Alyssa al

405120165
 Abses Hati - Definisi
Abses hati adalah berbentuk infeksi pada hati
yang disebabkan oleh karena infeksi bakteri,
parasit, jamur maupun nekrosis steril yang
bersumber dari sistem gastrointestinal yang
ditandai dengan adanya proses supurasi
dengan pembentukan pus yang terdiri dari
jaringan hati nekrotik, sel sel inflamasi atau
sel darah di dalam parenkim hati. (IPD)
 Abses Hati - Epidemiologi
Di negara negara yang sedang berkembang,
AHA didapatkan secara endemik dan jauh lebih
sering dibandingkan AHP.
AHP ini tersebar di seluruh dunia, dan terbanyak
di daerah tropis dengan kondisi higiene yang
kurang.
AHP lebih sering terjadi pada pria dibandingkan
perempuan, dengan rentang usia berkisar lebih
dari 40 tahun, dengan insidensi puncak pada
dekade ke-6.
 Abses Hati
Klasifikasi berdasarkan etiologi
Abses Hati Amebik (AHA)
Salah satu komplikasi amebiasis ekstraintestinal yang paling
sering dijumpai di daerah tropik/subtropik.
Etiologi: Entamoeba histolytica

Abses Hati Piogenik (AHP)

Dikenal juga sebagai hepatic abscess, bacterial liver abscess,
bacterial abscess of the liver, bacterial hepatic abscess.
Etiologi: Enterobacteriaceae, Microaerophilic streptococci,
Anaerobic streptococci, Klebsiella pneumoniae, Bacteriodes,
Fusobacterium, Staphylococcus aureus, Staphylococcus milleri,
Candida albicans, Aspergillus, Actinomyces, Eikenella corrodens,
Yersinia enterolitica, Salmonella typhi, Brucella melitensis, dan
fungal
Etiology
Pathogenesis
 hematogenous spread of bacteria or from
local spread from contiguous sites of infection
within the peritoneal cavity
appendicitis with rupture and subsequent
spread of infection
associated disease of the biliary tract is most
common
Pylephlebitis (suppurative thrombosis of the
portal vein)
 Classification
Bacterial abscess Protozoal abscess
Amoebiasis
Helminthic abscess
Ascaris lumbricoides
Fasciola hepatica
Fungal abscess
Aspergillosis
Candida sp
Mucormycosis
Torulopsis glabrata
Trichosporon sp
 Clinical manifestations
Fever of unkown origin
Pain, muscle guarding, punch tenderness,
rebound tenderness on RUQ
Non-specific symptoms chills, anorexia,
weight loss, nausea, vomiting
Hepatomegaly & jaundice: 50%
 Laboratory findings
Alkaline phosphatase >> (70%)
Serum bilirubin >> (50%)
Aspartate aminotransferase >> (48%)
Leukocytosis (77%)
Normocytic normochromic anemia (50%)
Hypoalbuminemia (33%)
 Imaging studies
Radiography
Thorax Abdominal
elevation of the right Evidence of intrahepatic air
hemidiaphragm / lack of
diaphragmatic motion Intrahepatic air-fluid level
right pleural effusion Free air in biliary tract
hypoventilation and atelectasis Foreign bodies
of the right lower pulmonary
lobe
subdiaphragmatic air-fluid level
free air in the
subdiaphragmatic area
infiltration of the lungs
 USG
Circular foci which are hypoechoic to anechoic
fluid level can actually be detected
Multiple small abscesses aggregate beginning of
coalescence into a single larger abscess ( cluster sign)
no gas be present in the abscess, a dorsal reduction in
sound waves ( comet tail)
anechoic centre inside the echo-rich area ( double wheel
structure)

Mycotic abscess anechoic focus is visible with a centre

that is rich in echoes ( target phenomenon)
 CT
Pyogenic & mytotic abscess hypodense areas
both in their natural state as well as after
administration of a contrast medium; ring-shaped
enhancement
small amount of ascites
 Culture
Liver abscess from biliary tract
enteric gram-negative aerobic bacilli and enterococci
Liver abscess from pelvic & other intraperitoneal sources
mixed flora aerobic and anaerobic species
B. fragilis
hematogenous spread of infection
a single organism is encountered
S. aureus or a streptococcal species such as S. milleri
Candida sp
Entamoeba histolytica
 Complications
Abscess penetration to the biliary tract
Abscess rupture into the abdominal cavity or
subphrenic space
Thrombosis of the portal vein
Abscess penetration to the pleural cavity
Pyogenic / mycotic sepsis ophthalmitis
 Treatment
Antibiotic therapy
cephalosporin + metronidazole + aminolycoside
Aminoglycoside + clindamycine
Candidal liver abscess amphotericin B or liposomal
amphotericin or fluconazole alone (6 mg/kg daily)
Drainage (percutaneus or surgical)
I/ antibiotic fail, persistence of fever, leucocytosis,
bacteriaemia)
Antibiotic continued
Liver resection
 Prognosis
Mortality was appreciable despite treatment,
averaging 15%
Several factors predict the failure of
percutaneous drainage
multiple, sizable abscesses
viscous abscess contents that tend to plug the
catheter
associated disease (e.g., disease of the biliary tract)
requiring surgery
lack of a clinical response to percutaneous drainage in
47 days
ABSES HATI PIOGENIK
 Abses hati piogenik
Terjadi akibat komplikasi apendisitis bersamaan dgn
fileplebitis (era pre-antibiotik)

