Corrections :

1. Page 6 : ceftriaxone 750 mg twice daily

once daily
2. Page 20 : Cross sectional study
retrospective study
PYOGENIC LIVER ABSCESS
DELFICAN
English Case Presentation
Introduction
Recognised since the time of Hippocrates (400 BC)
Today, it remains a surgical problem with considerable morbidity and
mortality
Frequently encountered disease in children from developing countries
Liver
abscess
An important clinical entity for which prompt recognition and treatment are
essential to favorable outcome
It is critical to promptly recognize these patients, for whom traditional open
surgical intervention is the definitive treatment
Pyogenic
liver
abscess
Report a boy with pyogenic liver abscess
This
case
Case Illustration
TMP, a 4 year and 4 month
old boy was hospitalized in
pediatric ward of Dr. M. Djamil
hospital
Was referred from pediatric
out patient
Chief complain : swelling in the upper right abdomen since
1 month before hospitalization
Present illness history
Fever since
2 months
before
admission
Swelling
and pain in
the upper
right
abdomen
Decreased
appetite and
body weight
No cough,
breathlessness,
nausea,
vomiting,
oedema and
also no history
of jaundice or
active
tuberculosis
close contact
No history
of direct
trauma to
stomach
Urination and defecation were normal
Massage by a traditional healer in their village
A general practitioner (4 kinds of tablet)
Painan district hospital for 13 days (ceftriaxone 375 mg twice a day)
suspected liver abscess
Surgery out patient of Dr. M. Djamil hospital (anemia and suspected liver
abscess from abdominal USG)
Consult to pediatric out patient hospitalized

Held upper right
abdomen while walking

Past illness history
Never had similar disease before
Family illness history
None of the family ever experienced
such disease
Born by vaginal delivery after a fullterm
second pregnancy, birth weight of 2000 gram,
forgotten birth length, vigorous and healthy
Growth and development were normal
Basic immunization was complete
Lived in a permanent house with poor hygiene
and sanitation
General appearance : moderately
ill, conscious, cooperative
Blood pressure : 90/60 mmHg
Pulse rate : 96 times/minute
Respiratory rate : 26 times/minute
Body temperature : 36,9
0
C
Physical examination
Nutritional status
Body weight : 15 kg
Body height :104 cm
Weight for age : 88,2%
Height for age : 99%
Weight for height : 88,2%
Nutritional status :
undernourished
Skin was`warm and there was no
enlargement of lymph nodes
Conjunctivas were anemic, scleras
were not icteric
The chest was symmetric,
normochest without any retraction
Heart sound was regular with no
murmur.
Breath sound was vesicular without
rales or wheezing
The abdominal was tender, no distension and
the right side was more prominent than the
left side. The liver was palpable 1/3 1/3, flat,
sharp edge and tenderness. The spleen was
not palpable and there was no ascites
There was no abnormality on extremity
Laboratory findings
Hemoglobin : 9,1 gr%
Leucocyte : 20.900/mm
3
ESR : 80 mm
Differential count : 0/2/5/47/42/4
Hematocrit : 28%
Platelet : 679.000/mm
3
Erythrocyte : 4,55 millions/mm
3
Reticulocyte : 18
MCH : 20 pg
MCV : 61,5 fl
MCHC : 23,9%

Microcytic hypochrome anemia
Blood
Normal
Urine
Normal
Stool
Suspected pyogenic liver abscess
with differential diagnosis of
amoebemic liver abscess
Undernourished
Microcytic hypochrome anemia
caused by suspected iron defficiency
List if problems = working diagnosis
Management
Suspected pyogenic liver abscess with
differential diagnosis of amoebemic liver
abscess

Diagnostic
Liver function test
Blood cultures
Fecal analysis
Amoeba serology test

Chest X-ray
Plain photo of abdomen
CT scan
Manage the patient together
with pediatric surgery
Open laparatomy to drain the abscess
Paracetamol 150 mg if the body
temperature was more than 38,5
0
C
Therapy
Diagnosis, management, monitoring,
complication and prognosis
Education
Anthropometry
Clinical assessment
Diagnostic
High calorie foods and protein 1400 kcal
Nutritional consultation
Therapy
Education : diet compliance
Undernourished

