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Liver Abscesses

1. Liver abscesses (Ref. Hari. 18th ed., Pg - 1080)
Liver abscesses can be classified as pyogenic, hydatid or amoebic
  1. Pyogenic Liver Abscess (Causes of Pyogenic Liver Abscesses)
    1. Biliary obstruction (cholangitis)
    2. Hematogenous
      1. Portal vein (mesenteric infections)
      2. Hepatic artery (bacteriemia)
    3. Direct extension
    4. Trauma - Penetrating or non- penetrating
    5. Infection of liver tumour or cyst
Clinical features
  1. Fever,
  2. Abdominal pain
  3. Hepatomegaly
    (Jaundice is uncommon)
The most frequently encountered organisms are
  1. E coli
  2. Klebsiella pneumoniae, 
  3. Proteus vulgaris,
  4. Enterobacter aerogenes, 
  5. Multiple microaerophilic and anaerobic species (eg, streptococcus milleri).
  6. Staphylococcus aureus.
  7. Hepatic candidiasis, tuberculosis, actinomycosis are seen in immunocompromised patients and those with hematologic malignancies. 
Laboratory Findings

  1. Chest roentgenograms usually reveal elevation of the diaphragm if the abscess is on the right side. Ultrasound,
  2. CT, or MRI may reveal the presence of intrahepatic defects.
  3. CT appearance of hepatic candidiasis, usually seen in the setting of systemic candidiasis, is that of multiple “bulls-eyes”.
Antimicrobial agents (a third generation cephalosporin such as cefoperazone, metronidazole. Hepatic candidiasis often responds to intravenous amphotericin B.
  1. Hydatid cysts
    1. Hydatid cysts are caused by echinococcus granulosus infection. (LQ 2012)
    2. They have an outer layer derived from the host, an intermediate laminated layer and an inner germinal layer.
    3. Can be single or multiple.
    4. Chronic cysts become calcified.
    5. The cysts may be asymptomatic but may present with abdominal pain or a mass. 
    6. There may be a peripheral blood eosinophilia, X-rays may show calcification, imaging shows the cyst(s), and serological tests are positive in 50% of cases.
    7. Rupture or secondary infection of cysts can occur, and a communication with the intrahepatic biliary tree can then result.
    8. All patients are treated medically with albendazole or mebendazole prior (LQ 2012) to definitive therapy, in the absence of communications with the biliary tree, treatment of percutaneous aspiration of the cyst following by then aspiration of the cyst content (PAIR).
    9. Where communication occurs between the cyst and biliary system, surgical removal of the intact cyst is the preferred treatment.
  2. Amoebic liver abscesses
    1. Amoebic liver abscesses are caused by Entamoeba histolytica infection.
    2. Abscesses are usually large, single and located in the right lobe.
    3. Pain or swelling are the most common symptoms.
    4. Diagnosis may depend on cyst aspiration revealing the classic anchovy sauce appearance of the of the cyst fluid.
Metronidazole or Tinidazole + Luminal agent (Diloxanide furoate) hydroxychloroquine. 
2. The Liver and HIV
Causes of abnormal Liver Blood Tests In HIV Infection
  1. Chronic hepatitis C
  2. Chronic hepatitis B
  3. Antiretroviral drugs
  4. Cytomegalovirus
  5. Tuberculosis
  6. Atypical mycobacterium
  7. Sclerosing cholangitis due to Cryptosporidia
3. Pregnancy and the Liver (Ref. Hari. 18th ed., Pg - 60)
Liver disease in pregnancy may be intercurrent, pregnancy-associated or pre-existing.
  1. Intercurrent liver disease
    1. When elevated serum transaminases are present, acute viral hepatitis (particularly in IIIrd trimester, runs a severe course and can go in to fulminant hepatic failure) and occur during pregnancy. 
    2. Gallstones are more common during pregnancy.
  2. Pregnancy-associated liver disease
    These conditionals only occur during pregnancy, may recur in subsequent pregnancies, and resolve after delivery of the baby
Intrahepatic cholestasis of pregnancy
  1. This usually occurs in the third trimester of pregnancy but can occur earlier; 
  2. It is associated with intrauterine growth retardation and premature birth, increase fetal mortality. 
