specifity
• Ultrasound is more common, but it depends on the stage of the cyst
at the time of examination

45. • Simple hydatid cyst is well circumscribed with budding signs on the
cyst membrane
• May contain free floating hyperechogenic hydatid sand
• A rosette appearance is seen when daughter cysts are present

46. • Cyst can be filled with an amorphous mass, which can be
diagnostically misleading
• Calcification in the wall of the cyst is highly suggestive of hydatid
disease

48. • Similar findings are seen on CT or MRI scans
• In patients with suspected biliary involvement, ERCP or percutaneous
transhepatic cholangiography may neccesary

49. Treatment
• Primarily surgical
• Most cyst should be treated
• But in older patients with small, asymptomatic, densely calcified
cysts, conservative management ( drainage nad evacuation) is
appropriate.

50. • Epinephrine and steroids taken by anesthesiologist
• Packing off the abdomen is important because rupture can result in
anaphylaxis and diffuse seeding

51. • Then cyst ih aspirated through a closed suctionsystem and flushed
with a scolicidal agent (hypertonic saline)

52. • The cyst is then unroofed which can then be followed by a number of
possibilities, including
• excision ( or pericystectomy)
• Marsupialization procedures
• Leaving the cyst open
• Drainage of the cyst
• Omentoplasty
• Partial hepatectomy

53. • Pericystectomy or formal partial
hepatectomy can also be
performed without entering thy
cyst.

54. • Simple suture repair is often sufficient, but major biliary repairs,
approaches through the common bile duct, or postoperative ERCP
may be neccesary
• Recurrence rates after surgical treatment is generally 5% or less

55. • Preoperative treatment my decrease the risk of spillage.
• Albendazole or mebendazole is effective with E.granulosus infection,
but cyst appearance occurs 50% of patients
• Medical treatment without resection or drainage should be
considered only for widely diseminated disese or poor surgical
candidate

56. Thank you!