.... Management
Serum iron (SI) and total iron binding capacity (TIBC)
Diagnostic
Microcytic hypochrome anemia caused by suspected iron
defficiency

.... Management
The result of liver function test
Hypoalbuminemia
Total protein 7,3 g/dl
Albumin 2,8 g/dl
Globulin 4,5 g/dl

Total bilirubin 0,3 mg/dl
Aspartat aminotransferase
25 u/l
Alanin aminotransferase 20
u/l

Alkaline phosphatase 280
u/l
-glutamil transferase 80 u/l

Normal Elevated
PT : 14,8 seconds
APTT : 43,1 seconds
Elevated
On the 2
nd
day of admission
The condition was still the same
as the day before
The vital signs were normal.
The abdominal findings were
still the same
Laboratory findings :
SI : 11,2 mg/dl
TIBC : 223 mg/dl
Iron defficiency
Chest X ray and plain photo of
abdomen : no abnormality
A mass in the right lobus of liver, hypoechoic, homogen,
clear border, thick walled with size of 10 x 9 cm
Suspected liver abscess
The abdominal USG (had been done in surgery
out patient)
The liver was enlarged with a hypodense mass, rounded
shape, clear border, thick walled and the edge was
regular.
Liver abscess
Contrast CT-scan
We then treated him with intravenous
metronidazole 3 x 250 mg
On the 3
rd
hospital day
On the 4
th
hospital day
Blood culture : sterile
On the 5
th
hospital day
Planned to do laparatomy to
drain the abscess
Prepare for the operation such as
informed consent to his parent
and gave blood transfusion due
to anemic condition
Surgery department
Due to fever
Repeated blood culture
Transfusion of PRC
200 cc
Hemoglobin : 8,6 g/dl
Leucocyte : 15.600/mm
3
Thrombocyte : 603.000/mm
3

The repeated
hemoglobin of
12,1 g/dl
Laparatomy in general
anaesthesia
The abscess was located in the
posterior right lobus of the liver
250 cc of cloudy and sligthly
yellow fluid was successfully
evacuated
The surgeon then put the tube to
drain the residu of the pus
Sent for culture, isolating
amoebae and biopsy of the liver
tissue
On the 8
th
hospital day
Amoeba serological test was negative and
metronidazol was discontinued
Treated with ceftriaxon 1 x 750 mg

