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Surgical Management of Infectious Processes of the Liver. Houssam G. Osman, M.D. HPB surgery Associate Director, HPB Fellowship Methodist Dallas Medical Center, Dallas ACOS: In-Depth Review - 2014 Kansas C ity, MO. PYOGENIC LIVER ABSCESS. Secondary to bacterial infection

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surgical management of infectious processes of the liver

Surgical Management of Infectious Processes of the Liver

Houssam G. Osman, M.D.

HPB surgery

Associate Director, HPB Fellowship

Methodist Dallas Medical Center, Dallas

ACOS: In-Depth Review - 2014

Kansas City, MO

pyogenic liver abscess
PYOGENIC LIVER ABSCESS
  • Secondary to bacterial infection

Etiology / route of dissemination

  • Biliary : cholangitis , ERCP
  • Portal: intra-abdominal; appendicitis, diverticulitis
  • Arterial: IVDU, pneumonia, endocarditis
  • Adjacent organ: cholecystitis
  • Direct trauma: after ablation on TACE

Keep underlying tumor at the back of your mind specially if you don’t find a source!

pyogenic liver abscess1
PYOGENIC LIVER ABSCESS

Clinical presentation

  • Fever
  • Abdominal pain
  • Nausea, vomiting, weight loss
  • Sepsis
pyogenic liver abscess2
PYOGENIC LIVER ABSCESS

Diagnostic workup

  • Labs: leukocytosis and elevated LFTs
  • US
  • CT
  • MRI
  • Blood culture
  • Workup for source
pyogenic liver abscess3
PYOGENIC LIVER ABSCESS

Treatment:

  • Antibiotics

- IV

- prolong course

  • Percutaneous approach

- drain placement

- aspiration (may need multiple trips to IR)

  • Surgical drainage/debridement/resection

- failure of percutaneous approach

- intra-peritoneal rupture

- need for operative intervention to address other abdominal process

hydatid liver disease
HYDATID LIVER DISEASE
  • Echinococcusspecies
  • Humans become accidental intermediate hosts when they become infected after ingesting ova passed in dog feces¹
  • Liver is the most common involved organ²
  • It may take months to years for individual to become symptomatic after infection

¹William R. Jarnagin and Leslie H. Blumgart, MD. Blumgart\'s Surgery of the Liver, Pancreas and Biliary Tract, 5th Edition

²Shaw JM, Bornman PC, Krige JEJ: Hydatid disease of the liver. S Afr J Surg. 44:70-77 2006

hydatid liver disease1
HYDATID LIVER DISEASE

Potential complication

  • Rupture

- peritoneal cavity

- pleural space

- biliary tree

  • Secondary infection
  • Mass effect

Corona M et al, Case report: Percutaneous treatment of multiple honeycomb-like liver hydatid cysts (type III CE2, according to WHO classification). Indian J Radiol Imaging. 2012 Jan;22(1):23-6. doi: 10.4103/0971-3026.95399.

hydatid liver disease2
HYDATID LIVER DISEASE

Clinical presentation

  • Asymptomatic
  • RUQ pain
  • Allergic reaction and anaphylactic shock
hydatid liver disease3
HYDATID LIVER DISEASE

Diagnostic work up

  • Laboratory

- eosinophilia > 3% ¹

- LFTs may be normal

- serology; electrophoresis, ELIZA

  • CT/MRI

- multiple types

-hydatid sand, honeycomb

¹Pitt HA, et al.: Management of hepatic echinococcosis in Southern California. Am J Surg

William R. Jarnagin and Leslie H. Blumgart, MD. Blumgart\'s Surgery of the Liver, Pancreas and Biliary Tract, 5th Edition

hydatid liver disease4
HYDATID LIVER DISEASE

Treatment

  • Conservative

- asymptomatic small cyst < 5 cm¹

  • Surgery

- conservative

- radical

- avoid spillage

  • Percutabeous
  • Medication (Albendazole)

- perioperative

- definitive

¹Buttenschoen K, Buttenschoen D: Echinococcusgranulosus infection: the challenge of surgical treatment. Langenbecks Arch Surg. 388:218-230 2003

amebic liver abscess
AMEBIC LIVER ABSCESS
  • Entamoebahistolytica
  • Most common extra-intestinal location
  • Fecal-oral transmission

Killed Napoleon!!

amebic liver abscess1
AMEBIC LIVER ABSCESS

Presentation

  • Asymptomatic
  • Abdominal pain and fever

Unlikely to have concomitant colitis

amebic liver abscess2
AMEBIC LIVER ABSCESS

Diagnosis:

  • US
  • CT
  • Serology

? Role of aspiration

William R. Jarnagin and Leslie H. Blumgart, MD. Blumgart\'s Surgery of the Liver, Pancreas and Biliary Tract, 5th Edition

Courtesy Professor A.K. El Dory, Ain Shams University, Cairo.

amebic liver abscess3
AMEBIC LIVER ABSCESS

Treatment:

  • Metronidazole
  • Therapeutic aspiration

- imminent rupture

- failure or contraindication of medical treatment

- secondary bacterial infection

liver fluke
LIVER FLUKE

Fasciolahepatica

  • Fecal-oral transmission
  • Inhabit hepatocytes, bile duct, and gallbladder
  • Presentation: abdominal pain, fever, hemobilia
  • Diagnosis: CT, serology
  • Treatment

- Triclabendazole

- ERCP if biliary obstruction

liver fluke1
LIVER FLUKE

Clonorchissinensis

  • Fecal –oral transmission
  • Oriental cholangiohepatitis
  • CT, serology
  • Praziquantel
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