Sandbox:YK

Amoebic liver abscess diagnosis

Diagnosis of amoebic liver abscess

Signs and symptoms(a) Fever, abdominal pain, point tenderness over the liver, hepatomegaly, weight loss History Travel to endemic areas, immigrant from endemic areas, having had dysentery within last years, gender (male/female:9/1

Laboratory diagnosis(LD) and Radiologic Methods (RM) (US, CT or MRI)

LD negative and RM negative:Floow

LD negative and RM positive:aspiration, if possible(b)

LD positive and RM positive: chemotherapy / surgical treatment

Pyogenic abscesses Neoplasia (hepatocellular carcinoma) Cysticercosis Cystic echinococcosis

ALA

Liver abscess

Liver abscess

Risk factors

Hematogenous

Biliary

Underlying lesions or anamolies

Other causes

Portal vein Intra-abdominal infection Pyelophlebitis Abdominal abscess Amoebiasis Arterial ENT Oral cavity

Gall stones Obstructed bile duct Contiguous spread, ascending cholangitis Bile duct ischemia

Biliary cyst Hydatid cyst Cystadenoma Necrosis of a primary tumor Superinfection of a metastasis Caroli disease Biliary stricture Sclerosing cholangitis Ischemic cholangitis

Radiofrequency ablation / Chemoembolization in the presence of infected bile Pancreatoduodenectomy Liver transplantation Hepatic trauma ± arterial embolization

Causes liver abscess

Pyogenic liver abscess

Causes

Hepatobiliary

Portal

Arterial

Traumatic

Cryptogenic

Benign

Malignant

Benign

Malignant

• Endocarditis • Vascular sepsis • Dental infection • ENT infection

Benign

Malignant

• Lithiasis • Cholicystitis • Biliary enteric anastomosis • Percutaneous biliary procedures • Endoscopic biliary procedures

• Gall bladder • Common bile duct • Head of pancreas • Ampulla

• Appendicitis • Diverticulitis • Pelvic suppuration • Anorectal suppuration • Pancreatic abscess • Postoperative sepsis • Intestinal perforation • Inflammatory bowel disease

• Gastric cancer • Colon cancer

• Open or closed abdominal trauma

• Percutaneous ethanol injection or radiofrequency • Chemoembolization

Treatment

Treatment

Non-surgical treatment

Non-surgical treatment

Conservative management with antibiotics alone

Open surgical drainage

Drainage

Drainage

Percutaneous drainage

Open surgical drainage

Endoscopic retrograde cholangiopancreatography (ERCP)

CT guided

CT guided

The mainstay of therapy for pyogenic liver abscesses is percutaneous drainage and antimicrobial therapy. Empiric therapy for pyogenic liver abscesses consists of either a second- or third-generation cephalosporin with metronidazole or piperacillin-tazobactam. Amebic liver abscesses are often treated medically with a short course of metronidazole or tinidazole followed by 20 days of iodoquinol.

Medical Therapy

• It is essential to differentiate between pyogenic and amebic liver abscesses for appropriate therapy. Differentiation can be established based on serology, culture results, and response to therapy.
• The mainstay of therapy for pyogenic hepatic abscesses is ultrasound/CT-guided percutaneous drainage with at least 2 weeks (may last up to 6 weeks) of intravenous antibiotics.
• Empiric antibiotics should only be used initially, with diagnostic aspiration and culture performed as soon as possible.
• Amebic liver abscesses can be treated successfully with antimicrobial agents and do not require drainage except in special conditions, such as:

• Severe clinical illness
• Uncertain diagnosis
• No response to metronidazole therapy (after 4 days of treatment)
• Large left-lobe abscesses (risk of rupture into pericardium)
• Imminent rupture

Antibiotic Regimens

• Pyogenic Liver Abscess

• 1. Empiric antimicrobial therapy

• Preferred regimen (1): (Ceftriaxone 1-2 g IV/IM q24h OR Cefotaxime 1-2 g IV or IM q8h) AND (Metronidazole 15 mg/kg IV single dose THEN 7.5 mg/kg PO/IV q6h)
• Preferred regimen (2): Ciprofloxacin 400 mg IV q12h AND (Metronidazole 15 mg/kg IV single dose THEN 7.5 mg/kg PO/IV q6h)
• Preferred regimen (3): Piperacillin-Tazobactam 3.375 g IV q6h
• Note: The empiric therapy for pyogenic abscesses should be based on local resistance patterns, with particular attention to resistant Klebsiella spp.. Ampicillin is not recommended due to the high resistance found among Klebsiella spp.. There is no set duration for treatment, which may vary from 2 to 6 weeks.

• 2. Pathogen-directed antimicrobial therapy

• 2.1 Klebsiella spp.

• Preferred regimen: Gentamicin AND (Piperacillin-Tazobactam 3.375 g IV q6h OR Cefazolin 0.5-1 g IV q6-8h OR Ceftriaxone 1-2 g IV/IM q24h OR Cefotaxime 1-2 g IV or IM q8h) for 2–3 wk
• Note: Acute therapy may be followed by 4 weeks of oral antibiotics (fluoroquinolone or second/third-generation cephalosporin).

• Amebic Liver Abscess

• Preferred regimen (1): Metronidazole 2-4 g PO qd for 2 days THEN Iodoquinol 650 mg PO tid for 20 days
• Preferred regimen (2): Tinidazole 2 g PO qd for 3 days THEN Iodoquinol 650 mg PO tid for 20 days