Abscess of liver

What is a liver abscess? This development of the inflammatory process in the liver tissues to the state of their necrosis and the formation of a cavity with purulent contents. That is, the abscess is the result of inflammation, which can be due to a variety of reasons.

[1], [2], [3], [4], [5], [6], [7], [8], [9], [10]

Epidemiology

According to clinical statistics, the abscess of the right lobe of the liver is diagnosed five times more often than the abscess of the left lobe, and twice exceeds the number of cases when bilateral suppuration is detected.

The epidemiology of liver abscesses gives every reason to assert that purulent abscesses of the liver are the most common type of visceral abscess: they account for almost 48% of cases of purulent abscesses of the abdominal organs. According to some data, the annual incidence is estimated at 2.3-3.6 cases per 100 thousand population; while the pathology in men appears 2.5 times more often than in women.

The highest level of development of amoebic liver abscess in the world is recorded in the countries of East Asia and the Asia-Pacific region. According to WHO, 12% of the world's population are chronically infected with dysenteric amoeba and can have a latent chronic liver abscess.

[11], [12], [13], [14]

Causes of the abscess of liver

Experts call as the most common cause of liver abscess stones in the gallbladder and arising on their background cholecystitis or cholangitis. Also, liver abscess can be a consequence of rupture of an inflamed appendix, perforation of a stomach ulcer or sigmoid colon with diverticulosis; ulcerative colitis; pyogenic inflammation of the portal vein; Crohn's disease; general infection of blood; cholangiocarcinomas; colorectal cancer or malignant tumor of the pancreas; suppuration of liver cysts or organ trauma.

Pyogenic or purulent liver abscess (code K75.0 for ICD-10) always has an infectious etiology. And pathogenesis is associated with the ingestion of microbes into the liver (mainly E. Coli, St. Milleri, St. Pyogenes, St. Faecalis, Pseudomonas spp., Clostridium welchii, Proteus vulgaris, Klebsiella pneumoniae, Bacteroides Spp.) Migrating from the outbreak primary inflammation with a blood flow in the form of a septic embolus.

In the liver, the multiplication of bacteria continues, which leads to the death of parenchyma cells and the necrosis of its individual areas with the formation of an infiltrate; then the infiltrate is melted and a cavity filled with pus surrounded by a fibrous capsule is formed. Often capsules form septa. This is how the bacterial abscesses of the liver develop.

When the same bacteria enter the liver from the gallbladder (the primary focus of infectious inflammation) through the extrahepatic bile ducts, doctors determine biliary or cholangiogenic liver abscesses. Among their causes, in addition to the violation of the patency of the bile ducts due to the presence of stones in them, narrowing of the lumen (stenosis and stricture) of the channels of iatrogenic origin is noted: after the bile-hepatic surgical interventions, as well as the use of medicines (eg, steroids or cytostatics).

In addition, the causes of liver abscess can be associated with the invasion of parasites (ascarids, echinococcus or dysentery amoeba). In particular, with liver damage, dysenteric amoeba (Entamaeba histolytica) develops amoebic liver abscess (ICD-10 code - A06.4) or extraintestinal dysenteric amoebiasis of the liver. Infection occurs by the fecal-oral route in endemic regions (tropics and subtropics). Amoebs invade the intestinal mucosa and can access the portal vein system and then penetrate into the liver tissue, where they transform into the form of tropho-isotides and clog the hepatic capillaries. As a result of necrosis of deprived nutrition of hepatocytes, a chronic liver abscess is formed.

It has been established that amoebic liver abscess can occur without the previous history of amoebic colitis and dysentery, that is, the infection can manifest itself in months and even years after amoeba invasion.

It is much less likely to diagnose a liver abscess of a fungal etiology (candida, aspergillus) that develops after chemotherapy of malignant neoplasms in the organs of the abdominal cavity or leukemia in patients with severely weakened immunity.

The focus of purulent inflammation of the hepatic parenchyma is more often solitary (single), but in some pathologies - in the case of the formation of concrements in the liver, with cholangiogenic origin of the foci of infection, with extraintestinal amebiasis - multiple abscesses of the liver may occur.

[15], [16], [17], [18]

Risk factors

Risk factors for hepatic abscess development include diabetes mellitus, liver cirrhosis, severe pancreatic diseases, liver transplantation, cancer, immunodeficiency, age over 70 years.

[19], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29]

Symptoms of the abscess of liver

The clinical symptoms of liver abscess are non-specific and are similar to other hepatobiliary inflammatory processes and infections. As a rule, the first signs of purulent abscess in the liver include pyrexia (fever with a temperature above + 38.5 ° C with chills and heavy sweating at night), lethargy and general malaise, discomfort and periodic pain in the right upper quadrant of the abdomen pressing), an earthy complexion. Also, nausea and vomiting, complete loss of appetite and body weight, a significant increase in liver size (often with a bulge in the right hypochondrium) are observed.

Less common are cough, dyspnea, or hiccoughs caused by irritation of the diaphragm with a damaged liver; irradiation of pain in the right shoulder and back; yellow skin tone and sclera (when cholangiogenic abscesses of the liver develop).

Practical same symptoms can have an amoebic liver abscess, but it happens that the only complaint is either a fever (up to + 38 ° C) or pain on the right side of the abdomen.

[30]

Complications and consequences

If the appropriate medical measures are not taken in time, the consequences of a purulent liver abscess will inevitably result in death from subsequent complications.

