Dr. Muayad Abbas
Lec. 2
LIVER INFECTIONS
Thurs. 5 / 11 / 2015
DONE BY : Ali Kareem
مكتب اشور لالستنساخ
2015 – 2016
LIVER INFECTIONS Dr. Muayad Abbas
5-11-2015
2
LIVER INFECTIONS
Ascending cholangitis
Ascending bacterial infection of the biliary tract is usually associated with
obstruction and presents with clinical jaundice, rigors and a tender
hepatomegaly.
The diagnosis is confirmed by the finding of dilated bile ducts on ultrasound,
an obstructive picture of liver function tests and the isolation of an organism
from the blood on culture.
The condition is a medical emergency, and delay in appropriate treatment
results in organ failure secondary to septicaemia.
Once the diagnosis has been confirmed, the patient should be commenced on
a first-line antibiotic (e.g. Third generation cephalosporin) and rehydrated,
and arrangement should be made for endoscopic or percutaneous
transhepatic drainage of the biliary tree.
Biliary stone disease is a common predisposing factor, and the causative
ductal stones may be removed at the time of endoscopic cholangiography by
endoscopic sphincterotomy.
Pyogenic liver abscess
The aetiology of a pyogenic liver abscess is unexplained in the majority of
patients.
It has an increased incidence in the elderly, diabetics and the
immunosuppressed, who usually present with anorexia, fevers and malaise,
accompanied by right upper quadrant discomfort.
The diagnosis is suggested by the finding of a multiloculated cystic mass on
ultrasound or CT scan.
And is confirmed by aspiration for culture and sensitivity.
LIVER INFECTIONS Dr. Muayad Abbas
5-11-2015
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The most common organisms are Streptococcus milleri and Escherichia coli,
but other enteric organisms such as Streptococcus faecalis, Klebsiella and
Proteus vulgaris also occur, and mixed growths are common.
Treatment is with antibiotics and ultrasound-guided aspiration.
First-line antibiotics to be used are a penicillin, aminoglycoside and
metronidazole or a cephalosporin and metronidazole.
Percutaneous drainage without ultrasound guidance should be avoided as
an empyema may follow drainage through the pleural space.
A source for the liver abscess should be sought, particularly from the colon.
Amoebic liver abscess
Entamoeba histolytica is endemic in many parts of the world. It exists in
vegetative form outside the body and is spread by the faeco-oral route.
The most common presentation is with dysentery, but it may also present
with an amoebic abscess, the common sites being paracaecal and in the
liver.
The amoebic cyst is ingested and develops into the trophozoite form in the
colon, and then passes through the bowel wall and to the liver via the portal
blood.
Diagnosis is by isolation of the parasite from the liver lesion or the stool and
confirming its nature by microscopy.
Often patients with clinical signs of an amoebic abscess will be treated
empirically with metronidazole (750 mg t.d.s. for 5–10 days) and
investigated further only if they do not respond.
Hydatid liver disease
Very common condition in countries around the Mediterranean.
The causative tapeworm, Echinococcus granulosus, is present in the dog
intestine, and ova are ingested by humans and pass in the portal blood to the
liver.
LIVER INFECTIONS Dr. Muayad Abbas
5-11-2015
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Presentation :
Upper abdominal discomfort
Acute abdomen after minor abdominal trauma due to rupture of the cyst into
the peritoneal cavity.
Active cysts contain a large number of smaller daughter cysts and rupture
can result in these implanting and growing within the peritoneal cavity .
Liver cysts can also rupture through the diaphragm, producing an empyema,
into the biliary tract, producing obstructive jaundice, or into the stomach.
Diagnosis :
On ultrasound multiloculated cyst
CT scan finding of a floating membrane within the cysts .
Clinical and radiological diagnosis can be supported by serology for
antibodies to hydatid antigen in the form of an enzyme-linked
immunosorbent assay (ELISA).
Treatment :
In the first instance, a course of albendazole or mebendazole may be tried.
Failure to respond to medical treatment usually requires surgical
intervention,
Percutaneous treatments with hypertonic saline and alcohol have been
attempted.
The surgical options :
Liver resection or
Local excision of the cysts or
De-roofing with evacuation of the contents.
Hydatid cyst of the liver
Treatment
Ideally managed in a tertiary unit by a multidisciplinary team of
hepatobiliary surgeon, physician and interventional radiologist
Leave asymptomatic and inactive cysts alone – monitor size by ultrasound
Active cysts should first be treated by a full course of albendazole
Several procedures are available – PAIR, pericystectomy with omentoplasty
and hepatic segmentectomy; it is important to choose the most appropriate
option
Increasingly, a laparoscopic approach is being tried
LIVER INFECTIONS Dr. Muayad Abbas
5-11-2015
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Active hydatid daughters should be avoided by continuing drug therapy with
albendazole and adding peroperative praziquantel.
This should be combined with packing of the peritoneal cavity with
hypertonic (20%) saline-soaked packs and instilling into the cyst before it is
opened.
A biliary communication should be actively sought and sutured.
The residual cavity may become infected, and this may be reduced, as may
bile leakage, by packing the space with pedicled greater omentum (an
omentoplasty).
Calcified cysts may well be dead. .
Rupture of daughter hydatids into the biliary tract may result in obstructive
jaundice or acute cholangitis.
