Liver abscess: main symptoms, signs, causes, treatment and prevention
Description
AA liver abscess is a limited accumulation of pus in the liver parenchyma with a focus of lytic tissue fusion in the center, resulting from the penetration of microflora (bacteria, fungi) or parasitic invasion (protozoa, helminths).
Often a liver abscess is secondary, as it is formed as a result of other pathological processes. It is possible to form both single and multiple foci of pus.
In different countries, the incidence varies greatly. This may depend on the general development of medical care and the timely diagnosis of diseases in which liver abscesses develop more often. A significant contribution is made by the general conditions and the degree of invasion of the population by protozoa and helminths. Thus, the number of abscesses in the liver is about 2 cases in North America per 100 thousand of the population and 275.4 per 100 thousand in Taiwan.
Liver abscess is a serious disease with a large number of causes. It is shown that the frequency of detection of abscesses in the general surgical hospital tends to increase in recent years. Every year, from 0.5 to 2-3% of patients with diseases of the hepatobiliary zone are forced to be hospitalized due to the formation of purulent processes in the liver.
In socially developed industrial countries, liver abscesses of bacterial etiology are usually recorded, and in countries with a tropical climate, amoeba invasion is a common cause. Until recently, before the mass introduction of antibiotics and other antibacterial therapy into medical practice, the main cause of liver abscess was acute appendicitis. Recently, the dominant causes in the formation of purulent foci in the liver are diseases of the biliary tract and liver, malignant neoplasms, as well as complications after performing invasive medical measures.
Liver abscesses are a serious problem in surgery due to difficulties in diagnosis, the development of fatal complications and high mortality.
Despite the use of antibacterial therapy for liver abscesses of bacterial etiology, the number of deaths is high, reaching 20-30%.
With abscesses of amoebic and opisthorchiasis etiology, despite ongoing therapy, mortality is 26% and 15.5%, respectively. Mortality in multiple liver abscesses is significantly higher compared to single abscesses, reaching, according to some authors, more than 50%.
Symptoms
The main clinical signs of the development of a liver abscess are the following symptoms: pain in the right hypochondrium, fever 380C-400C, chills, an increase in the size of the liver, in the presence of large abscesses, jaundice may develop.
The pains are long, have the character of aching, dull, radiating to the right shoulder girdle. Patients feel a feeling of heaviness and fullness on the right. There is loss of appetite and weight loss. General weakness, malaise develops. Appear nausea and vomiting, loose stools. With compression of the bile ducts, patients may feel the appearance of itching.
Perhaps the development of portal vein thrombosis and, as a result, the development of splenomegaly (enlargement of the spleen), the appearance of ascites (fluid in the abdominal cavity), which are signs of the development of portal hypertension.
Cholangiogenic liver abscesses, according to the literature, represent the main etiological group of liver abscesses. They are characterized by an unclear clinical picture, high mortality, which is due to the combination of two surgical infections – purulent cholangitis and abscesses.
The clinical manifestation of a liver abscess may be the development of pleural effusion, which occurs with fever, pain in the upper abdomen or pain in the lower chest, the appearance of pleural pain. Such manifestations of a liver abscess present diagnostic difficulties, since pleural effusion can be with many other pathologies – viral hepatitis, perforation of the abdominal organs, spleen abscess, subdiaphragmatic abscess, diseases of the abdominal cavity.
During a physical examination, liver abscesses are determined – soreness in the projection of the liver on palpation, an increase in the size of the liver, the appearance of an irritable peritoneum syndrome, icterus of the sclera and skin is possible.
Forms
Abscesses of the liver are divided into primary and secondary.
The primary ones include purulent foci caused by bacteria and parasites that spread through the hematogenous and lymphogenous pathways.
Secondary – are formed as a result of suppuration of pathological formations in the liver. These include post-traumatic abscesses.
The classification of liver abscesses is based on several features.
Primary abscesses – bacterial (pyogenic), parasitic (amebic, ascarid, echinococcal, opistochosis, giardia).
