Lecture on liver abscess (amoebiasis, bacteria)

2021-08-10 01:22 PM

In the liver, the amoeba grows and clogs the small veins, leading to infarction and necrosis of liver cells, creating sterile pus-filled foci; Many small pustules merge into a large pus

Liver abscess is the accumulation of pus in the liver forming one or more scattered foci of pus, usually, there are two types of liver abscess: amoebic liver abscess and bacterial liver abscess.

Abscess of amoebic liver

Amoeba is a parasite called Entamoeba histolytica that causes ulcers in the intestinal mucosa and then invades the capillaries of the portal veins to the liver and is usually localized in the right lobe.

In the liver, the amoeba grows and clogs the small veins, leading to infarction and necrosis of liver cells, creating sterile pus-filled foci; Many small pustules merge into large pus.

Definite diagnosis

Based on 4 criteria of La Monte:

Clinical: fever, liver pain, hepatomegaly, history of dysentery.

Subclinical: stool, blood, x-ray.

Probe poke.

Trial treatment.

There are 3 out of 4 criteria that can confirm the diagnosis. Today, in addition to the above 4 standards, there are:

Serum amoeba (+) is high in 95% of cases.

Ultrasound: helps to detect abscess early (90% in the right lobe), helps to treat and monitor the disease.

Differential diagnosis

Liver Cancer:

Enlarged or hard liver, vibrating liver (-), intercostal pressure (-).

Rapid deterioration.

AFP (+).

Ultrasound can distinguish between liver abscess and cancer.

Bacterial liver abscess:

Liver pain.

There is sepsis: high fever with chills, dry lips, and dirty tongue.

Jaundice, mucous membranes.

Ultrasound: there are many abscesses scattered in the liver.

Treatment

Amoebic liver abscess is a disease that can be treated medically, combined with ultrasound aspiration when the pus is large and surgery is required when there is a complication of abscess rupture.

It is a disease that, if treated early and appropriately, can be completely cured without leaving any sequelae.         

Internal treatment

Therapeutic drugs:

Emetin or Dehydroemetin (20 mg/tube; IM):

It is an effective antibiotic against amoeba both inside and outside the intestines.

There are side effects: muscle pain, headache, vomiting, diarrhea, and especially toxic to the heart muscle.

Dosage: 1 mg/kg/day x 10 days; not more than 70 mg/day.

Adults usually take a dose of 40 mg/day (in Vietnam).

Because the drug has a slow half-life; has a toxic effect on cardiomyocytes; liver failure, kidney failure should only be used again after 45 days.

Metronidazone (250 mg/tablet; 500 mg/tablet):

As an effective antibiotic against amoebae inside and outside the intestines, it is popular for the treatment of amoeba-induced liver abscesses; More than 90% of patients respond to treatment such as pain and fever relief within 72 hours.

It is an antibiotic belonging to the Nitro-5 imidazole family (Metronidazole, Tinidazole, Secnidazole, Ornidazole...).

Side effects: headache, vomiting, muscle pain.

Dosage: 750 mg x 3 times/day x 5-10 days. Average 2g/day. Secnidazole, Tinidazole, Ornidazole orally 2g/day x 10 days.

Chloroquine (250 mg/tablet- 150 mg base):

It is an extraintestinal amoebic antibiotic used for the prevention of recurrence in amebic liver abscesses.

Dosage: First two days: 1g/day

The following days: 500 mg/day x 4 weeks.

Iodoquinol (Direxiode 210 mg/tablet):

An enteric amoebic antibiotic is used to prevent recurrence in amoeba-induced liver abscesses.

Dosage: 650 mg x 3 times/day x 20 days. Average 3 tablets x 3 times/day.

Treatment regimens:

Harrison 1980 has 3 regimens:

Emetin 1 mg/kg/day x 10 days.

Or chloroquine phosphate 1g/day x 2 days.

Then 0.5g/day x 4 weeks.

Combined with Dehydroemetin 1 mg/kg/day x 10 days.

