1.Patel Institute Of Nursing & Allied Health Sciences By: Farooq Marwat

2. At the end of this presentation, student will know about: Abscess Liver Abscess Types of Liver Abscess Incidence Rate and Epidemic Data about Liver abscess Who are at risk Clinical Manifestations Diagnosis Treatment Complication Prognosis 3. What is Abscess Abscess may be define as a collection of pus (dead cells and neutrophils) that has accumulated within a tissue because of an inflammatory process in response to either an infectious process (usually caused by bacteria or parasites) or other foreign materials 4. Liver abscess 5. Liver abscess A liver abscess is a collection of pus in the liver caused by bacteria, fungi, or parasites. It may occur as a single lesion or as multiple lesions of different sizes. The abscess may contain thick, bad smelling pus or reddish-brown anchovy paste-like fluid with no odor. Occurs when bacteria/protozoa destroy hepatic tissue, produces a cavity which fills up with infective organisms, liquefied cells & leucocytes. Necrotic tissue then falls off the cavity from rest of the liver. 6. Incidence & Epidemiology 7. Incidence & Epidemiology Liver organ most subject to the development of abscesses 13% of total intraabdominal abscesses 48% of all visceral abscess Mortality - 5-30% of cases most common causes of death include sepsis, multiorgan failure, and hepatic failure Equal Male to female ratio. Males have poorer prognosis 8. Types Of Liver Abscess There are three major forms of liver abscess, classified by etiology: Pyogenic liver abscess, which is most often polymicrobial, accounts for 80% of hepatic abscess cases in the United States. Amoebic liver abscess due to Entamoeba histolytica accounts for 10% of cases. Fungal abscess, most often due to Candida species, accounts for less than 10% of cases. 9. Pyogenic Liver Abscess 10. Pyogenic Liver Abscess A pyogenic liver abscess is a type of liver abscess caused by bacteria, can be single or multiple. The right lobe is affected twice as often as the left; 5% have bilateral involvement. No cause found in 15% cases. Most are secondary to infection originating in the abdomen. Bacterial endocarditis and dental infection are other causes. More common in the immunocompromised and in people with Liver cirrhosis. 11. Pyogenic Liver Abscess 12. Etiology Disorders or bacterial infection of following origins may invade liver to cause abscess: Biliary disease (most common) e.g.: stones, cholangiocarcinoma, infection Colonic disease. e.g.: diverticulitis, appendicitis, Crohn's disease Pancreatitis Infection of blood Intra-abdominal sepsis Endocarditic, Dental infection (with streptococci) Traumatic, Iatrogenic 13. Common Causative Agents Most common species invloved are Streptococcus milleri Pseudomonas E. coli Klebsiella pneumoniae Proteus vulgaris Bacteroides Opportunistic Pathogens (Staphylococcus)` 14. Amoebic Liver Abscess Amoebic liver abscess or amebiasis is a type of liver abscess caused by Entamoeba Histolytica (Protozoa). E. histolytica causes amoebic colitis and dysentery but liver abscess is the most common extra-intestinal manifestation of infection Route of entry via oro-fecal roue by ingestion of contaminated food or water. Amoebae invade intestinal mucosa and can gain access to the portal venous system. 15. Causes a large necrotic area which is liquefied into thick reddish-brown pus (Anchovy sauce pus) due to liquefied necrosis, thrombosis of blood vessels, lysis of liver cells It affects the right lobe in 80%. This type is common in overcrowded areas with poor sanitation and in alcoholics. Amoebic Liver Abscess 16. Amoebic Liver Abscess 17. Fungal Liver Abscess Fungal abscesses is a less common type, primarily due to Candida albicans and occur in individuals with prolonged exposure to antimicrobials, hematologic malignancies, solid-organ transplants, and congenital and acquired immunodeficiency. 