Abscess of liver - Clinicals, Diagnosis, and Management

Gastroenterology

Clinicals - History

Fact Explanation
Asymptomatic Asymptomatic liver abscess is very rarely seen. Asymptomatic
Asymptomatic liver abscess is very rarely seen.
Fever Liver abscess causes fever as a result of release of pyrogens. Fever can come as spikes or may be continuous presenting as pyrexia of unknown origin. Fever is associated with chills, nausea, vomiting, anorexia and malaise. Fever
Liver abscess causes fever as a result of release of pyrogens. Fever can come as spikes or may be continuous presenting as pyrexia of unknown origin. Fever is associated with chills, nausea, vomiting, anorexia and malaise.
Right upper quadrant pain Patients complain of right upper quadrant pain due to inflammation and swelling of the liver. Right upper quadrant pain
Patients complain of right upper quadrant pain due to inflammation and swelling of the liver.
Cough Patient develop cough and sometimes hiccup due to diaphragmatic irritation. This can cause referred pain over the right shoulder as well. Right sided empyema and collapse can also cause cough. Cough
Patient develop cough and sometimes hiccup due to diaphragmatic irritation. This can cause referred pain over the right shoulder as well. Right sided empyema and collapse can also cause cough.
Loss of appetite and loss of weight Patients can complain of long term loss of appetite and weight. Loss of appetite and loss of weight
Patients can complain of long term loss of appetite and weight.
Yellowish discoloration of the skin and eyes Jaundice can be the only presenting complain in some patients. Jaundice is commonly associated with multiple liver abscesses. Yellowish discoloration of the skin and eyes
Jaundice can be the only presenting complain in some patients. Jaundice is commonly associated with multiple liver abscesses.
Presence of risk factors Biliary diseases are common risk factors for the development of hepatic abscesses. Presence of inflammatory bowel disease, diverticulitis, appendicitis, history of bowel surgery, diabetes, alcoholism and immuno-compromised states can lead to spread of the infective organisms in to the liver and development of liver abscess. However some patients may not have a detectable foci of origin of the infection, these abscesses are called cryptogenic abscesses. Presence of risk factors
Biliary diseases are common risk factors for the development of hepatic abscesses. Presence of inflammatory bowel disease, diverticulitis, appendicitis, history of bowel surgery, diabetes, alcoholism and immuno-compromised states can lead to spread of the infective organisms in to the liver and development of liver abscess. However some patients may not have a detectable foci of origin of the infection, these abscesses are called cryptogenic abscesses.

Clinicals - Examination

Fact Explanation
Febrile Patients can be febrile to touch. Febrile
Patients can be febrile to touch.
Jaundice Liver abscess can give rise to jaundice. Jaundice
Liver abscess can give rise to jaundice.
Abdominal examination Tender hepatomegaly can be detected. If the abscess is situated in the left liver abscess, epigastric pain can be found and hepatomegaly may not be detected. Hepatic rub can be found in some patients. Abdominal examination
Tender hepatomegaly can be detected. If the abscess is situated in the left liver abscess, epigastric pain can be found and hepatomegaly may not be detected. Hepatic rub can be found in some patients.
Examination of the respiratory system Liver abscess can lead to development of right pleural effusion. This can be detected by the presence of reduced chest movements, stony dull percussion note, and absent breath sounds over the right lower lobe of the lung. Examination of the respiratory system
Liver abscess can lead to development of right pleural effusion. This can be detected by the presence of reduced chest movements, stony dull percussion note, and absent breath sounds over the right lower lobe of the lung.

