Purulent liver abscess. Bacterial liver abscess: causes, signs, treatment tactics

What it is? Liver abscess is a limited cavity in the organ of different sizes and filled with pus. In most patients, an abscess is diagnosed as a secondary disease, that is, it occurs as a result of the negative influence of other pathologies. Pathology is more often detected in persons from 30 to 45 years old, in children it happens in very rare cases. The prognosis of the course of the disease is always very serious and the complete recovery of the patient depends on a number of concomitant pathology factors.

Liver abscess is a dangerous disease. With a single purulent lesion, a positive effect of treatment is observed in almost all patients, but of course if the therapy was carried out in a timely manner. And multiple purulent formations of the liver often have a fatal outcome.

Depending on the route of infection, the following forms of liver abscesses are distinguished:

• cholangiogenic - the infection enters the liver cells from the biliary tract;
• hematogenous - the infection spreads with blood flow through the vessels of the body;
• contact and post-traumatic - occur after open and closed injuries of the abdomen;
• cryptogenic - the source of infection has not been established.

Bacterial microflora is the cause of the development of the disease in 50% of all cases. Streptococcus, staphylococcus and a mixture of microorganisms are detected by bacterial culture.

According to the ICD-10 coding (International Code of Diseases of the Tenth Revision), liver abscess is coded under item K75.

Classification

Abscesses of the liver are divided into the following groups of species.

1. Primary and secondary.
2. Complicated by a suppurative process or not complicated.
3. Single and multiple.
4. Pyogenic and amoebic.

Complications include various atypical phenomena that occur with festering areas: first of all, it is sepsis, purulent pericarditis, pleural empyema. Also, the disease can have complications in the form of a subdiaphragmatic abscess, and a breakthrough of the latter into the pleural or abdominal cavity.

Symptoms of a liver abscess

With a liver abscess, the main symptoms can manifest as follows: high body temperature;

• constant, aching, dull, radiating to the right shoulder, shoulder blade;
• hepatomegaly, chills, "goosebumps" 2-3 times a day;
• loss of appetite, nausea, vomiting is possible;
• significant increase in heart rate;
• pain in the projection of the liver,
• rapid weight loss due to intoxication and dyspeptic disorders;
• yellowness of the skin, sclera, darkening of the urine, sallow complexion.

Symptoms of such a serious pathology can be accompanied by blood poisoning and convulsions. In the patient, in most cases, there is an accumulation of fluid in the abdominal cavity, as a result of which the abdomen increases significantly in size (this is especially noticeable against the background of severe thinness due to weight loss due to intoxication).

Amebic liver abscess

Diseases caused by Entamoeba histolytica (dysentery amoeba) are mainly common in countries with a hot and tropical climate: Asia, Africa and South America, where amoebic abscesses account for 80-90% of purulent liver lesions.

In amoebic bowel disease, liver damage occurs, according to various sources, in 1-25% of cases. However, there may not be obvious intestinal manifestations in amebiasis.

Diagnostics

The first step in diagnosing a liver abscess is a thorough examination by a doctor. It may reveal an enlarged liver (on palpation), jaundice (such as yellowing of the skin or eyes), rapid heartbeat, and skin sweating. Your doctor may order blood tests to check for a liver abscess. The results usually show a significant increase in the concentration of leukocytes in the blood due to a concomitant bacterial infection, as well as increased indicators of inflammation, such as the acute phase protein CRP.

The doctor may prescribe other studies:

• Growing bacteria from a blood sample can detect the microbe responsible for the appearance of a liver abscess in 50% of cases. The material for the study is taken by puncturing the wall of the abdominal cavity and extracting fluid from the affected area of ​​the liver. The sample is then sent for microbiological testing for bacterial colonies, aerobic and anaerobic bacteria. It is not recommended to take samples of the contents of the abscess from a previously laid drainage.
• When conducting radiography in the projection of the liver, a cavity with a liquid level (pus) and a gas bubble above it is revealed. Also, some reactive changes in the organs of the right side of the chest cavity can be determined - high standing and limited mobility of the dome of the diaphragm, fluid in the pleural cavity, signs of pneumonia in the right lung. These radiological symptoms are not typical for a hepatic abscess, but their presence makes it possible to suspect a pathological process in the liver.
• Computed tomography or ultrasound can visualize a space with purulent fluid in the liver along with accompanying edema. An experienced specialist should distinguish a liver abscess from possible tumors or cysts.

Other laboratory tests may reveal an increase in the concentration of bilirubin and enzymes in the liver. With such a disease, hepatocytes are damaged, which in this case release substances into the blood that are indicators of their damage.

Treatment of a liver abscess

In the case of an uncomplicated process, treatment gives a good chance of recovery. If complications develop, the prognosis becomes unfavorable, and the likelihood of death increases.

Medical therapy

In cases of pyogenic bacterial abscesses, the complex treatment includes antibiotic therapy. As a rule, it complements the surgical methods of draining the abscess.

The isolated use of conservative treatment is rarely carried out, only in cases where the patient does not tolerate surgery or when he has multiple abscesses that cannot be drained. In these cases, patients require many months of antibiotic therapy with constant and careful monitoring for the development of complications. Most often, antibiotics are prescribed in addition to surgical treatment.

Before obtaining the results of blood culture or the contents of the abscess cavity and determining the type of pathogen, doctors prescribe broad-spectrum antibiotics - carbapenems, third-generation cephalosporins and metronidazole. After receiving the results of the microbiological examination, the treatment is changed, prescribing drugs based on the determination of sensitivity to them. The duration of antibiotic therapy can range from 6 weeks (with a single and well-drained abscess) to 3 months (with multiple liver abscesses).

• In the case of amoebic liver abscess, 90-95% of patients can achieve recovery without surgical intervention. They are prescribed metronidazole. Most patients improve within 72-96 hours. If metronidazole is ineffective, chloroquine is used, to which emetine or dihydroemetine is sometimes added. After successfully treating an amoebic abscess, doctors prescribe diloxanide furoate, which destroys amoebas in the intestines.
• In the case of fungal abscesses, systemic antifungal therapy is performed. This treatment is in addition to surgical drainage of the abscess cavity. Doctors most often prescribe Amphotericin B or Fluconazole.

In addition to antibiotic or antifungal therapy, patients with liver abscess may need fluid therapy (to correct fluid and electrolyte balance), pain medication, and nutritional deficiencies.

Surgery

The operation is performed in case of ineffectiveness of the drug within 4-6 months or in the presence of complications due to acute medical indications.

1. Percutaneous drainage of a liver abscess - two rubber tubes are inserted into the abscess cavity, a liquid containing antibiotics is supplied into one, and the contents come out of the other. The procedure is lengthy and takes 3-4 days;
2. Laparotomy - midsection of the abdominal cavity. It is performed in the presence of multiple liver abscesses or with the development of complications. The liver is removed into the surgical wound, the cavities of all abscesses are opened, the contents of them are aspirated with a special aspirator device. An empty, dried cavity is excised to the healthy tissue of the organ and then sutured.

Remember that with this disease, folk methods of treatment are prohibited.

Diet

With an established diagnosis, nutrition should be sparing, with the exception of fatty foods.

