A 41 YEAR-OLD MAN CAME WITH RIGHT UPPER

ABDOMINAL PAIN
SINCE ABOUT 1 WEEK BEFORE ADMISSION

By:
Bima Indra
Ainindia Rahma

Advisor:
Prof. dr. Eddy Mart Salim, SpPD, K-AI, FINASIM
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 CASE

 Mr. IW, 41 years-old came to Mohammad Hoesin General

Hospital with right upper abdominal pain since about one
week before admission. He felt pain in his upper right
abdomen like being stabbed. Three weeks before admission,
he had diarrhea with blood in his stool. He felt nauseous but
there was no vomit. He also had continous low grade fever.
Four days before admission, the pain get worse that make
patient prefer to lay down to reduce the pain.

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CASE ILLUSTRATION

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 IDENTIFICATION

 Name : Mr. IW
 Age : 41 yo
 Address : Palembang
 Religion : Islam
 Status : Married
 Occupation : Parking attendant
 Admission : February 13th 2019

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ANAMNESIS

Autoanamnesis and Aloanamnesis

On February 14th 2019, 05.00 PM

Chief Complaint

Right upper abdominal pain since about one week before

admission

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 PRESENT HISTORY OF DISEASE

3 weeks before admission, he had diarrhea with blood in his

stool. He felt nauseous but there was no vomit. He also had
continous low grade fever. There was no shivering, cough, and
flu. 1 week before admission, he felt pain in his upper right
abdomen, like being stabbed. Nauseous was present but without
vomit. He also felt fatigue. Diarrhea was still present with blood
in his stool. There was no chest pain, shortness of breath, and
yellowish eyes.

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PRESENT HISTORY OF DISEASE

 4 days before admission, the pain get worse that make

patient prefer to lay down to reduce the pain. He still felt
nauseous and decrease appetite. Then the patient was
taken to Muhammadiyah Hospital then the patient was
refered to Mohammad Hoesin General Hospital.

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PREVIOUSLY HISTORY OF
DISEASE
 No history of liver disease
 No history of hypertension
 No history of DM
 No history of heart disease, kidney disease and lung
disease
 No history of allergy

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FAMILY HISTORY OF DISEASE

 No history of diarrhea and abdominal pain in family

 No history of DM
 No history of hypertension

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HISTORY OF SOCIAL ECONOMY,
JOBS, AND HABITS

The patient is a parking attendant. He earns Rp 2.000.000,- per

month. He never smoke and consume alcohol.

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PHYSICAL EXAMINATION

(February 14th 2019, 05.00 PM)

General Condition
 General Appearance : moderately sick
 Awareness : compos mentis
 Blood Presure : 110/70 mmHg
 Pulse : 83x/minute (irregular)
 Respiratory : 18x/minute (reguler)
 Temperature : 36,8oC.
 Body Weight : 60 kg
 Height : 160 cm
 IMT : 23,43 kg/m2

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PHYSICAL EXAMINATION

Head
 Shape : Normocephali
 Expression : Normal
 Hair : Black, half white
 Alopesia : (-)
 Deformity : (-)
 Tenderness : (-)
 Puffy Face : (-)

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PHYSICAL EXAMINATION

Eye
 Konjungitva Palpebra : pale
 Vision : normal

Ear
 Pain : (-)
 Secret : (-)
 Hearing disorders : (-)

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PHYSICAL EXAMINATION

Mouth
Hygiene : Good
Lips : Cheilitis (-), sianosis (-)
Tongue : dirty (-), atrophy papil (-)

Neck
Inspection : Trachea deviation (-)
Palpation : Enlargement of the thyroid gland/struma (-)
JVP : (5-2)cmH2O

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PHYSICAL EXAMINATION

Chest
Inspection : Normal chest form, no spacing
of the ribs, chest wall retraction (-), Spider nevi (-),
venektasi (-)
Palpation : tenderness (-)
Percussion : pain (-)
Auscultation : crepitation (-)

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 PHYSICAL EXAMINATION
Lung
Inspection :
 Static : dextra same with sinistra , Retraction(-)
 Dynamic : dextra same with sinistra , Retraction(-)
Palpation : Tenderness (-), spacing of ribs (-), Tactile fremitus was
symmetrical on both lungs.
Percussion : pain (-), sonor in both areas of the lung
Auscultation : Vesicular (+) normal, rhonchi (-/-) on basal of the
lung, wheezing (-/-)

