[2] Liver Abscess

Question 1

What do liver abscesses typically result from?

Answer 1

Polymicrobial bacterial infection spreading from the biliary or gastrointestinal tract to the portal or hepatic veins

Question 2

How can bacterial infection spread from the biliary or GI tract to the portal and hepatic vein?

Answer 2

Either via contiguous spread or seeding

Question 3

What are the common causes of liver abscesses?

Answer 3

Cholecystitis
Cholangitis
Diverticulitis 
Appendicitis
Septicaemia

Question 4

What are the most commonly isolated organisms involved in liver abscesses?

Answer 4

E. Coli
K. Pneumoniae
S. Constallatus

Question 5

When might fungal cases of liver abscesses be present?

Answer 5

In immunocompromised patients

Question 6

How do patients with liver abscesses typically present?

Answer 6

Fever
Rigors
Abdominal pain

Question 7

When should pyogenic abscesses be considered?

Answer 7

In all patients presenting with pyrexia of unknown origin associated with associated abdominal pain or bloating

Question 8

What are the other symptoms of liver abscesses?

Answer 8

Bloating
Nausea
Anorexia
Weight loss
Fatigue 
Jaundice

Question 9

What will be found on examination with liver abscesses?

Answer 9

RUQ tenderness, with or without hepatomegaly

Question 10

How may a patient present with a ruptured liver abscess?

Answer 10

Signs of shock

Question 11

What investigations should be done in suspected liver abscess?

Answer 11

Bloods

Imagingq

Question 12

What may bloods show in liver abscesses?

Answer 12

FBC will show leucocytosis

LFTs are often abnormal, with raised ALP in most cases and deranged ALT and bilirubin in a proportion

Question 13

What should all patients with liver abscesses have sent for microscopy?

Answer 13

Peripheral blood and fluid cultures

Question 14

What imaging can be done in liver abscesses?

Answer 14

Ultrasound imaging

CT imaging with contrast

Question 15

What will be shown on ultrasound imaging with liver abscesses?

Answer 15

Poorly-defined lesions with hypo- and hyper-echoic areas, with potential gas bubble and septations

Question 16

What is the purpose of CT scan with contrast in liver abscesses?

Answer 16

It can provide further delineation

Question 17

What may a CT scan with contrast show in liver abscesses?

Answer 17

Similar pattern from the collection as seen on ultrasound, with associated surrounding oedema

Question 18

How should patients with liver abscesses be managed initially?

Answer 18

They should be fluid resuscitated and stabilised accordingly, and started on appropriate antibiotic therapy

Question 19

What antibiotic therapy should be given in liver abscesses?

Answer 19

Choice guided by sensitivities and local policy

Question 20

How can liver abscesses be managed definitively?

Answer 20

Most cases can be drained via image-guided aspiration of the abscess, with or without catheter drainage

Question 21

What image guidance is used in aspiration of liver abscesses?

Answer 21

Either ultrasound or CT

Question 22

When should the underlying cause of a liver abscess be managed?

Answer 22

Once the patient has been appropriately managed

Question 23

When is surgery indicated in liver abscesses?

Answer 23

Rarely indicated, predominantly if the abscess has ruptured, or refractory to antibiotic treatment

Question 24

What is an amoebic abscess?

Answer 24

The most common extra-intestinal manifestation of amebiasis infection

Question 25

What causes an amoebic abscess?

Answer 25

The organism Entamoeba histolytica

Question 26

How does amebiasis infection spread?

Answer 26

Via faeco-oral route

Question 27

What happens once the amebiasis infection is in the colon?

Answer 27

The trophozoite begins to invade the mucosa and spread to the liver via the portal system

Question 28

What % of the worlds population is estimated to be infected with the Entamoeba histolytica?

Answer 28

12%

Question 29

Where is infection with Entamoeba histolytica most common?

Answer 29

In developing regions such as South America, the Indian subcontinent, and Africa

Question 30

What are the clinical features of an amoebic abscess?

Answer 30

``` Patients present with vague symptoms; Abdominal pain Nausea Fever or rigors Weight loss Bloating ```

Question 31

When should cases of amoebic abscesses be suspected?

Answer 31

In patients presenting with the symptoms and a history of recent travel (<6 months) to an endemic region

Question 32

What early clinical features may patients with amebiasis infection present with due to intestinal involvement?

Answer 32

Abdominal pain and diarrhoea

Question 33

What investigations should be done in suspected amoebic abscess?

Answer 33

Bloods | Ultrasound imaging

Question 34

What will bloods show in amoebic abscesses?

Answer 34

Leucocytosis with deranged LFTs

Question 35

What should all patients with amoebic abscesses have sent for microscopy?

Answer 35

Peripheral blood and fluid cultures

Question 36

What is the purpose of testing blood and stool samples in suspected amoebic abscesses?

Answer 36

To check for the presence of E. histolytica antibodies

Question 37

What will ultrasound imaging show in amoebic abscesses?

Answer 37

Poorly-defined lesions

Question 38

How can amoebic lesions seen on ultrasound be further characterised?

Answer 38

CT imaging

Question 39

How are most patients with amoebic cysts managed?

Answer 39

Antibiotics alone

Question 40

What antibiotic are used in the management of amoebic cysts?

Answer 40

Typically metronidazole or tinidazole

Question 41

When may surgical treatment of amoebic cysts be required?

Answer 41

Large cysts, or those which do not respond well to antibiotic therapy

Question 42

What is the surgical treatment for amoebic cysts?

Answer 42

Surgical drainage

Question 43

What can be prescribed to eradicate amoebiasis in the colon?

Answer 43

A luminal agent, such as paramomycin