Or Metronidazol 750 mg x 3 times / day x 5 - 10 days.

Lectures on internal medicine pathology the University of Medicine. Ho Chi Minh City 1992:

Emetin 1 mg/Kg/day x 10 days repeat ultrasound: if the abscess is greatly reduced, continue to use Metronidazole 2g/day + Chloroquine until the abscess disappears.

If the abscess does not reduce or reduce a little, surgery is indicated.

Current Diagnosis & in treatment in Gastroenterology 1996; Harrison 1998; 2001:

Metronidazol 750 mg x 3 times/day x 10 days is the preferred regimen followed by Iodoquinol 650 mg x 3 times/day x 20 days.

Harrison 2005 has only one regimen left:

 Metronidazol 750 mg x 3 times/day x 10 days or derivatives of the Nitro-5 imidazole family: Tinidazole, Secnidazole, Ornidazole orally 2g/day x 10 days.

Combination of broad-spectrum antibiotics (eg, bacterial liver abscess) if superinfection is present:

Outpatient treatment:

Combined medical treatment with ultrasound-guided drainage when the abscess diameter is ³10 cm, the left lobe alone can be indicated when the abscess is smaller (6 cm).

Aspiration drainage through ultrasound during internal treatment, but the size of the abscess did not decrease or decrease slightly.

Surgery when there is a complication of abscess rupture.

Bacterial liver abscess

Upstream biliary tract infections caused by enteric bacteria account for 80% of cases.

Sepsis is caused by an infection elsewhere that enters the bloodstream to the liver.

Due to adjacent foci of infection.

Due to the wounds penetrating the abdomen into the infected liver.

Clinical

Liver pain, continuous pain, liver fibrillation (+), intercostal pressure (+).

High fever 39-40 oC with chills.

Jaundice, mucous membranes.

The liver is large, tender, and the face is smooth.

The gallbladder may be enlarged and painful.

Subclinical

Blood count:

Leukocytes are elevated with a very high neutrophil rate of 80-90%.

Elevated erythrocyte sedimentation rate.

Liver function tests are less disturbed.

Blood chemistry:

Bilirubin, alkaline phosphatase, GGT all increased.

Abdominal X-ray:

Like amoebic liver abscess.

Hepatobiliary ultrasound.

Treatment

Internal treatment:

Bacterial liver abscess is a small, multifocal abscess that can be treated internally when the pus is small and must be treated outside when it is certain that there is a large pus pocket.

If treated early, appropriately, the prognosis is still severe due to its complications and the underlying cause of the disease.

Treatment of liver abscess caused by bacteria should be cultured blood before antibiotics.

Adequate hydration and electrolytes must be provided.

Use broad-spectrum antibiotics, injectable route, full dose, full time (10-14 days).

Treatment regimens:

Ampicillin 50-100 mg/Kg/day in 3 divided doses + Gentamycin 3-5 mg/kg/day in 2 divided doses or Tobramycin (nebcin) 80 mg x 2 times/day (intramuscular).

Amikacin

3rd generation Cephalosporins ±Aminoglycosides:

Cefotaxime 1-2g (TM) / 8 hours or

Ceftriaxone 2g (TM)/day.

Fourth-generation cephalosporins.

Quinolon ± Aminoglycoside:

Ciproloxacin 200 mg (TTM) / 12 hours or Peflox 500 mg (TTM) / 12 hours.

Levoxacin.

Anti-shock if you have septic shock.

Outpatient treatment:

Ultrasound-guided drainage if large pus-filled foci are present.

Surgery when there is a complication of abscess rupture.

Treat the cause of biliary obstruction.

Preventive treatment

Amoebic liver abscess:

Guidance and propaganda in food hygiene: cooked food, boiled drink.

Thorough treatment (elimination) of acute amoebic dysentery in the intestinal tract.

The problem of relapse treatment is presented in the treatment regimens.

Bacterial liver abscess:

Guidance and propaganda on food hygiene.

Use an anthelmintic every 6 months