Food should not put a load on the organ itself, the bile ducts and the gastrointestinal tract system. It is necessary to choose dishes containing large amounts of vitamins. In the postoperative period, food should be wiped, you need to eat in small portions.

Complications and prevention

Liver abscess is terrible precisely because of its complications. So, in cases where treatment is not started in time, a breakthrough of an abscess is possible, bleeding, which can also provoke blood poisoning.

As a result of a breakthrough, peritonitis can form (an inflammatory process taking place in the membrane of the abdominal cavity), pleural epinema (when pus accumulates in the pleural region of the sternum), and the membrane of a liver abscess can open and pus is likely to enter the area of ​​the following organs:

• into the abdominal cavity;
• intestines;
• pericardial bag;
• bronchi.

Purulent complications today are found in various pathologies. The formation of a liver abscess is typical in conditions accompanied by the development of purulent foci. That is, among the causes of this pathology, diseases of other organs occupy a large part. A liver abscess is a purulent focus that has delineated boundaries. It is dangerous for the development of septic bacterial shock, as well as the possibility of the formation of foci of dropouts in other organs. A serious problem is the identification of the disease in the elderly.

• Pseudomonas aeruginosa;
• pyogenic staphylococcus;
• streptococcus;
• amoeba;
• echinococcus and alveococcus;
• Proteus;
• coli;
• roundworm.

Staphylococcal or Pseudomonas abscess, as well as focal purulent formation caused by Escherichia coli, develop as secondary diseases. In old age, the risk of their occurrence increases.

The primary forms of abscesses include purulent foci that appear after an injury. This refers to polytrauma, when several organs or organ systems were damaged during a fall or accident. The hematoma (accumulation of blood) that occurs under these conditions can become infected and fester.

Purulent processes that cause purulent effusion in the abdominal cavity - peritonitis, can become an etiological factor in the described purulent disease. Among these diseases, appendicitis is the most common. What matters is not catarrhal or hemorrhagic forms of inflammation of the appendix, but a purulent variant. Therefore, in surgical hospitals, to prevent this complication, the patient takes positions with an elevated head end.

Any disease in which the contents of the peritoneal cavity becomes inflammatory can lead to the formation of liver abscesses. These include peritonitis, complicating the course of diverticulitis, intestinal obstruction. Dropout centers penetrate into the liver tissue through the portal vein system more often than through the vessels of the lower caval venous system.

Inflammatory diseases of the organs of the hepatobiliary zone can become a source of purulent foci-screenings in the liver. What diseases belong to this group?

1. Calculous cholecystitis is an inflammation of the wall of the gallbladder, in the lumen of which there are stones - calculi.
2. Cholangitis. It is a purulent lesion of the walls of the common bile duct.
3. Purulent non-calculous cholecystitis (in the absence of stones in the cavity of the organ).
4. Malignant neoplasms of the bile ducts or the liver itself.

Regardless of the causative factor, the manifestations of a purulent disease are monotonous. But first, we should consider the forms and approaches to the classification of liver abscesses.

Classification

There are various approaches. The most important classification of hepatic purulent formations is based on pathogenesis. It provides for the selection of the following forms.

1. Cholangiogenic abscess. It occurs due to an inflamed gallbladder or main bile duct. Most often, these processes are accompanied by the presence of microliths or larger stones.
2. Foci that appeared hematogenously. Through the bloodstream, infectious particles enter the liver from any organ in which there is purulent inflammation.
3. Abdominal injuries are accompanied by the occurrence of post-traumatic liver abscess.
4. The appearance of a contact purulent focus is due to purulent-inflammatory processes in the abdominal cavity.
5. A cryptogenic abscess is a form of a disease in which the cause cannot be definitively established.

Localization is another classification criterion for the described pathology. Forms of a liver abscess are similar to the lobes that are affected by it.

The division into primary and secondary variety is described above.

Surgeons distinguish large and small formations. It depends on the size of the abscess: up to 30 mm, the focus is considered small, and if its size exceeds this value, it is worth talking about a large abscess. There are also multiple and single options.

Complications

Separately, abdominal surgeons consider the problem of complications. They develop with inadequate management of patients by the doctors themselves, as well as untimely seeking medical help and performing an operation.

The rupture of the abscess is dangerous because the pus will begin to spread through the peritoneum. The result will be the development of purulent peritonitis, which is very difficult. This condition causes another very serious and prognostically unfavorable process. We are talking about toxic shock.

This pathological condition is accompanied by dissemination of pyogenic bacteria in all organs and systems of the body. In this case, vascular insufficiency occurs due to the process of centralization of blood circulation. The danger lies in the violation of perfusion of the brain, kidneys and heart with its subsequent stop.

An increase in pressure in the portal vein system can progress in the presence of a purulent focus in the liver. The appearance of portal hypertension for the first time in this disease is atypical. The progression of this condition can lead to bleeding from varicose hemorrhoidal or esophageal veins.

The next complication is jaundice. It is possible to develop a mechanical, as well as a parenchymal variant of this clinical syndrome. It is dangerous with a possible toxic effect on the substance of the brain with the onset of symptoms of encephalopathy.

Clinical manifestations

There are quite a few reasons and factors that cause the formation of a liver abscess. The symptoms of this disease are similar for all forms. First of all, the manifestations characteristic of the intoxication syndrome should be considered, because they are very pronounced from the very initial stages of the disease.

Signs of intoxication

Patients complain of severe headaches, sometimes dizziness. At the height of the pain syndrome, nausea and vomiting may occur, which will not bring relief. This may result in visual impairment. The more severe the intoxication, the more difficult the visual manifestations. With the addition of mental disorders, hallucinations are possible.

Patients say that their appetite is greatly reduced. They refuse to eat, while the thirst persists. At the same time, urination is reduced, the volume of urine excreted decreases markedly. Against the background of jaundice, the appearance of acholic, uncolored feces is possible.

Low mood and drowsiness accompany intoxication from the very beginning. No desire to study or work. There is a feeling of severe fatigue, weakness. After sleep, these manifestations do not weaken.

An important manifestation of intoxication syndrome is hyperthermia. The temperature rises sharply and quickly to 39-40 degrees, that is, it is in the nature of hyperpyrexia. Non-steroidal antipyretic drugs reduce the severity of hyperthermia, but not for long. The patient complains of hyperhidrosis - excessive sweating. The sweat is clammy and cold. All these manifestations are subjectively accompanied by a feeling of pronounced chills.

The skin becomes dry and hot to the touch. At night, dryness is replaced by hyperhidrosis.

Manifestations of impaired hepatic functions

The liver performs a large number of functions in the human body. With limited purulent education, they suffer to one degree or another.

With a large abscess, as well as in the presence of a large stone in the choledochus, as the cause of this disease, there is a violation of bilirubin metabolism. It has a parenchymal (cytolytic) character in the first case, obstructive - in the second. This syndrome is called jaundice.

In addition to yellow or yellowish staining of the skin, mucous membranes, jaundice can be manifested by itching. It is associated with the action of bile acids on nerve endings. The size of the liver usually increases. The color of the excreted urine becomes darker, it becomes frothy (due to the detergent action of bile acids).

At the expressed sizes the pain syndrome appears. It is localized in the right hypochondrium if the abscess is in the right lobe of the liver, or in the mesogastric region if it is localized in the left lobe. An alternative to pain can be a feeling of discomfort.

