Hepatobiliary—Liver Abscess
Concept
Usually a complication of an underlying disease process (appendicitis, biliary disease, diverticulitis). Less likely the result of amebic infection. More commonly today associated with immunosuppression (HIV) or IVDU (endocarditis).
Way Question May be Asked?
“A 35 y/o male is evaluated in the ED for fever, chills, and a constant, dull ache in the right flank. He has a history of IVDU, and his CT scan shows multiple liver abscesses.
What do you want to do?”
How to Answer?
Full H + P
History
IVDU HIV
Recent abdominal infections Travel hx
History of malignancy (could this be presentation of metastatic disease)
Physical Exam
Full physical especially abdominal exam (liver enlarge- ment, tenderness)
Lymphadenopathy
Diagnostic Tests
Hepatitis panel/LFTs (still working up RUQ pain) CBC
Ultrasound RUQ
CT scan abdomen/pelvis
Agglutination/compliment fixation tests to r/o amebic abscess
Surgical Treatment
Amebic abscess (Entamoeba histolytica) →Flagyl unless:
Secondary infection
Rupture into biliary tree or abdominal cavity Failure to initially improve on abx (may need to be
on abx for months if see initial improvement) Pyogenic abscess
(Either from biliary tree or from portal venous system from direct extension from adjacent organ)
→ Percutaneous drainage and IV Abx (can try to treat multiple small abx with IV abx)
→ Open drainage if percutaneous is not possible:
(depends on location of abscess)
posteriorly through bed of 12th rib and extraperi- toneal approach interiorly through subcostal inci- sion and extraperitoneal approach transperitoneally
Common Curveballs
Pt will have history of malignancy
Pt will have associated intraabdominal process Pt will have history of IVDU/HIV
Pt will have amebic abscess Will have multiple abscesses
Will need to perform open drainage and be asked to describe your approach
Amebic abscess will rupture into abdominal cavity or biliary tree
Will need to describe treatment of diverticulitis or cholangitis (change of scenario) once you take care of abscess
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Strikeouts
Not checking for pyogenic abscess from abdominal source Not ruling out amebic abscess
Not getting biopsy of abscess wall to r/o malignancy Mixing up treatment of Ecchinococcal cysts and amebic
abscess
(Ecchinococcal/hydatid cysts identified by electropho- resis, initially treated with mebendazole, failure to resolve demands first ERCP to r/o communication with biliary tree, then surgery and injection of cyst with hypertonic saline, avoiding any spillage—anaphylaxis—and perform- ing pericystectom y)
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