Abscess of liver

Any abscess is a cavity filled with pus. Liver abscess also fits this classic definition. The peculiarity of the disease lies in the source of inflammation. Before the doctor, questions arise: where does the infection come from in the sterile liver? How did it come about on the spot? Finding the answers, you can choose the right treatment and achieve a favorable outcome of the disease.

The disease is more common among men of young and middle age. The disease is registered in men 7 times more often than in women. According to statistical data, nonparasitic abscesses are 4.9-5.1 per 10 thousand hospitalized. In the general surgical department of a multidisciplinary hospital, the proportion of patients with this disease reaches 0.5%.

Reasons for

The causes of liver abscess in each tenth case remain unknown. The greatest interest is shown in the primary abscess formation. This includes the emergence of the focus directly in the hepatic tissue against the background of previously unchanged organ structures.

Secondary liver abscesses involve pathways of infection. Most often, infection occurs on:

• bile ducts( 30-40% of all abscesses) - with inflammation( cholangitis), cholelithiasis, malignant neoplasm, they are called cholangiogenic abscesses;
• blood( up to 20%) - from the vessels of the abdominal cavity through the portal vein and the hepatic artery( appendicitis, peritonitis, diverticulitis, peptic ulcer, enterocolitis, sepsis);
• to the tissues by contact - in case of a breakthrough in the liver, empyema from the gallbladder, sub-diaphragmatic abscess, penetration of the stomach ulcer;
• destruction in case of trauma, surgical intervention on the liver, purulent foci in the liver can develop not only with direct injury of the parenchyma of the organ, but also due to closed injuries caused by traffic accidents, falling, beating due to suppuration of hematomas, usually occurs after 3-4 weeks after injury.

When an infection occurs through the blood vessels, the abscess develops within 10 days.

After a surgical procedure, up to 30% of all cases occur on the liver abscess. Abscesses with an unknown cause are called cryptogenic. Different authors indicate their share in the number of 10 to 20%.

An abscess also occurs:

• in the breakdown of a tumor and specific granulomas( tuberculosis) in the liver;
• infecting various cysts( parasitic and other).

The main pathogens of the inflammation focus are:

• hemolytic streptococcus;
• enterobacteria;
• Staphylococcus aureus;
• E. coli;
• Klebsiella;
• protozoa( amoeba).

More rarely - Proteus and Pseudomonas aeruginosa. Mixed infection is very common. Abscessing in the liver can cause infection:

• worms( more often ascaris);
• alveococcus;
• with echinococcus.

For amoebic and parasitic origin, typically enter the body through the mouth, insert into the wall of the small intestine, transport to the hepatic parenchyma and the formation within three months of the cyst-center, filled with infectious agents and necrotic masses. Gradual growth leads to rupture.

The main risk factor for liver abscess is a sharp drop in immunity. This condition leads to the development of a purulent foci in the liver, as complications of other diseases. This course of the disease is observed in 3-5% of cases.

Frequency of dissemination of different forms of

Statistical analysis and studies of the etiology of liver abscesses revealed the following prevalence among patients:

• amoebic - 64.7% of patients;
• echinococcal - 12,5%;
• bacterial - 6,5%( including consequences of dysentery, phlegmonous appendicitis, putrefactive colitis, cholecystitis);
• cholangiogenic - 5.2%;
• traumatic - 1,8%;
• giardiasis - 0,4%.

According to other data, the proportion of abscesses of the liver of appendicular etiology is up to 32%, and the cholangiogenic - 39%.Rare cases of primary tuberculous abscess formation of the liver have been identified, only about 100 such cases have been described.

Classification of

In addition to the already mentioned primary and secondary species, as well as classifications along the pathways of infection, there are abscesses in the etiology:

• parasitic;
• bacterial - more common in women 30-60 years.

By number:

• single - 87.5% of patients;
• multiple - 12.5%.

On ultrasound, multiple abscesses are seen as rounded formations

In size:

• large;
• small.