Investigations - Diagnosis

Fact Explanation
Full blood count Anemia can be detected. Neutrophilic leukocytosis can be found secondary to infection. Full blood count
Anemia can be detected. Neutrophilic leukocytosis can be found secondary to infection.
Serum protein levels Hypoalbuminemia is the most common association of liver abscess. Serum protein levels
Hypoalbuminemia is the most common association of liver abscess.
Alkaline phosphatase Elevation of alkaline phosphatase enzyme can be found is many patients. Alkaline phosphatase
Elevation of alkaline phosphatase enzyme can be found is many patients.
Serum bilirubin Serum bilirubin can be elevated. Serum bilirubin
Serum bilirubin can be elevated.
Hapatic transaminases Elevated hepatic transaminases can be found in some patients. Hapatic transaminases
Elevated hepatic transaminases can be found in some patients.
Blood culture Blood culture can be positive in some patients. But bacteremia cannot be detected in some. Blood culture
Blood culture can be positive in some patients. But bacteremia cannot be detected in some.
Culture of abscess fluid aspirate Gram stain and culture of the aspirate of the abscess lead to the isolation of the organism. Both aerobic and anaerobic cultures are indicated in most of the patients. Antibiotic sensitivity test can lead the necessary treatment. Culture of abscess fluid aspirate
Gram stain and culture of the aspirate of the abscess lead to the isolation of the organism. Both aerobic and anaerobic cultures are indicated in most of the patients. Antibiotic sensitivity test can lead the necessary treatment.
Chest X-ray Chest X-Ray is often normal in many patients. Elevated hemidiaphragm can be seen due to the liver abscess. Right sided pleural effusion, lung atelectasis or right lobar consolidation can be detected in some patients. Chest X-ray
Chest X-Ray is often normal in many patients. Elevated hemidiaphragm can be seen due to the liver abscess. Right sided pleural effusion, lung atelectasis or right lobar consolidation can be detected in some patients.
Ultrasound scan of the abdomen This is a noninvasive investigation option to diagnose liver abscess. Ultrasound scan shows a irregular cystic mass. However if gas forming organisms are present (Klebsiella pneumoniae, ) in the abscess the ultrasound visualization is a little difficulty. Ultrasound scan of the abdomen
This is a noninvasive investigation option to diagnose liver abscess. Ultrasound scan shows a irregular cystic mass. However if gas forming organisms are present (Klebsiella pneumoniae, ) in the abscess the ultrasound visualization is a little difficulty.
CT abdomen Contrast enhanced CT scan has higher sensitivity in diagnosing liver abscess than the ultrasound scan. Fluid and gas filled intrahepatic mass or masses can be detected in CT. CT abdomen
Contrast enhanced CT scan has higher sensitivity in diagnosing liver abscess than the ultrasound scan. Fluid and gas filled intrahepatic mass or masses can be detected in CT.
Endoscopic retrograde cholangiopancreatography If biliary etiology is suspected ERCP is helpful in diagnosis. Magnetic resonance cholangiopancreatography is more advanced alternative for ERCP. Endoscopic retrograde cholangiopancreatography
If biliary etiology is suspected ERCP is helpful in diagnosis. Magnetic resonance cholangiopancreatography is more advanced alternative for ERCP.

Investigations - Management

Fact Explanation
Ultrasound scan of the abdomen Ultrasound scan is a non-invasive investigation option to monitor the size of the abscess and to detect recurrence of lever abscess. Ultrasound scan of the abdomen
Ultrasound scan is a non-invasive investigation option to monitor the size of the abscess and to detect recurrence of lever abscess.

Management - Specific

Fact Explanation
Drainage of the abscess Since the action of antibiotics is limited in an abscess, drainage of the abscess will hasten the recovery. Percutaneous drainage can be done if the abscess can be approached percutaneously, if not or if the abscess is larger than 5cm in diameter surgical drainage is necessary. Drainage can be guided by ultrasound or CT for accurate localization and drainage. Minimal invasive procedures like laparoscopic drainage are practiced recently. Drainage of the abscess
Since the action of antibiotics is limited in an abscess, drainage of the abscess will hasten the recovery. Percutaneous drainage can be done if the abscess can be approached percutaneously, if not or if the abscess is larger than 5cm in diameter surgical drainage is necessary. Drainage can be guided by ultrasound or CT for accurate localization and drainage. Minimal invasive procedures like laparoscopic drainage are practiced recently.
Antibiotic treatment Antibiotic therapy should be guided by the isolated organism’s antibiotic susceptibility. If sepsis is suspected, early administration of broad spectrum antibiotics will be helpful. An extended spectrum B-lactam, third generation cephalosporin and metronidazole are commonly used combination. Fluoroquinolone is an alternative to B-lactams. Antibiotic treatment
Antibiotic therapy should be guided by the isolated organism’s antibiotic susceptibility. If sepsis is suspected, early administration of broad spectrum antibiotics will be helpful. An extended spectrum B-lactam, third generation cephalosporin and metronidazole are commonly used combination. Fluoroquinolone is an alternative to B-lactams.

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