Sigit Widyatmoko

Fakultas Kedokteran
Universitas Muhammadiyah Surakarta
 Definisi: infeksi pada hati yang
disebabkan oleh infeksi bakteri,
parasit, jamur, maupun nekrosis steril
yang bersumber daris sitem GIT
 Ditandai dengan proses supurasi
dengan pembentukan pus, terdiri dari
jaringan nekrotik hati, sel inflamasi,
sel darah
 Organisme mencapai hati melalui jalur
berikut:
◦ Infeksi asenden di saluran empedu (kolangitis
asenden)
◦ Melalui pembuluh darah porta dan arteri
◦ Infeksi langsung hati melalui sumber di sekitarnya
◦ Luka tembus
 Timbul pada defisiensi imun
 Secara umum dibagi dua: abses hati piogenik
(80%) dan abses hati amebik (10%), ada juga
abses hati fungal (<10%)
Pyogenic Abscess
 Introduction

• Described since age of Hippocrates

• In 1883 Koch described the amoeba
as a cause of liver abscess.
• In 1938 Debakey published largest
series in the literature.
• Over last 2 decades, percutaneous
drainage has become a therapeutic
option.
 Frequency

• Uncommon, prevalence in autopsy

series 0.29-1.47%.
• Incidence in the US is 8-15 per
100,000.
• Male to female ratio is 2:1 in recent
studies.
• 4th-6th decades of life.
 Etiology

• Biliary disease accounts for 21-

30%, with extrahepatic obstruction
leading to ascending cholangitis
and abscess. Also CBD stones,
benign and malignant tumors,
biliary enteric anastamoses.
 Etiology

• Biliary disease accounts for 21-

30%, with extrahepatic obstruction
leading to ascending cholangitis
and abscess. Also CBD stones,
benign and malignant tumors,
biliary enteric anastamoses.
 Etiology

• Infection via portal system:

infectious process originates in
abdomen, reaches liver by
embolization of portal system.
• Ex.: appendicitis, diverticulitis, IBD,
proctitis
 Etiology

• Hematogenous: via hepatic artery,

from systemic septicemia.
• No cause in 50% of cases, but
increased in diabetics and
metastatic cancer.
 Pathophysiology

• Access to liver by direct extension from

nearby organs.
• Through portal vein and hepatic artery.
• Hepatic clearance of bacteria via portal
system is a normal phenomena, but
organism proliferation, tissue invasion
and abscess can occur with biliary
obstruction, poor perfusion,
microembolization.
 Microbiology

• Most contain more than one

organism, with source biliary or
enteric.
• Blood cultures positive in 33-65%:
• E.Coli 33%.
• Klebsiella 18%.
• Bacteroides 24%.
• Streptococcal 37%.
 Lebih berat dibanding abses amuba
 Sindrom klasik:
◦ Nyeri perut kanan atas ditandai jalan membungkuk
ke depan dengan dua tangan ditaruh di atasnya
◦ Demam tinggi
◦ Syok
 Clinical
• Fever, right upper quadrant pain
(80%).
• Right shoulder pain, pleuritic chest
pain.
• Fever 87-100%.
• Anorexia, weight loss, mental
confusion.
• Physical exam shows RUQ
tenderness, hepatomegaly, liver
mass, jaundice.
 Workup

• Lab studies include CBC: anemia in

50-80%, leukocytosis in 75-96%.
• LFTs: elevated alkaline phosphatase
95-100%, elevated AST, ALT 40-
60%.
• Elevated bilirubin in 28-73%.
• Decreased albumin in 71-87%.
 Medical Therapy

• Most dramatic change has been CT

guided percutaneous drainage.
• Previously, open surgical
procedures had a mortality rate as
high as 70%.
• Current approach has three steps.
 Medical Therapy

• Initiation of antibiotic therapy.