Localization:

• right share( 80.2%),
• left( 14.7%);
• in both( 5.1%).

Depending on the concomitant complicating factor:

• complicated;
• uncomplicated.

Secondary processes are considered to be complicated against the background:

• pleurisy;
• of hepatic insufficiency.

In these cases, the progression of the disease is threatened by the rupture of the abscess and general sepsis. According to the international classification, all types of liver abscesses are coded K 75.0, except amoeba, it is included in the class of infectious diseases with code A 06.4.

Pathological and anatomical signs of

The foci of infection is surrounded by dilated veins, the shaft of inflamed edematous parenchyma cells. A cavity is formed in the center. First, the abscess is delimited from the surrounding tissues by a grayish-red membrane. Then it becomes thicker and forms a dense capsule. Cholangiogenic abscesses are located along the branches of the bile duct. At the same time, inflammation forms in the walls, bile duct stagnation in the lumen of the ducts.

If the abscess originates directly from the gallbladder, then more often it has a single character, is located close to the bed of the bladder. The longer the disease, the greater the chance of infection in the inside of the liver tissue, the formation of thick-walled multi-chamber structures.

Symptoms of liver abscess

Initial clinical manifestations of liver abscess are not very specific. A person feels several days:

• a general malaise;
• cure;
• slight increase in temperature;
• dizziness;
• drowsiness, weakness;
• aches in the joints;
• nausea.

Nausea attacks - one of the signs of the pathological condition of

Usually patients associate symptoms with colds. The duration of this period is determined by the state of the body's defenses: the higher the immunity, the more active and longer the person resists infection.

Further course of the disease is expressed:

• in a significant temperature increase( up to 39-40 degrees);
• constant chills with copious, sticky cold sweat on the body;
• the retardation;
• headache;
• tachycardia;
• nausea and vomiting;
• hallucinations;
• memory reduction.

Signs of liver damage include:

• intense pain in the hypochondrium to the right with precise localization - is blunt, aching, permanent, pushes into the right shoulder and shoulder blade, patients note the gain in lying position on the left side, with movements, deep breathing and decrease if curled up on the right side;
• feeling of heaviness;
• severe soreness with pressure on the lower ribs and the zone of hypochondrium on the right;
• the appearance of ascites( a large abdomen due to the accumulation of fluid in the abdominal cavity) - is associated with squeezing the blood vessels of the liver, thrombosis;
• palpable enlargement of the liver and spleen, the edge painful to the touch;
• weight loss - makes diagnosis difficult in terms of suspected malignant tumor;
• dark urine and the appearance of discolored stool;
• presence of bloody discharge in feces;
• signs of esophageal or intestinal bleeding( vomiting of brown contents, called "coffee grounds", liquid black stools);
• bloating;
• diarrhea;
• exacerbation of chronic hemorrhoids;
• lack of appetite.

Jaundice of the skin, sclera, mucous attach at late stages of the disease

A feature of the course of secondary liver abscesses is a prolonged predominance of the clinical symptoms of the underlying disease. This complicates and increases the duration of diagnosis.

Some authors distinguish during the disease three types:

• I - all classical symptoms manifest;
• II - signs of abscess "masked" by the clinic of diseases of the digestive system;
• III - manifestations develop gradually in the absence of a clear symptomatology, most likely in immunodeficient conditions.

Diagnosis

To make the right diagnosis the doctor needs to find the main focus of the infection and find out the ways of infection of the liver. When the patient is questioned, attention is paid to:

• duration of symptoms;
• previous septic diseases( endocarditis, osteomyelitis, furunculosis), inflammatory diseases of the digestive system( enterocolitis, amoebic dysentery);
• residing in territories with endemic prevalence of echinococcus, alveococcus, amoebiasis;
• professional and home contact with animals, cutting carcasses, processing skins and skin;
• clarification of alcohol history for the exclusion of chronic alcoholic hepatitis, cirrhosis of the liver.