The laboratory of post laparatomy
Hemoglobin 10,9 g/dl
Leucocyte 16.100/mm
3

Thrombocyte
412.000/mm
3

Anemic and
leucocytosis
Sodium 134 mg/dl
Potassium 3,5 mg/dl

Normal
Albumin 2,9 g/dl
Globulin 3,1 g/dl
Protein 6 g/dl

Hypoalbuminemia

No trophozoit form of Entamoeba histolytica from the pus
Repeated blood culture :
Klebsiella sp in which sensitive
to ciprofloxacine, ceftazidime,
netilmicine and meropenem
and also resistant to
ceftriaxone
Substituted the antibiotics with
netilmicine 125 mg once daily
On the 10
th
hospital day
Pus culture revealed no aerobic
and anaerobic microorganism
Biopsy of liver tissue : aspecific
chronic inflammation
The next day, since there was
no more pus came out from the
drainage tube, it was getting off
On the 12
th
hospital day
On the 14
th
-23
rd
hospital day
The condition was getting better
No fever, nausea, vomit and
abdominal pain
Discharge on day 23 and oral
antibiotic was continued for 2 more
weeks
LITERATURE REVIEW
Pyogenic abscess, accounts for 80% of hepatic abscess cases in the US
Amoebic abscess due to Entamoeba histolytica accounts for 10% of
cases.
Fungal abscess, most often due to Candida species, accounts for less
than 10%
Liver
abscess
Three-quarters of liver abscesses in industrialized countries
A bacterial pathogen may be identified in two-thirds of liver abscesses
cases
Pyogenic
abscesses
A pus-filled lesion as the result of bacterial infection of the liver
parenchyma, with subsequent infiltration by inflammatory cells and
formation of a collection of pus
Opinions vary on the proper duration of intravenous and oral antibiotics for
pediatric pyogenic liver abscess therapy
Pyogenic
liver
abscess
Incidence
The global reported incidence for pyogenic liver abscess is
variable, ranging from 3 to 25 per 100,000 pediatric
hospital admissions
The incidence of hepatic abscess in children is on the rise
The mortality rate was as high as 40% until the 1980s
More potent antibiotics, improvement in imaging
techniques and appropriate use of surgical intervention
have reduced the mortality rate to less than 15%.
Predisposing factors
2. Genetic Disorders
1. Parasitic infestations
4. Abdominal infections
3. Skin infections
6. Cryptogenic
5. Post trauma
Causative organism
The most common pathogen isolated from liver abscess
in children is Staphylococcus aureus
1
E. Coli, Klebsiella, Proteus, Pseudomonas and
Enterobacter
2
Anaerobes such as Bacteroides and Clostridium consti
3
May also be sterile because the patient has received
prior antibiotic therapy.
4
Multiple liver abscesses constitute 20-25 % of all cases
Left lobe abscesses should be treated with caution
associated with complications like rupture into
peritoneum and pericardium and cause pericardial
effusions life threatening
Majority are solitary
Most of liver abscesses occur in the right lobe of liver
Location and number of liver abscesses
Pathophysiology
Bacteria enter the liver through various routes including
the biliary tract, portal vein and hepatic artery
Infections in the portal bed can also result in localized septic
thrombophlebitis, releasing septic emboli into circulation which are
trapped by hepatic sinusoids and become the nidus for hepatic
abscess formation
Penetrating hepatic trauma can inoculate organisms
directly into the liver parenchyma, resulting in pyogenic
liver abscess
Non-penetrating can also cause localized hepatic necrosis,
intrahepatic hemorrhage and bile leakage, thus providing a suitable
environment for bacterial growth
Clinical Features
Symptoms
Nonspecific
Acute, with rapid onset of severe symptoms, or chronic, with
a more insidious onset over weeks to months

Common
complaints
Fever often with chills
Abdominal pain specially in right upper quadrant and
tender hepatomegaly
Nausea, vomiting, anorexia, malaise, weakness, weight loss,
unexplained anemia, jaundice and cough with breathing
difficulty
Some children present only with fever of unknown origin
Physical Examination
Fever and tender hepatomegaly are the most
common signs


May present with complications like fulminant sepsis or an acute
abdomen either due to rupture of the liver abscess or due to infection
of ascitic fluid
transmigration of infection


Mid epigastric tenderness, with or without a palpable
mass, is suggestive of left hepatic lobe involvement
Decreased breath sounds in the right basilar lung zones, with
signs of atelectasis and effusion on examination or radiologically
Investigations
Laboratory
Anemia
Leucocytosis
Raised erythrocyte
sedimentation rate
Altered liver enzyme
Do not differentiate amoebic from pyogenic
Have lower sensitivity than pus aspirate in
identification of organism in pyogenic abscesses
Culture of abscess fluid should be the goal in
establishing microbiologic diagnosis
Blood cultures
Negative amoebic serology points strongly to a
pyogenic source of infection
The low level of positive blood culture could be
due to prior antibiotic therapy
Imaging Studies
Elevation of the right
hemidiaphragm with
decreased mobility or a
right pleural effusion
Air fluid level could also be
found from the abscess
cavity
Findings are abnormal in
approximately half the
patients
1. Chest roentgenographs
The imaging of first choice
Quick, safe, cheap and
accurate
May be a rounded or an
oval lesion with hypo
echoic and heterogenous
echotexture
The abscess have a well
defined wall which may be
thin or irregular
2. Ultrasound
More sensitive in detecting
small abscesses
Inconvenient and expensive
with risk of contrast
nephropathy
A hypodense lesion with low
attenuation areas and an
enhancing rim
3. Computed tomography
scanning
Treatment
Traditionally : treated by
open surgical drainage and
antibiotic therapy
Treatment
Accurate imaging and
percutaneous drainage
(nonsurgical methods)