Violation of the protein-synthesizing function is manifested by an imbalance between the coagulant and anticoagulant systems. A tendency to bleed may develop. Sometimes there are bruises, bruises of various shapes.

Diagnostic methods

The diagnosis of a liver abscess can be made after a complete list of laboratory and instrumental examination methods. Already at the stage of general clinical methods, there may be signs of a purulent inflammatory process:

• an increase in the number of white blood cells of more than 15 thousand per milliliter of blood (leukocytosis);
• a shift in the leukocyte formula with a predominance of segmented forms;
• acceleration of the erythrocyte sedimentation rate (it can be pronounced and many times exceed the normal values ​​​​of the indicator).

Icteric syndrome in a biochemical blood test will be obvious. The level of bilirubin rises (more than 21 µmol/L) due to its direct fraction. Urobilinogen appears in the urine. AST and ALT rise, indicating cytolysis of liver cells.

If the balance in the hemostatic system is disturbed, there will be changes in the level of fibrinogen in the direction of its decrease. Prothrombin time, activated partial thromboplastin time and other indicators will change, characterizing the hypocoagulation background.

The gold standard for diagnosing any liver formations is ultrasound. It allows you to see the focus, as well as differentiate it. In addition, it is possible to assess the vascular formations of the liver. This is important in order not to miss the progression of complications such as portal hypertension. Ultrasound allows you to see the level of fluid in the abdominal cavity if peritonitis occurs.

Tomography is the most accurate way to visualize an abscess. Preference is given to computed tomography. At the same time, it is possible to accurately assess the size and structure of the formation. This is important in terms of prognosis, including the development of life-threatening complications.

Treatment approaches

Patients with this disease or suspicion of it are treated in a surgical hospital. The operative method is used for severe liver abscess. Treatment of milder forms may be limited at first to drug therapy.

Antibacterial therapy is the key to successful treatment. It is used as an independent method of therapy (conservative), and in the postoperative period. Antibiotics are administered parenterally. A combination of two antibacterial agents is desirable. In case of ineffectiveness, drugs from the reserve - carbapenems - should be used.

Detoxification is carried out immediately after diagnosis. It includes forced diuresis. In the recovery period, the appointment of hepatoprotectors will be required.

Surgical intervention can be carried out using laparoscopy and laparotomy. Despite the fact that the first technique is accompanied by minimal trauma, surgeons prefer laparotomic incisions, since the revision of the organs is better.

An abscessing focus in the liver is an acute disease. You should not delay contacting a doctor if signs of intoxication appear, accompanied by pain in the hypochondrium or jaundice. This can be fatal.

This video demonstrates the operation - drainage of a liver abscess under ultrasound control:

Version: Directory of Diseases MedElement

Liver abscess (K75.0)

Gastroenterology

general information

Short description

- purulent delimited inflammation of the liver tissue.

Notes

In this sub-heading included the following concepts:
- unspecified (cryptogenic) liver abscess;
- cholangitis liver abscess (abscessus hepatis cholangiticus; syn. cholangiogenic liver abscess) - localized along the intrahepatic bile ducts and occurs as a complication of purulent cholangitis;

Hematogenous liver abscess;

Pyelophlebitic liver abscess;

Lymphogenic liver abscess.

Classification

There is no single classification of liver abscess.

Meyers classification (2001)

1. Cryptogenic abscesses.

2. Cholangiogenic:

3. Intestinal:

benign origin;

malignant origin.

4. Hematogenous (arterial).

5. Other portals.

6. Liver injury.

7. Other types of spread (chronic granulomatosis, local spread, operations on the abdominal organs, etc.).

8. Amoebic.

Various clinics also use the following classifications:
- Johansen E.C. et (2000);
- Pitt H.A. (1990);
- Alvarez Perez J.A. et (2001).

Traditionally in clinical practice applies the division of abscesses into pyogenic (including fungal) and amoebic (excluded from this subheading), as well as single and multiple.

Etiology and pathogenesis

Bacteriology
The most common infectious agent is represented by gram-negative bacteria:
- Escherichia coli (found in 2/3 of patients);
- often Strepto-coccus faecalis, Klebsiella Spp. and Proteus vulgaris;
- recurrent purulent cholangitis can be caused by Salmonella typhi.

Currently, there is a growing role of anaerobic microorganisms in the development of liver abscesses.

Streptococcus milleri is one of the most common pathogens.
Approximately half of the patients, especially those who received chemotherapy, are resistant to therapy (in the bulk) staphylococci.
In patients with a liver abscess, Friedlander's diplobacillus, Pseudomo-nas Spp. and Clostridium welchii.

Rare causes of liver abscess:
- septic form of melioidosis Melioidosis is an infectious disease from the group of bacterial zoonoses caused by Pseudomonas pseudomallei, endemic to some areas of the tropical zone (Ch. sample of Southeast Asia and Northern Australia); in humans, it proceeds according to the type of septicemia with the formation of abscessing granulomas in various organs
;
- infection with Yersinia enterocolitica, Pasteurella multocida, Salmonella, Haemophilus and Yersinia spp;
- tuberculosis and actinomycosis infections can cause liver abscess in patients with immunodeficiencies (AIDS, drug immunosuppression Immunosuppression - genetically determined or caused by external influences, the loss of the ability of the body's immune system to an immune response to a particular antigen.
);
- Listeria monocytogenes (very rare).

Sources of infection are often multiple, and the sown flora in a third of cases is mixed.
On examination, an abscess may appear striatal, but this is usually due to inadequate culture technique, especially anaerobic ones, or prior use of antibiotics.

Pathogenesis

Infection of the liver is most often carried out by the hematogenous route (with blood flow): the infectious agent is transferred through the vessels of the portal vein from inflammatory foci of the abdominal cavity (peritonitis, diverticulitis, etc.).
The origin of an abscess may be cholangiogenic: with purulent cholangitis, ascending infection spreads into the intrahepatic and bile ducts.
An abscess can develop in a septic condition: the infection enters the liver directly from the systemic circulation through the hepatic artery.

Morphologically, the abscess contains polymorphonuclear neutrophils and detritus from hepatocytes. hepatocyte - the main cell of the liver: a large cell that performs various metabolic functions, including the synthesis and accumulation of various substances necessary for the body, the neutralization of toxic substances and the formation of bile (Hepatocyte)
. It is delimited by a fibrous capsule, next to which there are hepatocytes in the stage of fatty degeneration. Abscesses may be single or multiple. Hematogenous dissemination Dissemination - the spread of the causative agent of an infectious disease from the primary focus or tumor cells from the main node through the blood and lymphatic tracts within one organ or the whole organism.
more often leads to the development of multiple abscesses (from 1 to 10 cm in diameter), which can merge to form irregularly shaped cavities containing septa of necrotic tissue. The right lobe of the liver is most often involved in the pathological process.

Abscesses due to portal pyemia Pyemia is a form of sepsis in which microorganisms are carried with the bloodstream to various organs and tissues, where they cause the development of metastatic abscesses.