And the complications of this pathology are numerous and very dangerous. First of all, this is a rupture of the cavity of the abscess with the outflow of necrotic masses into the pleural or peritoneal cavity. The result is pleural empyema or peritonitis with the threat of sepsis development. Having poured pus and its accumulation in a depression located under the dome of the diaphragm, leads to the so-called sub-diaphragmatic abscess. And getting the serous-purulent contents of the perforated abscess of the left lobe of the liver in the pericardial bag can cause inflammation of the outer shell of the heart (pericarditis), as well as exudative pericarditis and pericardial tamponade.

In addition, complications of liver abscesses are manifested by increased pressure in the portal hepatic vein system (which can result in bleeding); accumulation of fluid in the abdominal cavity (ascites); septic embolism of pulmonary arteries; an abscess of brain tissue.

Amoebic liver abscess can also penetrate through the diaphragm into the pleural cavity and lungs, which often leads to the appearance of fistulas.

[31], [32], [33], [34], [35]

Diagnostics of the abscess of liver

Diagnosis of liver abscess begins with anamnesis and palpatory examination of the abdominal organs. Laboratory examinations are absolutely necessary, for which tests are taken: a general and biochemical blood test (including bilirubin and alkaline phosphatase), blood collection, urinalysis.

If there is a suspicion of extraintestinal amoebiasis (if it turns out that the patient was in endemic regions), a stool test for cysts or trophozoites of dysentery amoeba, as well as the behavior of serological tests, is necessary. And to determine the type of bacteria, percutaneous puncture aspiration of purulent exudate is performed.

Today, instrumental diagnostics expands the possibilities of medicine, and besides the usual X-ray of the abdominal cavity, cholangiography (x-ray of the bile ducts with a contrast drug) and splenoportography (X-ray of the blood vessels of the liver), ultrasound and CT is used.

The main ultrasound signs of liver abscess are the presence in the tissues of the organ of various hypoechoic structures with a low attenuation coefficient of the ultrasonic signal.

Contrasting in the study allows you to more accurately determine the nature of the formations, establish their size and the presence of internal partitions. This is important, since with small abscesses (up to 3 cm) with partitions inside the purulent cavity, drainage is not recommended.

[36], [37], [38], [39], [40], [41], [42]

Differential diagnosis

Significant difficulties are caused by differential diagnosis of liver abscesses. First, it is difficult to clearly differentiate amoebic abscesses in the liver from pyogenic. A purulent abscess should be distinguished from a cyst of the liver, pleurisy with purulent capsules, sub-diaphragmatic abscess, cholecystitis, liver cancer or metastases in the liver.

Treatment of the abscess of liver

Doctors warn that with abscesses of the liver, neither homeopathy, nor alternative treatment, nor attempts to use herbal medicine are acceptable.

Currently, the standard is the treatment of liver abscesses by minimally invasive methods in combination with targeted antimicrobial therapy.

To remove purulent contents from the cavity, a controlled ultrasound or CT puncture drainage of the liver abscess occurs. Installation of drainage catheters through the skin is carried out to all patients either immediately after the initial aspiration during the diagnosis, or within 24 hours from the time of exacerbation. The length of placement of catheters through which pus leaves can range from three days to a week, depending on the results of the re-visualization of the abscess and the clinical condition of the patients. The aspirated contents of the abscess are sown by pathogens of inflammation. During placement of the catheter, there is a risk of spreading pus from the abscess followed by bacteremia and sepsis.

At the same time, antibiotics Amoxiclav (Amoxil, Augmentin), Clindamycin (Klimitsin, Cleocin, Dalacin C), Ceftriaxone and others are prescribed. The drugs are injected into the vein: Amoxiclav - 1000 mg every 8 hours; Clindamycin - 250-300 mg up to 4 times a day; Ceftriaxone - 50 mg per kilogram of body weight. Side effects of these antibiotics may be manifested by nausea and diarrhea, hives, increased liver transaminases and alkaline phosphatase levels (especially in elderly patients).

Antiprotozoal drugs used to treat amoebic liver abscess include Metronidazole, Tinidazole and Diloxanide. Metronidazole acts directly on trophozoites of E. Histolytica. Even a single oral dose of this drug (2.5 g) and simultaneous puncture drainage of liver abscess gives a positive effect. More often Metronidazole is used parenterally - in the form of continuous infusions of 0.5-1 g 4 times a day. Side effects include gastrointestinal symptoms, headaches, plaque on the tongue, dryness and smack of metal in the mouth; sometimes there is dizziness, ataxia and paresthesia, urination disorders, as well as allergic reactions.

Treatment of liver abscess with fungal etiology is carried out with an antifungal antibiotic Amphotericin B (it is administered intravenously drip, the dosage is calculated by body weight).

Operative treatment of liver abscess is necessary in the absence of the effect of conservative therapy. And, as a rule, the operation is necessary when the abscess is complicated. Intervention can be performed by an open method or laparoscopic and can include either open drainage of the abscess cavity, or resection (excision) of the focus of inflammation and affected tissues.

Helps to alleviate the course of the disease diet with liver abscess, in particular, the diet No. 5 for Pevzner is very suitable .

Prevention

Given the etiology and pathogenesis of liver abscesses, their prevention consists in the timely treatment of hepatobiliary and gastrointestinal diseases, as well as in compliance with hygiene rules.

[43], [44], [45], [46], [47], [48], [49], [50], [51], [52], [53], [54], [55], [56]

Forecast

The prognosis of the outcome of liver abscess, according to WHO, over the past 30 years has greatly improved. If in the middle of the last century the mortality of patients who developed a purulent abscess of the liver was 60-80%, then to date - with the timely identification of the disease and adequate medical care - the lethality ranges from 5 to 30%.

[57], [58], [59], [60], [61], [62], [63]