• Diagnostic aspiration and drainage
of abscess.
• Surgical drainage in selected
patients.
 Antibiotic Therapy

• Diagnostic aspiration should be

employed prior to antibiotic
therapy.
• Coverage should include aerobic
gram negatives, streptococcus,
anerobic, including bacteroides.
• Flagyl and clindamycin is usually
good.
 Percutaneous Drainage

• CT or US guided placement of a
catheter.
• Drain is removed once abscess
cavity collapses.
• Success 80-87%.
• Consider open drainage if fails, or
patient worsens over 72 hrs.
 Complications of
Percutaneous Drainage
• Perforation of a viscous.
• Pneumothorax.
• Bleeding.
• Leakage of pus into the abdomen.
• Immunocompromised patients with
multiple abscesses are best treated
with high dose antibiotics rather
than open or percutaneous
drainage.
 Indications For Open
Drainage
• Abscess not amenable to
percutaneous drainage
• Co-existing intra-abdominal
disease that requires operative
management.
• Failure of antibiotic therapy.
• Failure of percutaneous aspiration
or drainage.
 Complications

• Result from rupture of abscess into

adjacent organs or cavities. These
include both pleuropulmonary and
intrabdominal types.
• Pleuropulmonary are themost common
15-20%, include effusions, empyema,
bronch-hepatic fistula.
• Intraabdominal include subphrenic
abscess, rupture into peritoneal cavity,
stomach, colon, vena cava, or kidney.
Amoebic Abscess
Frequency
 Pyogenic(80%): E. coli, K.P
 Paracytic(10%): Entamaeba histolytica
 Others(10%): candida
 -Host immune: Kupffer cell
 -Age: 6th-7th decades
 -Sex: equal
 Mekanisme terjadinya abses amuba:
◦ Penempelan E histolitica pada mukosa usus
◦ Perusakan sawar intestinal
◦ Lisis sel epitel intestinal serta sel radang
◦ Penyebaran amoeba ke hati. Sebagian besar
melalui vena porta  akumulasi netrofil
periportal
 Acute phase with prominent symptoms of <
10 days duration
 Febrile and RUQ pain, may be dull or
pleuritic, radiate to the shoulder
 Point tenderness over the liver
 Right sided pleural effusion are common
 Jaundice is rare
 FBE
◦ Aneamia, leukocytosis, eosinophilia
 LFT’s
◦ Jaundice, hypoalbuminaemia
◦ Elevated AST (acute) and ALP (chronic)
 Stool sample
◦ Low sensitivity (only 30% of patients have
concomitant intestinal amoebiasis)
Investigation

 Serologic testing: Enzyme immunoassay for

antibodies to E hystolitica
◦ Absence of antibodies after one week of symptoms
almost exclusive of Amoebic liver abscess
◦ Cannot distinguish between carriage and acute
infection
 Medical
1. Eradication of invasive trophozoites
Metronidazole 750mg tds (or tinidazole) for
seven days
Clinical recovery usually within 3 days
 2. Eradication of colonic carriage with a luminal
amebicidal agent
Paramomycin 500mg tds for seven days, other
agents:
Diloxanide furoate 500mg tds for twenty days
Iodoquinol
10% relapse rate without intestinal eradication
 Surgical
 1. Aspiration of cyst
◦ To confirm diagnosis (vs pyogenic)
◦ If no response to antibiotic therapy after 5-7d
◦ High risk of rupture (diameter > 5cm, abscess
wall < 10mm)
◦ Left lobe abscess (high rate or rupture at
smaller size into peritoneum or pericardium)
2. Open drainage
• Failed percutaneous aspiration
• Ruptured cyst with generalized peritonitis
 Liver abscess rupture
 Pleuro-pulmonary disease
 Bronchopulmonary fistula
 Subphrenic abscess
 Intraperitoneal rupture
 Pericardial rupture
 Secondary infection - pyogenic abscess
(usually S. aureus)
 Most cases resolve within 7 days of treatment
 Mortality is uncommon but can occur
with abscess rupture
Alhamdulillahi robbil ‘alamiin