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06-06-2008, 09:43 PM
Aetiology:
1- Pyaemic liver absces "due to general or portal pyaemia".
2- May follow suppurative cholangitis.
3- Infection of a cyst or haematoma.
4- Amoebic liver abscess "the commonest & most important".
I) Pyaemic Liver Abscess:
Ä Aetiology and pathology: These rare infections occur in the course of systemic or portal pyaemia. Multiple small abscesses walled by liver tissue is formed.
Ä Clinical picture: manifestations of severe toxemia. The liver is enlarged and tender. Jaundice is common.
Ä Treatment: Blood transfusion, antibiotics, fluids, and treatment of the original cause. Rarely a solitary big abscess may form in the liver and may need surgical drainage. The prognosis now become better after new antibiotic generations and advancements in the intensive care units.
2) Suppurative Cholangitis and Cholangitic Abscess:
Ä Aetiology and pathology: The commonest cause of suppurative cholangitis is obstruction of the common bile duct by a stone and therefore a history of long standing gall bladder disease is usually obtained. The infection ascends along the bile ducts leading to suppuration in the intrahepatic ducts and formation of multiple small abscesses.
Ä Clinical picture: There is fever with rigors. The liver is painful, enlarged and tender. Jaundice is usually marked.
Ä Treatment: Removal of the cause of obstruction and drainage of the common bile duct by T tube.
3-Amoebic Liver Abscess (Tropical abscess)
ÄPathogenesis:
1- The amoebae are carried by the portal vein to the liver {amoebic hepatitis}.
2- It cause autolysis and liquefaction of liver cells which lead to
Ÿ Shaggy wall of the abscess.
Ÿ Chocolate coloured pus " anchovy sauce"
ÄPathology:
Site: Posterosuperior surface of the right lobe. why Rt. lobe? As the amoeba affect the Rt. colon more than the left, and according the theory of double stream flow in the portal vein, amoeba goes from Rt. colon to the Rt. lobe.
Number: Usually solitary.
Size: Big, may occupy whole right lobe of the liver.
Contents: Chocolate-coloured pus composed of necrosed liver cells and haemolysed RBC's.
Wall :
At first composed of necrotic liver tissue.
If abscess become chronic, it become fibrous.
Amaeba is found in the wall not in pus.
ÄComplications:
1- Destruction of the liver substance.
2- Rupture into:
Pleura Empyema.
Bronchus expectoration of pus.
Pericardium effusion.
Peritonium peritonitis.
Hollow viscus. spont. cure.
Skin (point into costal margin).

ÄClinical picture:
1- General manifestations of toxaemia with earthy looking .
2- Local manifestations of abscess in the liver:
a) Enlarged liver with extension of its dullness in the chest.
b) Tenderness over it & in intercostal spaces.
c) Congestion & oedema may appear in the skin of the epigastrium.
ÄInvestigations:
1- Stool examination Entamaeba histolytica cysts.
2- X-ray elevated copula of diaphragm.
3- Ultrasongraphy Liver abscess.
4- Liver scanning area of reduced activity.
5- Therapeutic test by metronidazole dramatic response.
ÄTreatment:
(I) Medical treatment:
Indicated once the diagnosis is made, give flagyl (metrodidazol)
500mg t.d.s for l0days.
(II) Surgical treatment:
Indicated when inspite of treatment the abscess enlarges and the symptoms persists.
1- Aspiration and injection of Emitine HCl into the cavity:
Sonar guided or C.T. guided aspiration and injection of Emitine can be done.
2- Open drainage:
Indicated only when the abscess was in the left lobe or complicated.
It is done by one of 3 methods:
1- Post. subpleural approach as subpherinic abscess.
2- Transpleural approach.
3- Transperitoneal approach.
FN.B. Open drainage carries the risks of hemorrhage & 2ry infection.
SOURCE: DR. AYMAN SALEM'S BOOK
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