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 PHYSICAL EXAMINATION

Heart
Inspection : Ictus cordis is not visible
Palpation : Ictus cordis is not palpable
Percussion : Upper right heart border is on right linea sternalis of
ICS IV and left heart border is on linea midclavicularis of ICS V
Auscultation : HR 83 x/m, regular heart sound I-II, no murmur and
gallop

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 PHYSICAL EXAMINATION

Abdomen
Inspection : Convex, no venectation and scar
Palpation : Abdomen was relaxed, there was tenderness on upper
right quadrant, Ludwig sign (+), liver was palpable 3 cm below costal
margin and 3 cm below xiphoid process with soft consistency,
slippery surface, spleen and kidney ballotement are not palpable
Percussion : Thymphani, there was shifting dullness
Auscultaion : There was normal abdominal sound 5x/minutes

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PHYSICAL EXAMINATION

Extremity
Superior : no pale, warm, no peripheral edema, no
palmar erythema, and no clubbing finger
Inferior : no pale, warm. There was no peripheral
edema, no palmar erythema, and no clubbing finger
ROM : Active and passive range of motion of both
superior and inferior extremities is wide
Strength : The strength of right and left extremities
both superior and inferior is 5

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LABORATORY RESULT

Examination Result Normal Value

Hemoglobin 9,5 g/dl 13.40 – 17.00 g/dL
RBC 3,21x106/mm3 4.40-6,30x106/mm3
Leukosit 13,16x103/mm3 5000-10000/mm3
Hematokrit 28% 41-51 %
Trombosit 468.000/mm3 189.000-400.000/mm3
Diff. count 0/0/74/19/7 0-1/1-6/50-70/20-40/2-8
AST/SGOT 33 U/L 0-32 U/L
ALT/SGPT 48 U/L 0-31 U/L
Ureum 9 mg/dL 16.6 – 48.5 mg/dL

Kreatinin 0,61 mg/dL 0.50 -0.90 mg/dL

Glukosa Sewaktu 80 mg/dL <200 mg/dL

Natrium (Na) 138 mmol/L 135 – 155 mmol/L

Kalium (K) 3.3mmol/L 3.5 – 5.5 mmol/L

7.0 mmol/L 8.2-10,2mmol/L 20
Calcium
DIAGNOSIS

Temporary Diagnosis
Liver abscess

Differential Diagnosis
Cholecystitis
Gastroentritis

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MANAGEMENT

Non- Pharmacology Pharmacology

- Education  IVFD NS 0,9% gtt XX/minute
- Bedrest  Abscess aspiration
- Vital sign monitoring  Metronidazole 3x1gr IV
 Ceftriaxone 2x1gr IV
 Lansoprazole 1x 30 mg IV

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PROGNOSIS

 Quo ad vitam : dubia ad bonam

 Quo ad functionam : dubia ad bonam

 Quo ad sanationam : dubia ad bonam

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LITERATURE REVIEW

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 LIVER ABSCESS
An encapsulated collection of suppurative material within the
liver parenchyma.

Amoebic - found in the developing countries

Liver - tend to affect younger population especially males
Abscess - coexisting diarrhoea occurs in 30% of patient
(ALA)

Pyogenic - found in the developed countries

Liver - most common age group was 41–50 years
Abscess - rare but potentially lethal condition
(PLA)
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AMOEBIC LIVER ABSCESS (ALA)

 Caused by Entamoeba histolytica

 Most infections are asymptomatic. Among symptomatic amebic
dysentery is the most common presentation.
 Liver abscesses are the most common extraintestinal
presentation; the trophozoites reach the liver via the portal
venous circulation
 3-20 times higher in adult men than other groups
 patients who present with amebic liver abscess have usually
traveled to endemic region
 Increased in patients with altered cell-mediated immunity; HIV
infection

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AMOEBIC LIVER ABSCESS (ALA)

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AMOEBIC LIVER ABSCESS (ALA)

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AMOEBIC LIVER ABSCESS (ALA)

 Right upper quadrant (RUQ) pain

 Fever
 Associated diarrhea, although some will report (<30%)
 History of dysentery in the prior months
 Jaundice(<10%)
 On physical examination : tenderness to palpation over the RUQ.
 On laboratory evaluation : leukocytosis without eosinophilia and an
elevated alkaline phosphatase out of proportion to any elevation in
aminotransferases
 On ultrasound, the lesion is a round, well-defined hypoechoic mass

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AMOEBIC LIVER ABSCESS (ALA)