Patogenesis
Penyebaran infeksi scr hematogen & langsung
Penyakit biliaris obstruksi aliran empedu
proliferasi bakteri
Tekanan & distensi kanalikuli melibatkan cabang2 vena
portal & limfatik abses fileflebitis
Penetrasi akibat trauma tusuk inokulasi bakteri pd
parenkim hati AHP
Penetrasi trauma tumpul nekrosis & perdarahan
intrahepatik kebocoran saluran empedu
kerusakan kanalikuli masuknya bakteri ke hati
pertumbuhan bakteri pus & supurasi
 Etiologi
Enterobactericeae Staphylococcus milleri
Microaerophilic Candida albicans
streptococci Aspergillus
Anaerobic streptococci Actinomyces
Klebsiella pneumoniae Eikenella corrodens
Bacterioides Yersinia enterocolitica
Fusobacterium Salmonella typhi
Staphylococcus aureus Brucella melitensis
 Manifestasi klinis
Nyeri spontan perut kanan atas + jalan membungkuk ke
depan dgn kedua tangan diatasnya
Demam / panas tinggi
Keadaan syok
Abses dekat diafragma nyeri pd bahu kanan, batuk,
atelektasis
BB<<, anoreksia, mual, muntah, lemah, ikterus, tinja pucat,
urin gelap

Setelah era antibiotik

Malaise, demam subfebril, nyeri tumpul abdomen yg
semakin parah krn pergerakan
 Pemeriksaan fisik
Febris demam tinggi
Palpasi: hepatomegali
Perkusi: nyeri tekan hepar yg diperberat dgn
adanya pergerakan abdomen
Kronik splenomegali
Asites, ikterus, hipertensi portal
 Pemeriksaan penunjang
Laboratorium
Leukositosis tinggi dgn pergeseran ke kiri
Anemia, LED >>
ALP >>
Enzim transaminase & serum bilirubin >>
Albumin <<
PT >> kegagalan fungsi hati

Kultur darah (Gold Standard) bakteri penyebab

 Foto toraks & abdomen
Diafragma kanan meninggi
Efusi pleura, atelektasis basiler
Empiema, abses paru
Di bawah diafragma trdpt bayangan udara / air-fluid
level
USG
MRI
CT
Biopsi hati
 Diagnosis
Sangat sulit (krn tanda2 penyakit tdk spesifik)
CT scan nilai prediksi tinggi u/ AHP
Diagnosis berdasar penyebab menemukan
bakteri penyebab pd pemeriksaan kultur hasil
aspirasi standar emas
 Komplikasi
Septikemia / bakterimia mortalitas 85%
Ruptur abses hati disertai peritonitis generalisata
mortalitas 6-7%
Kelainan pleuropulmonal
Gagal hati
Perdarahan ke dalam rongga abses
Hemobilia
Empiema
Fistula hepatobronkial
Ruptur ke dalam perikard atau retroperitoneum
 Tatalaksana
Drainase perkutaneus dgn tuntunan USG atau CT
Komplikasi: perdarahan, perforasi organ intraabdominal,
infeksi, kesalahan dlm penempatan kateter
Antibiotik
Terapi awal penisilin
Kombinasikan dgn ampisilin, aminoglikosida / sefalosporin
generasi 3 dan klindamisin / metronidazol
48-72 jam belum ada perbaikan antibiotika sesuai hasil
kultur sensitifitas aspirat abses hati
Reseksi hati AHP multipel
 Prognosis
Mortalitas AHP setelah diterapi antibiotika yg
sesuai dgn penyebab & dilakukan drainase 10-
16%
Prognosis buruk jika
Keterlambatan diagnosis & pengobatan
Hasil kultur darah yg memperlihatkan bakterial
penyebab multipel
Tdk dilakukan drainase
Ikterus
Hipoalbuminemia
Efusi pleural / penyakit lain
ABSES HATI AMEBIK
 Amebic liver abscess
90% asymptomatic; 10% intestinal
disease (dysentry) & liver abscess

Life cycle
Etiology
 Pathogenesis
Intestinal colonization (may be asymptomatic)
intestinal wall lysis & thrombus formation
trophozoites invade vein to liver through portal
vein infiltration of neutrophil release of
neutrophils toxin necrosis of hepatocyte
Parenchyma is replaced by necrotic material
surrounded by liver tissue liver abscess
(composed of bacteriologically sterile granular
debris with few or no cells)
 Clinical manifestations
Febrile
right-upper-quadrant pain (dull or pleuritic in
nature and may radiate to the shoulder)
Point tenderness over the liver
right-sided pleural effusion
Jaundice is rare
active diarrhea (one third patients)
loss and hepatomegaly
 Laboratory findings
leukocytosis (>10,000 cells/L)
Anemia
liver enzyme levels are normal or minimally
elevated
alkaline phosphatase level is most elevated
and remain so for months
Aminotransferase elevations suggest acute
disease or a complication
 Differential diagnosis
pulmonary or gallbladder disease
Malaria
typhoid fever
 Treatment
Drugs
 Aspiration
Indications
the need to rule out a pyogenic abscess
the lack of a clinical response in 35 days
the threat of imminent rupture
the need to prevent rupture of left-lobe abscesses into
the pericardium
 Prevention
adequate sanitation and eradication of cyst
carriage
avoidance of unpeeled fruits and vegetables
and the use of bottled water
disinfection by iodination (tetraglycine
hydroperiodide)
 References
Buku Ajar Ilmu Penyakit Dalam, Abses Hati
Pyogenik
E. Kuntz. Hepatology Principles and Practice.
2nd edition. Germany: Springer; 2006
Fauci. Braunwald. Dkk. Harrisons Principles of
Internal Medicine. 17th edition. United State:
The McGraw-Hills; 2008