Secondary / secondary suppuration (suppuration of neoplasms in the liver) – the collapse of a granuloma in tuberculosis or syphilis, suppuration of a decaying cancer or non-parasitic cyst, post-traumatic suppuration, including suppuration around a foreign body in the liver.
There is also a classification that takes into account mainly the cause of the development of an abscess – by etiology. On this basis, distinguish:
- cholangiogenic (biliary) – due to the spread of infection to the liver through the biliary tract;
- liver abscesses as complications of purulent pathology of internal organs;
- post-traumatic liver abscesses due to suppuration of intrahepatic hematomas after injuries;
- liver abscesses, which are complications of parasitic lesions of the organ (amebiasis, alveococcosis, opisthorchiasis, etc.);
- liver abscesses that have developed as a result of hematogenous infection in the liver during sepsis;
- cryptogenic liver abscesses when the etiology is unclear.
By number, they are distinguished: single and multiple liver abscesses.
By location relative to the lobes of the liver: abscesses of the right lobe, left lobe, both lobes. According to the localization of cysts relative to the surface of the liver: subcapsular-parenchymal (the most common, more than 50% of cases), subcapsular, intraparenchymal.
Causes
The most common causes of a liver abscess are purulent-inflammatory diseases of the abdominal organs, postoperative complications, suppuration of cysts and hematomas, and liver neoplasms. In recent years, there has been an increase in liver abscesses of mycotic (fungal) or tuberculous etiology.
Prior to the widespread use of antibiotics, liver abscesses resulting from a complicated course of appendicitis occupied the leading role. The use of antimicrobial drugs, the frequency of such cases decreased to isolated cases. Since the middle of the last century, there has been a sharp increase in the number of cholangiogenic abscesses, which still represent the main group, reaching almost half of all cases of liver abscesses. Risk factors for this pathology include cicatricial strictures of the bile ducts and choledocholithiasis, as well as the use of transhepatic drains, endobiliary stents, and the presence of choledochoduodenoanastomosis.
Pyogenic liver abscesses, which developed as complications of purulent pathology of internal organs, account for about 30% – they are usually caused by diseases of the biliary tract and cholangitis. The most frequently detected microflora are ischerichia (Escherichia coli), Klebsiella, Staphylococcus aureus, streptococci. Almost 2/3 of abscesses have a mixed flora. The most common of these are paravesical abscesses in acute calculous cholecystitis. It can also occur with appendicitis, diverticulitis of the large intestine and directly with liver damage.
A large number of liver abscesses of amoebic etiology are recorded in the inhabitants of the African continent, Asia and South America. 50% of patients have a history of intestinal amoebiasis. Of the 6 species of amoeba, the causative agent is the species Entamoeba histolitica isolated from the large intestine. This is due to the epidemiological and cultural characteristics of these regions – the consumption of raw water and food, a low social standard of living, and elevated ambient temperatures. A high risk for amoebic amoebiasis is high in male homosexuals.
One of the etiological factors of parasitic liver abscesses is opisthorchiasis.
Post-traumatic liver abscess is formed as a result of traumatic injury and accounts for up to 15% of all purulent liver lesions. Its development is associated with damage to the vascular and biliary tract with septic necrosis of the liver parenchyma.
Ways of spread of infection, with the subsequent development of an abscess can be: biliary; portal (appendicitis, diverticulitis, Crohn’s disease, ulcerative colitis, etc.); arterial (sepsis – the cause of an abscess in 10% of cases); contact (spread of infection from adjacent organs); traumatic; cryptogenic – with an unexplained etiology account for about 18%. In the origin of liver abscesses, the following factors can be distinguished: laparotomy in the immediate history – about half of the cases of the total number of patients, cholangiogenic – 18.5%, infected hematomas – 6%, festering cysts – 2%.
The number of cases of formation of liver abscesses in patients with biliary acute pancreatitis has increased with untimely and inadequate surgical or conservative treatment of inflammation of the pancreas and parapancreatic fat.