 Management of ALA is mainly drug therapy with amoebicidal

drugs, the large ones may require needle aspiration
 Amoebicidalc drugs:
Metronidazole which acts on both intestinal and hepatic
amoebiasis is drug of choice, given as 750 mg orally TID for 5-10
days
Emetine, dehydroemetine and cloroquine are alternatives
Patient who continue to pass cyst in their stool after a course of
metronidazole may benefit from diloxanide furoate or di-
iodohydroxyquinolone

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AMOEBIC LIVER ABSCESS (ALA)

 Prognosis is better than pyogenic, but if untreated it may burst

into:
Right pleural cavity resulting in empyema
Right lung causing bronchohepatic fistula, lung abscess or
pneumonia
Peritoneal cavity or even the pericardial cavity if there is single
large abscess of the left lobe
 Rarely, the amoebic abscess may extend into kidney as well

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PYOGENIC LIVER ABSCESS (PLA)

 Rare disease
 Primarily affects older individuals, with peak incidence between
50 to 60 years of age
 Risk factors include diabetes mellitus, underlying hepatobiliary
or pancreatic disease, and gastrointestinal malignancy
 Most PLA cases are polymicrobial, with commonly identified
pathogens including mixed enteric facultative and anaerobic
species.

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PYOGENIC LIVER ABSCESS (PLA)

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PYOGENIC LIVER ABSCESS (PLA)

 The classic triad of right upper quadrant abdominal pain,

fevers/chills, and malaise is only present in approximately 30%
of patients.
 Other symptoms include rigors, nausea/vomiting, anorexia,
weight loss, and generalized weakness.
 Less commonly, patients may present with cough, hiccups, or
referred right shoulder pain due to diaphragmatic irritation.
 Common physical examination findings include right upper
quadrant abdominal tenderness, jaundice, and hepatomegaly.

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PYOGENIC LIVER ABSCESS (PLA)

 Laboratory evaluation often reveals leukocytosis, normocytic anemia,

hypoalbuminemia, and prolonged prothrombin time. Elevated
inflammatory markers, including erythrocyte sedimentation rate and
C-reactive protein, are sensitive, but nonspecific for diagnosis.
 An elevated alkaline phosphatase is the most commonly observed
laboratory abnormality, occurring in up to 90% of patients.
 Approximately 50%-65% of patients will have elevated aspartate and
alanine aminotransferases and total bilirubin levels.
 Blood cultures are positive in 30%-60% of cases, although rates are
higher with K. pneumoniae.
 Organisms are isolated from the majority (70%-80%) of abscess
aspirates

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PYOGENIC LIVER ABSCESS (PLA)

 Computed tomography (CT) and ultrasound are the preferred

imaging modalities for diagnosis of PLA, the former being
slightly more sensitive (93%-97% versus 83%-95%).
 PLAs appear as hypo- or hyperechoic lesions with internal debris
on ultrasound, and nonenhancing hypodense lesions with rim
enhancement on CT
 PLA presents as a solitary abscess in 65%- 85% of cases, with a
predilection for the right hepatic lobe due in part to its receipt of
the majority of portal venous return.

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PYOGENIC LIVER ABSCESS (PLA)

 Percutaneous drainage, along with targeted antimicrobial therapy, is

the mainstay of therapy.
 Criteria for percutaneous drainage include abscess size >5 cm,22
ongoing pyrexia despite 48 to 72 hours of appropriate medical therapy,
and clinical or imaging features concerning for impending perforation.
 Percutaneous drainage via ultrasound or CT with placement of a
drainage catheter is associated with high rates of success. However,
8%-36% of patients will fail this approach and require surgery.
 Indications for surgical drainage include abscess rupture, uncorrected
primary pathology, incomplete percutaneous drainage, inadequate
clinical response after 4–7 days of percutaneousdrainage, and
multiloculated abscesses.

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PYOGENIC LIVER ABSCESS (PLA)

 Empiric regimens should be formulated based on suspected

etiology and local antibiotic susceptibility patterns, and
modified based on culture results.
 Recommendations include parenteral therapy for 2–3 weeks or
until there is a favorable clinical response, followed by an oral
regimen for 2–6 weeks or until clinical, laboratory, and
radiographic studies demonstrate abscess resolution.

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PYOGENIC LIVER ABSCESS (PLA)

 Case series from the past decade report mortality rates of 2%-
14%.
 Risk factors for mortality include advanced age, malignancy,
shock, jaundice, multiple abscesses, hemoglobin <10 g/dL, and
elevated blood urea nitrogen

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THANK YOU
Any question?

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