Infectious diseases of the gastrointestinal tract or pelvic organs can cause the development of portal pylephlebitis Pylephlebitis - inflammation of the portal vein; occurs as a complication of purulent processes in the abdominal cavity, such as acute purulent appendicitis.
or formation of septic emboli An embolus is a circulating substrate in the blood that does not occur under normal conditions and can cause blockage of a blood vessel.
. Similar conditions can occur against the background of appendicitis, diverticulitis, regional enteritis, gallbladder empyema; ileitis caused by yersinia (a genus of bacteria that combines small ovoid gram-negative rods) and yersiniosis (Y. enterocolitica); perforated ulcer of the stomach or colon; pancreatitis; infected hemorrhoids; anastomotic failure.

Septic lesions of the umbilical vein in newborns can lead to the spread of infection through the portal vein, followed by the occurrence of liver abscesses.

Biliary abscess
The biliary tract is the most common source of infection. Purulent cholangitis can become a complication of any form of biliary tract obstruction (especially partial). In most cases, multiple abscesses are observed.
Among the possible causes of the development of the disease are gallstones, sclerosing cholangitis, cancer, congenital anomalies of the biliary tract, especially Caroli disease Caroli syndrome - a combination of congenital dilatation of the bile duct, portal hypertension and congenital liver fibrosis
.
An abscess may develop following biliary intervention such as stent insertion, stricture repair, or due to reflux of intestinal contents through a biliary-digestive anastomosis; in these cases, it may be asymptomatic.

contact abscess
Solitary (single) liver abscess may occur:
- due to penetrating injury of the liver;
- with direct spread of infection from a septic focus in adjacent tissues;
- after secondary infection of amoebic abscesses, metastases, cysts or intrahepatic hematoma;
- blunt trauma to the liver during road traffic accidents can lead to the formation of an abscess.

Other abscesses
The development of a liver abscess can be caused by iatrogenic effects: liver biopsy, percutaneous biliary drainage, damage or perfusion of the hepatic artery.
Liver abscess may develop in the following groups:
- patients with hematological diseases (leukemia);
- patients receiving chemotherapy;
- in the presence of a malignant disease (abscess may be caused by a fungal infection and amphotericin may be effective).
The formation of a liver abscess may be associated with severe dental disease.

In the case of an unclear cause of a liver abscess, it is necessary to consider the possibility of its development against the background of diabetes mellitus, often in the presence of gas-forming bacteria of the genus Klebsiella.

The apparent cause of the abscess cannot be identified in approximately 50% of patients, especially in the elderly.

Epidemiology

Age: Predominantly mature and elderly

Sign of prevalence: Rare

Sex ratio (m/f): 2.6

Incidence. Bacterial liver abscess is a rare pathology. The annual incidence is approximately 3.6 per 100,000 in the US and UK, and ranges from 8 to 20 cases per 100,000 hospital admissions in most studies.

Age
The distribution curve shows 3 peaks:
- in infants - associated with catheterization of the umbilical vein, intestinal infections;
- in children and adolescents - association with injuries, intestinal infections and peritonitis;
- the most significant peak occurs in middle-aged and elderly people (from 40 to 70 years).

Floor. It is believed that men suffer more often, but in some studies this fact is refuted.

Geography. The incidence is somewhat higher in Asian countries; in some studies, no dependence on the geographical area was found.

Causes:
- appendicitis and peritonitis - 20-30% of cases;
- cholangitis and malignant neoplasms of the liver and biliary tract - 37-55%;
- pyelophlebitis Pyelophlebitis - inflammation of the renal veins
- 11-25%;
- in 18-27% of cases, the abscess is cryptogenic.
The data vary considerably between studies, depending on the region and period of observation.

Factors and risk groups

Strong risk factors:
- diseases of the biliary tract (28-43% of patients);
- age from 50 to 60 years (people aged ≥ 65 years get sick 10 times more often than young people);
- tumors - approximately 10-20% of people with a liver abscess had malignant neoplasms in a retrospective analysis, the relative risk for a liver abscess is estimated as 13.3 (95%, confidence interval 6.9-24.4);
- diabetes mellitus is associated with an increased risk of purulent liver abscesses, with an odds ratio of 3.6 (95% CI 2.9-4.5);

Abdominal operations or endoscopic manipulations (operations).

Weak and discussed risk factors:
- cirrhosis of the liver, according to some reports, increases the risk by 15 times;
- liver transplantation;
- Roux anastomosis;
- alcoholism;
- male gender has a relative risk of 2.6 (95% CI 1.5-4.6);
- cardiovascular pathology;
- immunodeficiency;

Penetrating abdominal trauma;

Inflammatory bowel disease, pancreatitis Pancreatitis - inflammation of the pancreas
, appendicitis, diverticulitis Diverticulitis is inflammation of a diverticulum, usually caused by stasis of its contents.
or peritonitis;

Intrahepatic gallbladder;
- bacteremia, endocarditis or other hematogenous infections.

Clinical picture

Clinical Criteria for Diagnosis

Fever; chills; hepatomegaly; pain in the right upper abdomen; weight loss; weakness; cough; dyspnea; chest pain; nausea; vomit; jaundice

Symptoms, course

The clinical picture of a liver abscess is represented by the classic triad: fever, jaundice, moderate hepatomegaly.

Complaints(in descending order):

Fever (81.4%);

Abdominal pain (80%);

Nausea and vomiting (25.7%);

Loss of body weight (27.7%);
- anorexia Anorexia is a syndrome consisting in the lack of appetite, hunger, or in a conscious refusal to eat.
(25,6%);
- pain in the right shoulder (24.2%);
- weakness and malaise (21.1%);
- chills (9.1%);
- night sweat (8%);

Pleural pain (1.5%);

Diarrhea (1.5%);
- dyspnea Dyspnea (synonymous with shortness of breath) is a violation of the frequency, rhythm, depth of breathing or an increase in the work of the respiratory muscles, which is manifested, as a rule, by subjective sensations of lack of air or difficulty breathing
or shortness of breath (1%);
- cough (0.8%).

Symptoms found on examination:
- pain in the upper right corner of the abdomen (54%);
- hepatomegaly Hepatomegaly is a significant enlargement of the liver.
(47%);
- jaundice (25.3%);
- pleural effusion Pleural effusion - an abnormal accumulation of fluid in the pleural cavity
(14,3%);
- wheezing in the lower parts of the lungs (6.3%);
- raising the dome of the diaphragm on the right (6.3%).

Often, a liver abscess develops asymptomatically. Because of this, it can be diagnosed a month or more after the onset. With multiple abscesses, systemic disorders are more pronounced, so it is often possible to determine the cause of their occurrence. The latent course of the disease is especially common in elderly patients.
Solitary abscesses are less symptomatic and are often cryptogenic. Cryptogenic - of unknown or hypothetical origin
. With subdiaphragmatic irritation or pleuropulmonary spread of infection, pain in the right shoulder and cough may occur. In these cases, an enlarged and painful liver, pain during percussion of the lower ribs are determined.

In chronic abscesses, the spleen is palpable. Severe ascites Ascites - accumulation of transudate in the abdominal cavity
rarely observed. In the later stages, jaundice occurs (except in cases of purulent cholangitis).

Diagnostics

The process of diagnosing a liver abscess is complex, using clinical and laboratory signs in patients with risk factors. The diagnosis is confirmed with good sensitivity by various imaging modalities.