With percussion, enlarged borders of the liver, flatulence due to swelling of the intestine. Palpation is determined by the painful soft edge of the enlarged liver, in the left hypochondrium it is possible to identify the spleen.

Laboratory tests

The results of laboratory tests indicate a pronounced inflammatory reaction and intoxication of the body:

• leukocytosis with a shift of the formula to the left;
• appearance in the blood of reticulocytes;
• growth of ESR;
• drop in red blood cells and hemoglobin.

In urine, the growth of the pigment of bilirubin is detected. In the analysis of feces - a lot of undigested remnants of food, blood.

X-ray signs of liver abscess are:

• tissue enlightenment areas or one large formation with a liquid level;
• limited mobility of the right dome of the diaphragm;
• reactive pleurisy( fluid in the pleural cavity on the right).

The most convenient for diagnostic purposes is ultrasound( ultrasound).It is performed by patients for emergency indications, allows to reveal:

• enlarged sizes of the liver and its separate areas;
• presence of small and large cavities filled with liquid and pus;
• diameter and localization of ulcers.

The abscess has the form of a hypoechoic formation with round, even contours. Under the supervision of ultrasound in the surgical department, the material is taken from the proposed abscess with a thin needle for biopsy and bacteriological examination.

If possible, medical draining with evacuation of

contents. Subsequent tank.analysis allows you to accurately establish the pathological flora, its sensitivity to antibiotics. Specialists consider it necessary to study the histology of the capsule of an abscess. The result depends on the diagnosis of tuberculous abscess and detection of tumor disintegration.

If necessary, and during the preparation for the operation, magnetic resonance imaging and computed tomography are performed. They reveal even small foci. Methods of angiography and radioisotope scanning are required to clarify the features of the blood supply, confirm the functional state of the liver cells in the abscess zone.

Diagnostic laparoscopy - the introduction of an endoscope through a cut in the abdominal wall. It is carried out under anesthesia. It is necessary for differential diagnostics with liver cancer, subdiaphragmatic abscess, purulent pleurisy and cholecystitis. It also allows you to drain the abscess and take the material for analysis.

In differential diagnostics with parasitic abscesses, a blood test for serological samples is used. It is positive in the presence of antibodies to the suspected parasites in the body( with amoebiasis, echinococcosis, alveococcosis).Used:

• indirect hemagglutination reaction;
• precipitation test;
• latex test.

Conservative treatment of

Treatment of patients with suspected liver abscess is necessary only in a surgical hospital. The scheme of treatment measures is developed individually for each patient. If a small single or multiple foci are detected, then conservative agents are used. Of antibiotics, preference is given to drugs with a wide range of effects:

• third-generation cephalosporins;
• aminoglycosides;
• macrolides.

The drug is administered intravenously drip

Parasitic abscess requires the mandatory administration of specific antiparasitic agents:

• in amoeba etiology - according to indications Yatren, Emetin, Diiodohin, Hingamin, Chloroquine, Metronidazole, Tinidazole, Ornidazole;
• if alveococcosis is detected - Albendazole, Mebendazole;
• with echinococcosis is a group of benzenimidazoles.

If it is possible to drain the hepatic abscess after the procedure, a tube is installed, after which antibiotics are injected directly into the cavity for several days, and the antiseptic solution is rinsed.

Conservative treatment must necessarily be followed:

• by the appointment of vitamins to improve immunity and support the functions of the liver;
• by means of removing intoxication( Hemodez, Ringer's solution, glucose);
• by cardiac drugs and diuretics in ascites;
• hemostatic therapy with a tendency to bleeding;
• by the appointment of antipyretics;
• with sufficient anesthesia;
• by the course of enterosorbents for the removal of toxins and toxins through the intestine( Smekta, Enterosgel);
• if necessary - antiemetics.

Are there special dietary requirements?