Treatment includes :
Drainage of the abscess
Combined with appropriate antibiotics
Elimination of the underlying source of infection
Untreated liver abscess is almost always fatal
Medical treatment
Antibiotic therapy as a sole
treatment modality has been
successful
It is a common adjunct to
percutaneous or open surgical
drainage
Duration of treatment has always
been debated
4-6 weeks of antimicrobial
therapy is recommended
Surgical treatment
A paradigm shift from the
traditional open surgery to
the minimally invasive
percutaneous drainage
However, whether this has
lowered the mortality rate is
debatable
The treatment of choice remains controversial
The spectrum of treatment options ranges from sole medical therapy to
the more complex liver resection
3. Enlarged abscess with impending rupture
2. Lack of clinical response after 48-72 hours of
medical therapy
1. The abscess is large and there is risk of
spontaneous rupture
4. Liver failure
Indications for percutaneous drainage
5. As a temporal measure to improve patient conditions before
surgery
Left lobe abscess
Multiple abscesses
Abscess with thick pus
Multiloculated abscess
Ruptured abscess
Indication of open surgical drainage
Failure of percutaneous drainage
Algorithm for the treatment of pyogenic liver abscess
Poor prognosis : jaundice, liver
failure, acute abdomen, bilirubin
levels >3.5 mg/dl, encephalopathy,
large volume of abscess, multiple
abscesses, increased of amino
serum transferase and
hypoalbuminemia (<2 mg/dl)
Prognosis
Case Analysis
Pyogenic liver abscess
Confirm
Initial
laboratory
Physical
Examination
Symptoms
Altered liver function
The chest X-ray and plain photo of abdomen
The abdominal USG
Contrast CT-scan
Blood cultures
Amoeba serology test
At first he was treated with metronidazol
Difficult to differentiate between pyogenic
liver abscess and amoebic liver abscess
We didt give antibiotic because he had
received ceftriaxone for 13 days before
Negative amoebic serology test,
metronidazol was discontinued
The result from blood and pus culture revealed no microorganism
It didnt rule out the diagnosis of pyogenic liver abscess
It could be due to prior antibiotic therapy before admission
Besides that, there was no trophozoites found from aspirates of pus
Complication and recurrent were not observed in
this patient
Treated traditionally by antibiotic therapy and open surgical
drainage
He was still 4 year and 4 month years old which will be lack
of cooperation
Help the surgeon to create a large opening and
adequate drainage of the contents of the abscess
The cavity could also be cleaned by this method
The prognosis was good since there was no jaundice,
liver failure, acute abdomen, encephalophathy and
multiple abscesses
Serum bilirubin 0,3 mg/dl, albumin 2,8 g/dl and normal
amino serum transferase also pointed out to good
prognosis
PICO THERAPEUTIC ANALYSIS
Percutaneous aspiration versus open
drainage of liver abscess in children
Title
Shamsul Bari, Khurshid Ahmad Sheikh, Ajaz
A. Malik, Rauf A. Wani dan S. H. Naqash
Authors
Pediatr Surg Int 2007;23:69-74
Published in
Children suffering from liver abscess
Patient and
problems
Percutaneous aspiration of liver
abscess
Intervention
Open drainage of liver abscess Comparison
Open method was found still to be the
best modality of management
Outcome
In children with liver abscess, would
percutaneous aspiration compare with open
drainage method result in a better treatment
Formulated clinical questions
Retrospective study
What is the design of this study ?
Treatment
What area are being studied ?
Critical appraisal
Was the assignment of patients to treatment
randomized and was randomization
concealed?
No
Was follow-up of patients sufficiently long
and complete?
Yes
Were patients and clinicians kept
blind?
No
1. Are the results valid?
Were the groups treated equally, except for
the experimental therapy?
No
Were the groups similar at the start of the
trial?
Yes
Were all patients analyzed in the
groups to which they were
randomized?
No

Are the valid results important?
Is our patient so different from those in the
study that its results cannot apply? No
Is the treatment feasible in our setting?
Yes
Are the results applicable to my
patient?
Yes