A rare case of penetration of fish bone after perforation of the walls of the stomach into the liver tissue with subsequent development of a liver abscess is described.
Diagnostic methods
Diagnosis of liver abscess syndrome is carried out by a surgeon on the basis of clinical examination data, collection of complaints, anamnesis.
The importance is given to a carefully collected anamnesis – diseases of the biliary system, the presence of infectious diseases and chronic foci of infection, abdominal trauma, neoplasms in the abdominal cavity, and surgical interventions.
The presence of a mass formation in the liver is confirmed by imaging diagnostic methods – ultrasound examination of the liver, radiography, computed tomography (CT) of the abdominal cavity, magnetic resonance imaging (MRI). These methods allow you to determine the location of the purulent formation, and under the control of ultrasound, a fine-needle biopsy of the focus is performed in order to take material for microbiological examination of the contents for microflora with the determination of sensitivity to antibiotics. The radiograph reveals a cavity with a level of fluid, which is a characteristic sign of an abscess. Possible signs of reactive pleurisy.
It is believed that CT should become the method of choice when examining patients with an unclear nature of cavitary and parenchymal processes.
Additional diagnostic methods are angiography, intraoperative cholangiography, magnetic resonance cholangiopancreatography.
In complex diagnostic cases, diagnostic laparoscopy is prescribed.
In laboratory tests – an increase in the activity of transaminases (AST and ALT), an increase in the content of bilirubin. In 80% of patients, an increase in alkaline phosphatase activity is found.
In the clinical analysis of blood, more than half of the patients had leukocytosis more than 20×109/l (at a rate of 4-10×109/l).
Differential diagnosis of liver abscesses is carried out with – cholangitis, liver cancer, echinococcosis, cysts.
The main laboratory tests used.
- Biochemical blood test (including “liver tests”).
- Clinical blood test.
- Sowing the contents of the abscess with the determination of sensitivity to antibiotics.
Basic instrumental research methods
- Baked UZI.
- MRI of the abdomen.
- CT baked.
- Radiography of the liver, lungs.
Additional instrumental research methods
- Angiography.
- Intraoperative cholangiography.
- Magnetic resonance cholangiopancreatography.
Treatment
There are several algorithms on the basis of which they are guided when making a decision in the treatment of liver abscess.
Currently, the main method of treatment for liver abscess is minimally invasive intervention under ultrasound or CT control – single or multiple percutaneous punctures and drainage of abscesses.
With an abscess size not exceeding 1.5-3 cm, there is the possibility of antibacterial therapy or antiparasitic therapy if amoebiasis is detected. Drug therapy is carried out with a combination of antibiotics – ceftriaxone or ciprofloxacin with metronidazole (in the case of abscesses of amoebic etiology).
With sizes up to 8 cm, puncture is indicated under ultrasound control. With formations measuring 8–12 cm, after percutaneous puncture of the abscess, a drain is placed into the cavity for daily sanitation and evacuation of the contents. With large volumes of a purulent focus, damage to the lobe of the liver, laparotomy, open sanitation and drainage are resorted to. Liver resection is used for multiple abscesses within the same anatomical region, as well as abscesses occupying the entire anatomical region.
When diagnosing helminthic invasion (suppuration of an echinococcal cyst), albendazole or mebendazole is added to the treatment.
In the treatment of cholangiogenic liver abscesses, an important step is the removal of cholestasis and cholangitis using endoscopic retrograde cholangiopancreatography and endoscopic papillosphinctertomy.
Complications
Serious complications of a liver abscess include sepsis, peritonitis, bleeding. With an amoebic liver abscess, a right-sided pleural effusion can occur – reactive pleurisy, as a result of aseptic inflammation or as a result of an abscess rupture through the diaphragm.
Prevention
Timely treatment of diseases that contribute to the development of a liver abscess, as well as early treatment of an already formed purulent focus, in most cases leads to recovery and a decrease in the risk of death. In areas of increased risk for amoebiasis, general hygiene rules should be observed.