Instrumental Research

1. X-ray examination allows to detect pathological changes in 50% of cases. The radiograph shows the elevation of the right dome of the diaphragm, the blurring of the right costal-diaphragmatic angle, atelectasis Atelectasis is a condition of the lung or part of it in which the alveoli contain little or no air and appear to be collapsed.
lung. Below the diaphragm, levels of liquid and gas may be detected when gas-forming microorganisms act as causative agents of the abscess.

2. Ultrasound liver reveals a focus of a round, oval or elliptical shape with uneven edges and a hypoechoic heterogeneous structure, more than 1 cm in size. The sensitivity of the method is 80-90%. Ultrasound is the basic imaging modality.

The echographic picture of a liver abscess has a number of features associated with the time of its existence. Based on the relevant clinical and laboratory data, in the phase of abscess formation in the liver parenchyma, it is possible to identify a zone of reduced echogenicity with a heterogeneous structure and fuzzy contours that turn into normal tissue. In the central part of this zone of reduced echogenicity, as a rule, there is an anechoic, almost structureless area. Further, with a parallel increase in clinical manifestations, an echo-negative cavity is formed with internal echogenic contents (formed as a result of the presence of pus and tissue detritus Detritus - a mushy product of tissue breakdown
).

Echographic features characteristic of the liquid structure:
- the effect of strengthening the rear wall;
- effect of lateral acoustic shadows;
- the effect of distal pseudo-amplification of the echo signal.

specialfor liquid structureechographic signs:

2.1 Separation of the contents of the abscess cavity with the formation of a "liquid-liquid" border with a horizontal level, where the thicker echogenic part is at the bottom, and the more liquid echo-negative one is at the top.

2.2 The appearance of gas bubbles in the cavity of the abscess, resulting from an anaerobic inflammatory process, is possible. Gas bubbles appear as hyperechoic volumetric structures, occupying a position against the upper wall and giving a cone-shaped reverberation effect. Reverberation is the process of gradually reducing the intensity of sound when it is reflected multiple times.
("comet tail").

2.3 When the position of the patient's body changes, all internal contents move.

2.4 The abscess cavity is clearly delimited from the surrounding liver parenchyma by a somewhat heterogeneous rim of increased echogenicity. It is a pyogenic membrane Pyogenic membrane (purulent membrane, pyogenic membrane) - a membrane around a chronic abscess, formed from granulation tissue and a layer of fibrous fibers
and can have a different thickness - from 0.5-1 mm to 10-15 mm.

3. Computed tomography liver allows you to detect up to 94% of lesions. Using a contrast agent, it is possible to achieve image enhancement with a sensitivity of 95-100%.

4. MRI is the most sensitive method compared to CT without contrast, as it allows visualization of smaller lesions. When using the T1 mode, the damage has a low signal intensity, and in the T2 mode it is very high. Gadobutrol is used as a contrast agent for MRI.

5. Scintigraphy Scintigraphy is a radioisotope method for visualizing the distribution of a radiopharmaceutical in an organism, organ, or tissue.
. It is carried out using the property of gallium to accumulate in abscesses in large quantities. Tc-m99, In-111 are also used (indium-labeled leukocyte scan). The sensitivity when using gallium is 50-80%, technetium - 80%, indium - 90%.

The American College of Radiology (ACR) recommends a multifactorial assessment (size of a previously identified lesion, imaging techniques already used, duration of the process, etc.) to select the optimal imaging diagnosis in complex cases.

Laboratory diagnostics

Laboratory signs of a purulent abscess:

Anemia (occurs in half of the cases, usually within Hb 85-10 5 g / l);

Neutrophilic leukocytosis (72%);
- increase in ESR;
- moderate increase in bilirubin;
- an increase in alkaline phosphatase (in more than half of the cases);
- a moderate increase in serum transaminases (occurs in less than half of the cases, a significant long-term increase occurs only in extremely severe cases);
- an increase in prothrombin time (occurs constantly);
- Identification of hypoalbuminemia is common and is considered a poor prognostic sign.

Microbiological research

Blood cultures should be taken before starting antibiotic therapy (positive blood cultures are obtained in 50-100% of cases). In the presence of many etiological factors, not all pathogens can be sown from the blood. Bacteriological examination of the contents of the abscess is highly informative.

Blood culture isolation data according to the results of a study of 312 patients (according to the literature)

Differential Diagnosis

Liver abscess is differentiated with the following diseases:
- amoebic liver abscess;
- cholangitis;
- liver tumors (cystoadenomas or cystadenocarcinomas), liver metastases, hepatocellular carcinoma;
- solitary cysts of the liver;
- nodular hyperplasia of the liver;
- inflammatory pseudotumors of the liver: giardiasis (rarely leads to the formation of granulomas in the liver and cholangitis), Campylobacter colitis (may cause nonspecific acute hepatitis), Listeria monocytogenes (may cause the formation of liver abscesses);

Subdiaphragmatic and subhepatic abscesses of the abdominal cavity.

Liver nodules can also occur with cat-scratch disease. The presumed causative agents of this disease are pleomorphic rods. Nodule biopsy reveals necrotic granulomas containing microorganisms. Computed tomography of the liver shows focal defects, as well as mediastinal and periportal lymphadenopathy.

Complications

Most common complications liver abscess:

Sepsis Sepsis is a pathological condition caused by the continuous or periodic entry of microorganisms into the blood from the focus of purulent inflammation, characterized by a mismatch between severe general disorders and local changes and often the formation of new foci of purulent inflammation in various organs and tissues.
;

Metastatic abscesses;

septic shock;

respiratory distress syndrome in adults;

kidney failure;

Abscess rupture with peritonitis.

After recovery, the patient may develop portal hypertension. Portal hypertension is venous hypertension (increased hydrostatic pressure in the veins) in the portal vein system.
caused by portal vein thrombosis.

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Treatment

General provisions

1.Medical treatment

Antibacterial therapy (ABT) is directed against gram-negative, anaerobic microorganisms and microaerophiles. Treatment begins with intravenous antibiotics; in the future, it is possible to switch to their tablet form (depending on the effectiveness of the treatment).
Antibacterial therapy is recommended for 2-6 weeks. The isolated administration of high doses of antibiotics for at least 6 months may show higher efficacy, especially for streptococcal infections.
ABT also accompanies invasive treatments.

2. Surgery

"Expectant tactics": a flexible approach is needed when deciding whether to perform a surgical intervention. Surgical treatment is indicated for patients who do not respond quickly enough to conservative treatment.

"Immediate Intervention": tactics require immediate drainage of the abscess immediately after its discovery. Mandatory drainage should not be delayed, since intravenous antibiotics alone are rarely effective.

In some cases, a percutaneous helical catheter (usually an 8-gauge) may be required to drain the abscess.

In multiple abscesses, the largest abscess drains; smaller abscesses usually resolve spontaneously with antibiotic therapy. In some cases, percutaneous drainage of each abscess is necessary.

Complications when applying drainage:

Bleeding;

Perforation of internal organs;

Accession of an infection;

catheter prolapse.

In the past, surgical treatment has included open debridement and drainage of the abscess in combination with broad-spectrum antibiotics. Now "open" drainage of an abscess is rare. Modern studies have shown comparable results with transcutaneous (percutaneous) drainage, aspiration of the contents and sanitation of the abscess cavity in combination with antibiotics. However, a solitary left-sided abscess requires surgical drainage, especially in children.