This may be treated by endoscopic clearance of the daughter cysts prior to
cyst removal from the liver.
LIVER TUMOURS
Benign liver tumours
Haemangiomas
Most common liver lesions
They consist of an abnormal plexus of vessels, and their nature is usually
apparent on ultrasound.
If diagnostic uncertainty exists, CT scanning with delayed contrast
enhancement shows the characteristic appearance of slow contrast
enhancement due to small vessel uptake in the haemangioma.
Lesions found incidentally require confirmation of their nature and no
further treatment.
The management of ‘giant’ haemangiomas is more controversial Occasional
reports of rupture of haemangiomas have led some to consider resection for
the large lesions,
They have little if any malignant potential, and this is not indication for
surgery.
LIVER INFECTIONS Dr. Muayad Abbas
5-11-2015
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Percutaneous biopsy of these lesions should be avoided as they are vascular
lesions and may bleed profusely into the peritoneal cavity.
Hepatic adenoma
Rare benign liver tumours.
Imaging by CT demonstrates a well-circumscribed and vascular solid
tumour.
They usually develop in an otherwise normal liver.
Unfortunately, there are no characteristic radiological features to
differentiate these lesions from malignant tumours.
Angiography will demonstrate a well developed peripheral arterialisation of
the tumour.
Confirmation of the nature of these lesions is required by either
percutaneous biopsy or resection with histological confirmation.
These tumours are thought to have malignant potential, and resection is
therefore the treatment of choice.
An association with sex hormones (including the oral contraceptive pill) is
well recognised, and regression of symptomatic adenomas on withdrawal of
hormone stimulation is well documented.
Focal nodular hyperplasia
Unusual benign condition of unknown aetiology .
There is a focal overgrowth of functioning liver tissue supported by fibrous
stroma.
Patients are usually middle-aged females,
Ultrasound shows a solid tumour mass but does not help in discrimination.
Contrast CT may show central scarring and evidence of a well-vascularised
lesion.
LIVER INFECTIONS Dr. Muayad Abbas
5-11-2015
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A sulphur colloid liver scan may be useful.
FNH contain both hepatocytes and Kupffer cells. The latter take up the
colloid allowing differentiation of FNH from either a benign adenoma or a
primary or metastatic cancer, neither of which contains a significant
number of Kupffer cells.
Hepatocellular carcinoma
Primary liver cancer (HCC) is one of the world’s most common cancers,
and its incidence is expected to rise rapidly over the next decade due to the
association with chronic liver disease, particularly HBV and HCV.
Many patients known to have chronic liver disease are now being screened
for the development of HCC by serial ultrasound scans of the liver or serum
measurements of alphafetoprotein (AFP).
Patients often present in middle age, either because of the symptoms of
chronic liver disease (malaise,weakness, jaundice, ascites, variceal
bleed,encephalopathy).
Or with the anorexia and weight loss of an advanced cancer.
The surgical treatment options include resection of the tumour and liver
transplantation.Which option is most appropriate for an individual patient
depends on the stage of the underlying liver disease, the size and site of the
tumour, the availability of organ transplantation the management of the
immunosuppressed patient .
Staging and clinical assessment of HCC
o In addition to a general assessment of the patient’s fitness for surgery,
o crucial information is the severity of the underlying liver disease and the
size and site of the tumour.
o Extensive liver resections in patients with advanced cirrhosis are associated
with a high mortality due to liver failure and sepsis.
LIVER INFECTIONS Dr. Muayad Abbas
5-11-2015
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o In contrast, extensive resections for HCC in a non cirrhotic liver are
associated with a low risk of liver failure, and resection rather than
transplantation would be the treatment option of choice.
o Tumours often metastasise to the lung and bone
o and, therefore, a chest CT scan and a bone scan are useful staging
investigations.
o Evidence of intraperitoneal disease is difficult to determine by CT scan, and
laparoscopy may be useful for this purpose.
Surgical approach to HCC
The surgical approach should remove the known cancer with a 1-to 2-cm
margin of unaffected liver tissue.
In patients with associated chronic liver disease, the volume of liver resected
should be minimised to reduce the incidence of postoperative liver failure.
Local or segmental resections are preferred to major resections .
Non-surgical therapy for hepatocellular carcinoma
The majority of patients diagnosed with HCC will not be amenable to
surgical resection because of the advanced stage of the cancer or the
severity of the underlying liver disease.
These patients can be offered local ablative treatments such as transarterial
embolisation (TAE), transarterial chemoembolization (TACE), percutaneous
ethanol ablation (PEA) or RFA
Follow-up and adjuvant treatment
o There is little evidence that adjuvant chemotherapy will improve the
prognosis of patients following resection of HCC, and it may damage the
function of the liver in those with underlying chronic liver disease.
o AFP is a clinically useful tumour marker for follow-up, although its low
sensitivity would suggest that imaging should also be used.
LIVER INFECTIONS Dr. Muayad Abbas
5-11-2015
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Secondary Liver Metastases
The most common site for blood born metastases
Common Primaries : colon , breast , lung , stomach , pancreases &
melanoma
Mild cholestatic picture (ALP, LDH) with preserved liver function
Dx imaging or FNA
Treatment depends on the primary cancer
In some cases resection or chemoemobilization is possible .
#END …
Done by
Ali Kareem