Patients are advised to adhere to the dietary table number 5.It prohibits the reception of:

• fatty foods( meat, rich broths, confectionery, sour cream, cream);
• any canned food and smoked products;
• pickles and marinades;
• of spicy sauces, condiments;
• whole milk;
• fried foods;
• eggs;
• fresh baking;
• carbonated beverages;
• strong coffee and tea.

It is necessary to build a diet:

• from low-fat sour-milk products( cottage cheese, yogurt);
• boiled and stewed poultry;
• cooked fish;
• dried bread;
• vegetables cooked by extinguishing method;
• fresh juices;
• fruit;
• cereals with moderate addition of oil.

To facilitate the digestive process, you should eat small portions and more often( 6-7 times a day).Diets should be adhered to against treatment and after a liver abscess for at least a year. And patients with diseases of the digestive system - the whole life.

Surgical methods

Surgical treatment is preceded by puncture of abscess under the control of ultrasound equipment. Puncture of the liver is performed depending on the location through the intercostal spaces.

When the pus is viscous, a solution of sodium chloride is first introduced into the cavity, then it is aspirated by the

aspirator. The procedure ends with inserting a conductor into the needle, removing the needle and installing it along the drainage line conductor with side openings. Drainage is attached to the skin by separate sutures. Through the tube, you can not only wash the cavity, but also introduce a contrast agent. And according to the pictures, to assess the size and quality of drainage.

The development of endoscopic surgery allowed the removal of small abscesses. But large formations and foci located in an uncomfortable area for inspection are excised after a cut of the abdominal wall( laparotomy).Each abscess is carefully opened, the pusher is removed pus or other contents. The empty shell is washed with an antiseptic solution, then removed within the healthy liver tissues.

With such an operation, the risk of excreting pus from the abscess increases when it is opened in the abdominal cavity, flowing between the intestinal loops. Therefore, special skills and experience of the surgeon are required. The life of the patient depends on them. With cholangiogenic abscesses, after opening of the abscess, the common bile duct must be drained for washing and subsequent sanation of its inflammation( cholangitis).

Complications of

Untimely treatment of liver abscess can lead to serious complications related to the breakthrough of pus:

• into the abdominal cavity( peritonitis);
• in pleural sheets( purulent pleurisy or empyema of the pleura);
• in the pericardium( pericarditis);
• under the diaphragm( subdiaphragmatic localization of the abscess);
• in the intestines or stomach.

The weakened organism is not able to localize the infection in one place, so when the pus contacts the blood, sepsis and the formation of abscesses in different organs( kidneys, lungs, brain) is possible. Corrosion of the walls of the vessels with an inflammatory infiltrate is accompanied by massive internal bleeding with a drop in pressure, suppression of cardiac activity, the development of anemia.

Prognosis and prophylaxis of

Cholangiogenic multiple abscesses are most unfavorable in prognosis. Severe patient condition leads to a fatal outcome up to 50% of cases. If the abscess is single and treatment is started on time, then 90% of patients can achieve full recovery.

Hand washing with soap before meals, after contact with animals, conditionally infected objects - a simple method of prevention

Prevention measures should be considered:

• personal hygiene;
• timely treatment of inflammatory diseases of the digestive system;
• strengthening of immunity;
• adherence to a balanced diet;
• is wary of all kinds of traditional methods of therapy.

Health authorities require compliance with measures to identify people who carry amoebas( in whom the disease does not develop, despite the presence of a pathogen in the intestine).Institutions of epidemiological surveillance of the territory are involved in the early detection, involvement in treatment and prevention in the profession related to public catering, medicine, and working with children.

Supporting the sanitary protection of water bodies where water intake stations are located, swimming pools from contact with contaminated feces helps to reduce the prevalence of parasitic diseases.

Patients with diseases of the digestive system should be observed at the gastroenterologist, at least twice a year to take tests. Control of chronic diseases helps to prevent such a serious complication, as liver abscess.