Restoration of biliary tract patency is achieved using endoscopic retrograde cholangiopancreatography, papillosphincterotomy, and stone removal.
Fever may persist for 1-2 weeks even with adequate treatment.

Tactics
Patients with liver abscess are conditionally divided into hemodynamically unstable and hemodynamically stable.

Hemodynamically unstable patients with suspected liver abscess

1. Empiric ABT:

- piperacillin/tazobactam 3.375 every 6 hours, IV;
- imipenem/cilastatin 500 mg every 6 hours, IV;
- Meropenem 1-2 g every 8 hours, IV;
- Doripenem 500 mg every 8 hours, IV;
- cefepime 2 g IV every 8-12 hours;
- levofloxacin 500-750 mg, IV, every 24 hours + metronidazole 500 mg, IV, every 8 hours;
- ciprofloxacin 400 mg IV every 12 hours + metronidazole 500 mg IV every 8 hours;
- moxifloxacin 400 mg IV every 12 hours + metronidazole 500 mg IV every 8 hours.

Vancomycin 5-20 mg/kg IV every 8-12 hours + gentamicin 5-7 mg/kg/day. i.v. with dose adjustment depending on indicators of renal function + metronidazole 500 mg, i.v., every 8 hours;
- vancomycin 15-20 mg/kg IV every 8-12 hours + levofloxacin 500-750 mg IV every 24 hours + metronidazole 500 mg IV every 8 hours;
- vancomycin 15-20 mg/kg IV every 8-12 hours + ciprofloxacin 400 mg IV every 12 hours + metronidazole 500 mg IV every 8 hours;

Vancomycin 15-20 mg/kg IV every 8-12 hours + moxifloxacin 400 mg IV every 24 hours + metronidazole 500 mg IV every 8 hours.

2. Anti-shock therapy (general principles for the treatment of septic shock).

3. Drainage or opening of the abscess. Urgent percutaneous drainage is warranted for patients with shock or multiple organ dysfunction. Patients with a severe course and an Apache II score ≥ 15 points are likely to be more suitable for surgical resection.

4. Antifungal therapy is indicated in immunocompromised or neutropenic patients. The following schemes are empirically used:
- caspofungin 70 mg IV once a day on the first day, then 50 mg once a day;
- anidulafungin 200 mg IV once a day on the first day, then 100 mg once a day;
- micafungin 100 mg IV once a day;
- fluconazole 800 mg IV / orally once a day on the first day, then 400 mg once a day.

Fluconazole is indicated only in patients who do not have a history of azole antifungal therapy. The duration of therapy is 2 or more weeks (depending on the results).

Hemodynamically stable patients with suspected liver abscess

1. Empiric ABT:

1.1 Recommended basic first-line regimens (for adults):
- levofloxacin 500-750 mg IV every 24 hours + metronidazole 500 mg IV every 8 hours;
- ciprofloxacin 400 mg IV every 12 hours + metronidazole 500 mg IV every 8 hours;
- moxifloxacin 400 mg IV every 12 hours + metronidazole 500 mg IV every 8 hours;
- ceftriaxone 1-2 g IV every 12-24 hours + metronidazole 500 mg IV every 8 hours;
- cefotaxime 1-2 g IV every 6-8 hours + metronidazole 500 mg IV every 8 hours.

1.2 Alternative first-line regimens using broad-spectrum antibiotics:
- piperacillin/tazobactam 3.375 IV every 6 hours;
- ticarcillin/clavulanic acid 3.2 g IV every 6 hours;
- imipienem/cilastatin 500 mg IV every 6 hours;
- Meropenem 1-2 g IV every 8 hours;
- doripenem 500 mg IV every 8 hours;
- ertapenem 1 g IV every 24 hours;
- cefepime 2 g IV every 8-12 hours + metronidazole 500 mg IV every 8 hours;
Tigecycline 100 mg IV as a single dose followed by 50 mg every 12 hours.

1.3 ABT of the second line (for adults):
- ampicillin 2 g IV every 6 hours + gentamicin 5-7 mg/kg/day IV + metronidazole 500 mg IV every 8 hours;

Vancomycin HCl 15–20 mg/kg IV every 8–12 hours + gentamicin 5–7 mg/kg/day + metronidazole 500 mg IV every 8 hours

2. Drainage of the abscess. For liver abscesses less than 3 cm in diameter, antibiotic therapy may be sufficient for treatment. Possible puncture or placement of an indwelling catheter (under CT guidance), open or laparoscopic drainage, surgical removal of an abscess, or endoscopic drainage (in cases of biliary origin of infection). The choice of intervention depends on several factors, including the size, location, and complexity of the abscess.

3. Therapy with antifungal drugs is the same as above.

The group of patients responding to IV cephalosporin therapy should be further treated with oral antibiotics for 4-6 weeks. The following schemes can be used as recommended schemes:
- levofloxacin 500 mg orally every 24 hours + metronidazole 500 mg orally every 8 hours;
- ciprofloxacin 500-750 mg orally twice a day + metronidazole 500 mg orally every 8 hours;
- moxifloxacin 400 mg orally every 24 hours + metronidazole 500 mg orally every 8 hours;
- cefuroxime axetil 250-500 mg orally every 12 hours + metronidazole 500 mg orally every 8 hours;
- amoxicillin/clavulanate 2000 mg orally every 12 hours.

Recurrent/chronic abscess
There are no guidelines that have proven the efficacy of any particular empiric antibiotic regimen. Therefore, the schemes described above should be used.

Forecast

If untreated, purulent liver abscesses are fatal in almost 100% of cases. When treated, lethality depends on virulence Virulence - a quantitative characteristic of the pathogenicity of a microorganism for a particular organism
pathogen and the presence of concomitant pathology and averages 10-30%.
The prognosis is better with a single abscess of the right lobe of the liver, in which 90% of patients survive. The risk of death increases with pneumonia, a large abscess (more than 10 cm), septic shock, subdiaphragmatic location of the abscess, and an increase in serum creatinine.
In a large US population-based study, hospital mortality for purulent liver abscesses was 5.6% and was stable from 1994 to 2005.

Patients with concomitant gallbladder disease have the highest recurrence rate (up to 25%). Potential etiologies responsible for recurrences include biliary obstruction and fistula between the biliary tract and intestines. If liver abscess recurs, expert gastroenterology consultation and ERCP are required ERCP - endoscopic retrograde cholangiopancreatography
or magnetic resonance cholangioancreatography (MRCP).

Hospitalization

Emergency, in the surgical department.

Prevention

Treatment of acute infectious diseases of the biliary tract and abdominal organs at an early stage, as well as adequate, usually percutaneous, drainage of intra-abdominal accumulations of pus with the use of antibiotics. Prophylactic antibiotic therapy for chemoembolization and, in selected cases, for endoscopic retrograde cholangiography is used as a primary prevention strategy.