  3. The condition characteristically presents with profound itching and cholestatic LFTs. But the bilirubin may be normal and the liver biochemistry may show raised liver enzymes. 
  4. Placental bile salt deposition contribute to progressive uteroplacental insufficiency. 
  5. Resolves typically within two weeks of termination of pregnancy but can reoccur in next pregnancy or with the use of OC.
  6. Treatment is ursodiol. 
Acute fatty liver of pregnancy
  1. This is more common in twin and fist pregnancies. 
  2. It typically presents between 31 and 38 weeks of pregnancy with Vomiting pain following by lactic acidosis, a coagulopathy, encephalopathy and renal failure. 
  3. Hypoglycemia can occur. 
  4. The features are characteristic of a defect in beta-oxidation of fatty acids in the mitochondria that leads to the formation of small fat droplets in liver cells (known as microvesicular fatty liver). Some women are heterozygous for long –chain 3-hydroxy-CoA dehydrogenate deficiency (LCHAD). 
  5. Only treatment is termination of pregnancy.
Toxemia of pregnancy and HELLP syndrome
  1. The HELLP syndrome is a variant of pre-eclampsia that tends to affect multiparous women and comprised hemolysis, elevated liver enzymes and thrombocytopenia and fluid retention. 
  2. ii. Serum transaminases are high. 
  3. The condition can be complicated by hepatic infarction and rupture.
4. Cystic And Fibropolycystic Diseases Solitary Hepatic Cysts
  1. Adult hepatorenal polycystic disease
    1. The kidneys are predominantly affected in this condition. 
    2. ii. Hepatic cysts which do not communicate with the biliary system are present in over half of patients with renal cysts. 
  2. Caroli’s syndrome
    1. This is very rare and is characterized by segmental saccular r dilatations of the intrahepatic biliary tree.
    2. The whole liver is usually affected, and extrahepatic biliary dilation occurs in about one-quarter of patients.
    3. Recurrent attacks of cholangitis occur and may cause hepatic abscesses.
    4. Complication includes biliary stones and cholangio-cholangitis.
    5. Occasionally, localized disease can be treated by segmental liver resection.
5. Primary sclerosing cholangitis (PSC)
  1. Is a fibrosing cholangitis of bile ducts leading to inflammatory strictures and obliteration of both intrahepatic and extrahepatic ducts with dilatation of preserved segments.
  2. It's a progressive disease eventually resulting in secondary biliary cirrhosis.
  3. Autoimmune disorder, common in males.
  4. Association is seen with HLA, -DR3, -DQ2 and -DRw52A
  5. Its seen to be associated with ulcerative colitis and occasionally Crohn's disease (Ulcerative colitis seen in approx 2/3rd of patients of PSC).
  6. PSC is a risk factor for Cholangiocarcinoma
  7. Cholangiocarcinoma can present at any time during the disease process and does not correlate with the extent of sclerosing cholangitis.
Clinical Feature
  1. Mean age of presentation is 30 to 45 yrs.
  2. M: F ratio - 2 : 1
  3. Usual presentation is intermittent jaundice, fatigue, weight loss, pruritus and abdominal pain.
  4. Asymptomatic patients may come to attention because of persistent elevation of serum alkaline phosphatase
    1. GGT is typically elevated
    2. Asymptomatic elevation of GGT is the earliest finding
    3. ALP & bile acids are increased
  5. Endoscopic retrograde cholangiography is the definitive investigation.
  6. ERC shows multiple dilatation and strictures involving both intrahepatic and extrahepatic ducts.
  7. MRCP is the best non-invasive investigation. It is less sensitive than ERCP for intrahepatic ducts.
  8. Treatment
    1. There is no known effective medical treatment.
    2. Liver transplantation is the only option.
Important Points

Two important conditions more common in nonsmokers !!!

  1. Ulcerative colitis (UC)
  2. Primary sclerosing cholangitis (PSC)
Benign Tumors of Liver (Ref. Hari. 18th ed., Pg - 777)
  1. The most common benign neoplasm of the liver is the cavernous hemangioma. This lesion may enlarge in women who take hormonal therapy.
  2. Focal nodular hyperplasia
  3. Hepatic adenoma (Common in patient taking OCP).

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