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PYOGENIC LIVER ABSCESS 1938: 20 s and 30 s - acute appendicitis Now : 60 s - biliary tract disease or cryptogenic

Pathogenesis : Liver exposed- portal venous bacterial load

clear this bacterial loads-usual circumstances


Hepatic abscess-inoculum of bacteria- exceeds -the liver ability to clear it.

Potential route : 1. Biliary tree 2. Portal vein 3. Hepatic artery 4. Direct extension 5. Trauma

Biliary tree :

-Most common
-Biliary obstruction -Ascending suppurative cholangitis -Related to stone disease or malignancy Portal venous system : -drain the gastrointestinal tract -ascending portal vein infection -diverticulitis,appendicitis, pancreatitis .

Hepatic artery : -Endocarditis , pneumonia, osteomyelitis -Bacteremie and infection

Direct extension :
-Suppurative cholecystitis, subphrenic abscess, perinephric abscess, perforation of intestine Trauma : -penetrating and blunt trauma Commonly-no cause found

Pathologic and Microbiology :

- right lobe of liver


-20% left lobe -5% caudate lobe -Bilobar-uncommon -50% solitary -Size : millimeters-centimeters in diameter -Appear tan and are fluctuant -Can cause adhession

-Most common Escherichia coli and Klebsiella pneumoniae -Anaerobic organism 40% to 60%

Clinical features :

-Classic description

- fever
- jaundice - right upper quadrant pain - tenderness

-Fever and right upper quadrant tenderness40% to 70% -Jaundice - 25% -Chest findings- 25% -Hepatomegaly 50%

-Leucocytosis 70% to 90%


-Chest radiograph-50% -Ultrasuond and CT - mainstays -Ultra sound 80% to 90% -CT - 95% to 100%

Differential diagnosis :

1. Amebic abscess
2. Echinococcal cyst Treatment : -before antibiotics and drainage uniformly fatal -Combination gram negative + gram positive + anaerobe. -antibiotics-2 or more weeks -Percutaneous drainage

-Surgery if percutaneous drainage fails

Amebic abscess :

Pathogenesis
-E.histolitica ---Protozoon-thropozoite or cyst -Ingestion -cyst- fecal-oral route -Human are the pricipal host -Contaminated water and vegetable -Once ingested cyst not degraded in stomach pass intestinetropozoite release- passed on to the colon. In the colon - invade mucosa- desease.

-Trophozoite -liver portal venous system.

Pathology -Result liquefaction liver tissue

-Anchovy sauce and odorless


-Glisson capsule resistant -Mainly in the right liver

Clinical Feature -20s 40s years -Travel to endemic area -Fever, chills, anorexia, right upper quadrant pain, tenderness and hepatomegaly -abdominal pain-constant, dull, right upper quadrant

-1/3 diarrhea
-1/3 active amebic colotis

-mild to moderate leukocytosis without eosinophilia

-Anemia is common
-70% do not have detectable amebae in their stool -Circulating anti amebae antibodies-90%-95% -Plain chest radiographsbabnormal50% : - elevated right diaphragm - pleural effusion - atelectasis -Abdominal ultrasound- 90% -CT more sensitive

Differential Diagnosis a. pyogenic abscess b. hydatid cyat c. viral hepatitis d. cholangitis e cholecystitis

f. appendicitis

Management -Mainstay treatment -metronidazole--- 750mg orally three times perday for ten days curative in over 90% -Therapeutic needle aspiration -Operative- rupture

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