Information

Sources and literature

1. Ivashkin V.T., Lapina T.L. Gastroenterology. National leadership. Scientific and practical edition, 2008
2. McNally Peter R. Secrets of gastroenterology / translation from English. edited by prof. Aprosina Z.G., Binom, 2005
3. Raftery E. Surgery. Handbook / under the general editorship of Lutsevich O.I., Pushkar D.Yu., Medpress-inform, 2006
4. Sherlock S., Dooley J. Diseases of the liver and biliary tract, M.: Geotar, 1999
5. "Diagnosis and Management of Complicated Intra-abdominal Infection in Adults and Children: Guidelines by the SIS and the IDS of America" ​​Joseph S. Solomkin, John E. Mazuski, John S. Bradley etc, "Medicine Clinical Infectious Diseases" journal, no. 2(50), 2010
6. "Management of hepatic abscesses" Orlando Jorge Martins Torres, Alzira de Alencar Lima Lins, Paulo Marcio Sousa Nunes, Ricardo Lima Palacio, Ulrich Andreas Dietz and Arnaldo de Jesus Dominici, "Arq Bras Clr Dig", No. 14(2), 2001
7. "Modern management of pyogenic hepatic abscess: a case series and review of the literature" Helen M Heneghan, Nuala A Healy, Sean T Martin, Ronan S Ryan, Niamh Nolan, Oscar Traynor and Ronan Waldron, BMC Research Notes, 2011
8. "Liver abscesses" Akhaladze G.G., Tsereteli I.Yu., journal "Annals of Surgical Hepatology", No. 1, 2006
9. "Analysis of risk factors for mortality in liver abscesses" Tsereteli I.Yu., Akhaladze G.G., Galperin E.I., journal "Annals of Surgical Hepatology", No. 1, 2004
10. ACR Appropriateness Criteria: acute (nonlocalized) abdominal pain and fever or suspected abdominal abscess, American College of Radiology, 2012
11. ACR Appropriateness Criteria® liver lesion - initial characterization Lalani T, Rosen MP, Blake MA, Baker ME, Cash BD, Fidler JL, Greene FL, Katz DS, Miller FH, Small WC, Sudakoff GS, Yee J, American College of Radiology ( ACR); 2010
12. http://bestpractice.bmj.com
    1. "Liver abscess" Rachel P. Simmons, Lawrence S. Friedman, jun 2013 -
13. http://emedicine.medscape.com
    1. "Liver Abscess" Ruben Peralta, June 2013 -

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K75.0 Liver abscess

A06.4 Amebic liver abscess

Epidemiology

According to clinical statistics, an abscess of the right lobe of the liver is diagnosed five times more often than an abscess of the left lobe, and twice 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 100,000 population; at the same time, pathology in men occurs 2.5 times more often than in women.

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

Causes of a liver abscess

Experts name as the most common cause of a liver abscess, gallstones and cholecystitis or cholangitis that occur against their background. Also, a liver abscess may be the result of a ruptured inflamed appendix, perforation of a stomach ulcer or sigmoid colon with diverticulosis; ulcerative colitis; pyogenic inflammation of the portal vein; Crohn's disease; general blood poisoning; cholangiocarcinomas; colorectal cancer or malignant tumor of the pancreas; suppuration of liver cysts or organ injuries.

A pyogenic or purulent liver abscess (ICD-10 code K75.0) always has an infectious etiology. And the pathogenesis is associated with the entry of microbes into the liver (mainly E. coli, St. milleri, St. pyogenes, St. faecalis, Pseudomonas Spp., Clostridium welchii, Proteus vulgaris, Klebsiella pneumoniae, Bacteroides Spp.), which migrated from the focus primary inflammation with blood flow in the form of a septic embolus.

In the liver, bacterial reproduction continues, which leads to the death of parenchyma cells and necrosis of its individual sections with the formation of an infiltrate; then the infiltrate melts and a cavity filled with pus is formed surrounded by a fibrous capsule. Quite often partitions are formed in capsules. This is how bacterial liver abscesses develop.

When the same bacteria enter the liver from the gallbladder (the primary site of infectious inflammation) through the extrahepatic bile ducts, doctors define biliary or cholangiogenic liver abscesses. Among their causes, in addition to impaired patency of the bile ducts due to the presence of stones in them, there are narrowing of the lumen (stenosis and stricture) of the ducts of iatrogenic origin: after bile-hepatic surgical interventions, as well as the use of drugs (for example, steroids or cytostatics).

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

A liver abscess of a fungal etiology (Candida, Aspergillus) is diagnosed much less frequently, which develops after chemotherapy of malignant neoplasms in the abdominal organs or leukemia - in patients with a sharply weakened immune system.

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 stones in the liver, with a cholangiogenic origin of the focus of infection, with extraintestinal amebiasis - multiple liver abscesses can occur.

Risk factors

Risk factors for liver abscesses include diabetes mellitus, cirrhosis of the liver, severe pancreatic disease, liver transplantation, cancer, immunodeficiency, age over 70 years.

Symptoms of a liver abscess

The clinical symptoms of a liver abscess are nonspecific and are similar to other hepatobiliary inflammatory processes and infections. As a rule, the first signs of a purulent abscess in the liver include pyrexia (fever with a temperature above +38.5 ° C with chills and profuse sweating at night), lethargy and general malaise, discomfort and periodic pain in the right upper quadrant of the abdomen (pain becomes worse with pressure), earthy complexion. Nausea and vomiting, complete loss of appetite and body weight, a significant increase in the size of the liver (often with a protrusion into the right hypochondrium) are also observed.

Less commonly, there are symptoms such as coughing, shortness of breath, or hiccups due to irritation of the diaphragm by the crippled liver; irradiation of pain in the right shoulder and back; yellow tint of the skin and sclera (when cholangiogenic liver abscesses develop).

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

Complications and consequences

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

And the complications of this pathology are numerous and very dangerous. First of all, this is a rupture of the abscess cavity with the outpouring of necrotic masses into the pleural or peritoneal cavity. The result is pleural empyema or peritonitis with the threat of sepsis. The discharge of pus and its accumulation in a recess located under the dome of the diaphragm leads to the so-called subdiaphragmatic abscess. And the ingress of serous-purulent contents of a perforated abscess of the left lobe of the liver into the pericardial sac 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 hepatic portal vein system (which can result in bleeding); accumulation of fluid in the abdominal cavity (ascites); septic pulmonary embolism; brain abscess.

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

Diagnosis of a liver abscess

Diagnosis of a liver abscess begins with anamnesis and palpation examination of the abdominal organs. Laboratory tests are required, for which tests are taken: a general and biochemical blood test (including for bilirubin and alkaline phosphatase), blood cultures, and a urine test.

If extraintestinal amebiasis is suspected (if it turns out that the patient has been in endemic areas), a fecal examination for cysts or trophozoites of the dysenteric 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 in addition to the usual x-ray of the abdominal cavity, cholangiography (x-ray of the bile ducts with a contrast agent) and splenoportography (x-ray of the liver vessels), ultrasound and CT are used.

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

Contrasting during 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 for small abscesses (up to 3 cm) with partitions inside the purulent cavity, drainage is not recommended.

Differential Diagnosis

Significant difficulties are caused by the differential diagnosis of liver abscesses. First, it is difficult to clearly differentiate amoebic liver abscesses from pyogenic ones. And purulent abscesses should be distinguished from liver cysts, pleurisy with purulent capsules, subphrenic abscess, cholecystitis, hepatocellular carcinoma, or liver metastases.