18. Clinical Manifestation 1. Fever with Chills, (PUO in Amoebic Abscess) 2. Abdominal pain 3. Anorexia 4. Weight loss 5. Nausea, Vomiting 6. Right shoulder pain / irritable cough 7. Cough and Dyspnea 8. Hepatomegaly 9. Tenderness 10. Rebound tenderness 11. Jaundice (late) 19. People at Risk 20. People at Risk Age: Advanced age, particularly in people older than 70 years. Health: Having a long-term disease, (cancer, diabetes, tuberculosis) or splenectomy, a weak immune system, AIDS. Taking Drugs: Such as steroids, chemotherapy, prolong use of antibiotics (fungal abscess). Lifestyle: Drinking too much alcohol, too often. Living in over crowding area, poor sanitation Nutrition: Being malnourished (having poor nutrition). Activity: Traveling to places where amebiasis is common. Eating foods and drinking liquids that are sold in the street may further increase risk. 21. Laboratory Studies 1. CBC 1. Increased WBC, usually Neutrophilic Leukocytosis. 2. Raised erythrocyte sedimentation rate (ESR). 3. Mild normochromic normocytic anaemia. 2. Liver function studies 1. Hypoalbuminemia 2. Elevation of alkaline phosphatase 3. Elevations of transaminase and bilirubin levels (variable) 22. 3. Blood cultures are positive in roughly 50% of cases. 4. Stool DR: Stools can contain cysts or trophozoites of E. histolytica. 5. Serology should be carried out if E. histolytica is suspected. 6. Culture of abscess fluid should be the goal in establishing microbiologic diagnosis. Usually done through Percutaneous needle aspiration (under CT or Ultrasound Guidance) Laboratory Studies 23. Imaging Study 1. Chest X-Ray: May show raised right hemi-diaphragm on. 2. Ultrasonography a) Can show abscess and also allow guided percutaneous aspiration and drainage and biliary tree examination. A Doppler ultrasound study may be done to check for blood flow in your liver. 3. CT scanning a) Can show the abscess, allow guided aspiration and drainage and show other intra-abdominal abscesses or a possible cause such as diverticular disease, appendicitis, etc. It is good for the detection of small abscesses. 4. Liver Scan 5. MRI 24. CXR USG 25. CT Scan 26. Medical Management Antibiotics Pyogenic liver abscess: Broad spectrum antibiotics should be started before waiting for culture results. Usually start treatment with tri-therapy included the use of penicillin, amino-glycoside and metronidazole. A third-generation cephalosporin can be considered in the elderly or if renal function is impaired. Antibiotic therapy can be modified once culture results are available. Treatment may be needed for up to 12 weeks and should be guided by the clinical picture and radiological monitoring. 27. Amoebic liver abscess: Metronidazole is the treatment of choice. 95% of patients with amoebic liver abscess recover with this alone. Most patients show a response to treatment within 72-96 hours. Diloxanide furoate should be prescribed for 10 days to eliminate intestinal amoebae after the abscess has been successfully treated. Antifungal agents such as amphotericin B are used if fungal abscess is suspected. Medical Management 28. Surgical Management or Drainage Most patients with pyogenic liver abscess or with very large amoebic abscesses, may not recover with antibiotics alone need drainage guided by ultrasonography or CT. Percutaneous aspiration can be carried out for small abscesses although Catheter drainage carried out for larger abscesses. Open surgery may be necessary if Abscess ruptured Signs of peritonitis, Abscess 5 cm Appendicitis. 29. Nursing Management Pain Management: Alleviation or reduction in pain Nutrition Management: Assisting with or providing a balanced dietary intake of foods and fluids. Infection Protection: Infection Control, Prevention and early detection of infection in a patient at risk. 30. Complications 1. Return of Abscess 2. Widespread infection in abdomen. 3. Overwhelming sepsis. 4. Rupture of the abscess into adjacent structures (pleural, peritoneal and pericardial spaces). 5. Secondary infection of amoebic liver abscesses. 31. Prognosis Pyogenic liver abscess Mortality rate is 5-30%. Condition such as Diabetes Mellitus, immunodeficiency, malignancy, affect prognosis. Amoebic liver abscess Mortality rates have fallen to 1-3%.