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