Treatment of a liver abscess

Doctors warn that with liver abscesses, neither homeopathy, nor alternative treatment, nor attempts to use herbal treatment are allowed.

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

To remove purulent contents from the cavity, controlled ultrasound or CT puncture drainage of a liver abscess is carried out. Placement of drainage catheters through the skin is performed in all patients either immediately after the initial aspiration at the time of diagnosis or within 24 hours of the exacerbation. The duration of placement of catheters that drain pus can vary from three days to a week, depending on the results of re-imaging of the abscess and the clinical condition of the patients. Pathogens of inflammation are sown from the aspirated contents of the abscess. During catheter placement, there is a risk of spreading pus from the abscess, followed by bacteremia and sepsis.

At the same time, drugs are prescribed - antibiotics Amoxiclav (Amoxil, Augmentin), Clindamycin (Klimitsin, Cleocin, Dalacin C), Ceftriaxone, etc. The drugs are injected into a 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 can be manifested by nausea and diarrhea, urticaria, increased activity of hepatic 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 E. histolytica trophozoites. Even a one-time oral administration of this drug (2.5 g) and simultaneous puncture drainage of a liver abscess has a positive effect. More often Metronidazole is used parenterally - in the form of long-term infusions of 0.5-1 g 4 times a day. Side effects include gastrointestinal symptoms, headaches, tongue coating, dryness, and a metallic taste in the mouth; dizziness, ataxia and paresthesia, urination disorders, as well as allergic reactions are sometimes observed.

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

Surgical treatment of liver abscess is necessary in the absence of the effect of conservative therapy. And, as a rule, an operation is needed when the abscess is complicated. The intervention can be performed in an open way or laparoscopically and may include either open drainage of the abscess cavity, or resection (excision) of the inflammatory focus and affected tissues.

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

A liver abscess is a process of formation of a cavity filled with pus in the parenchyma of an organ due to the introduction of pyogenic microflora into it. The causative agents that cause this disease can be both bacteria and protozoa. If bacteria are introduced, a bacterial liver abscess develops, and if amoebas and other protozoa develop, an amoebic liver abscess develops.

Most often, this pathology is found in people living in unfavorable sanitary and hygienic conditions. Moreover, men suffer from this disease approximately 7 times more often than women.

According to its etiological features, a liver abscess can be primary and secondary. The primary develops if the infection enters the body from the outside, and the secondary - when it spreads from the inside, that is, with other diseases of the liver and other organs. For example, an abscess can occur in cases where a person suffers from, with the formation of granulomas in the liver. Also, an abscess can form if suppuration of the cysts of the organ occurs or the organ is affected by a benign tumor.

Classification

The classification of this pathology is very extensive, since there are many factors that affect the characteristics of the course of the disease. In particular, the main classification criteria are:

• origin;
• causes of occurrence;
• distribution routes;
• types of flow;
• size, quantity and location.

Ways of distribution of infectious agents in the body cause several varieties of abscesses. Depending on how the infection got into the organ, there are hematogenous abscesses of the liver, cholangiogenic, contact, post-traumatic. In addition, there is a category of abscesses, the cause of which has not been established - they are called cryptogenic.

They speak of a hematogenous abscess if the infection has entered the organ through the blood vessels (hepatic veins or reverse vena cava), and they speak of cholangiogenic when it has entered the organ through the biliary tract. A contact abscess involves infection from nearby organs, such as an inflamed appendix or an ulcerated intestine. And post-traumatic liver abscesses develop after surgical interventions, open or blunt injuries.

The course of the disease is uncomplicated and complicated. A complicated variety involves the development of concomitant pathologies:

• abscess rupture;

Liver abscesses are also classified by size (they can be small or large), number (one or many) and location (the right or left lobes can be affected separately, the caudate lobe or square).

Etiology

It has already been said above that the causes of the development of the disease are the penetration into the body of a certain bacterial flora or protozoa. In this case, the ways of penetration of infection can be different. If we talk about the cholangiogenic pathway of distribution, then diseases such as, and others contribute to this. Through the blood, the infection penetrates in the case of a general infection (sepsis).

In more detail, one should dwell on the post-traumatic path, the causes of which are a traumatic violation of the integrity of the liver. Suppuration in the organ can develop as a result of injury to the parenchyma, as well as with closed injuries (especially with the formation of hematomas). This can occur as a result of various accidents, fights and falls from a height, as well as during surgical interventions.

Symptoms

The initial symptoms of this disease are general clinical. The patient complains about, which can manifest themselves with different intensity depending on the state of immunity.

The classic symptoms of a liver abscess are:

• an increase in temperature to 38-39 degrees and above;
• chills and fever;
• the appearance of sweat on the face and neck, which is sticky to the touch;
• dizziness;
• visual hallucinations;
• headache;
• attention and memory disorders.

In some cases, a person feels nausea and vomits intestinal contents.

After the first signs of intoxication, symptoms of liver damage appear, among which the diagnostic may be explicit. Usually, a sick person can determine exactly where the painful area is.

Other symptoms of liver damage include:

• organ enlargement;
• enlargement of the spleen;
• development ;
• weight reduction;
• darkening of urine and discoloration of feces;
• the presence of blood in the feces;
• bleeding (esophageal and intestinal) - these symptoms are confirmed by the appearance of vomiting in the form of coffee grounds or tarry stools.

Diagnostics

In order to make an accurate diagnosis, it is not enough just to examine the patient, collect an anamnesis and conduct laboratory tests, since they do not give a complete picture of the pathology. Therefore, in addition to general and biochemical blood tests, patients with the complaints described above are prescribed an X-ray examination, CT and ultrasound.

The most effective diagnostic method is. It allows in 90% of cases to establish the correct diagnosis. It is possible to determine the microorganism that caused the abscess in order to select the most appropriate antibiotic by taking the contents of the abscess for analysis by percutaneous puncture under ultrasound control.

Necessary treatment

In the case of an uncomplicated process, treatment gives a good chance of recovery. If complications develop, the prognosis becomes unfavorable, and the likelihood of death increases.

The main drugs used to treat this pathology are antibiotics. Mostly third-generation drugs are used:

• ceftriaxone;
• norfloxacin;
• levofloxacin;
• amoxiclav.

Treatment of a pathology such as amoebic liver abscess involves the use of antiprotozoal drugs, the most effective of which is metronidazole.

In addition to antibiotics, treatment also involves symptomatic therapy:

• taking antipyretics;
• painkillers;
• enterosorbents;
• hemostatic drugs;
• antiemetics.

Treatment is carried out in a hospital under the supervision of a doctor, and most drugs are administered intravenously. If within a few months such therapy does not give a result or the patient develops complications, in the form of an abscess rupture and the spread of the inflammatory process to other organs, surgical drainage of a purulent cavity or cavities (with multiple abscesses) is indicated.

Surgical treatment can be carried out either in a minimally invasive way (by percutaneous introduction of drains), or by a full-fledged operation with organ extraction and excision of affected tissues.

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Jaundice is a pathological process, the formation of which is affected by a high concentration of bilirubin in the blood. The disease can be diagnosed in both adults and children. Any disease can cause such a pathological condition, and they are all completely different.