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212 Chapter 5: Hepatic, biliary and pancreatic systems
Management Intravenous broad-spectrum antibiotics until bacterial
d-penicillamine(acopper-chelatingagent)depletescop- culture and sensitivities are available.
perstores. Patients should avoid foods high in copper
(chocolate, nuts and dried fruits). Siblings and children Prognosis
of affected individuals should be screened. If diagnosed Poor prognostic factors are co-existent biliary tract dis-
and treated sufficiently early, there is some improvement ease, old age and multiple abscesses.
in liver function and further deterioration is arrested.
Amoebic liver abscess
Pyogenic liver abscess Definition
Infection of the liver by Entamoeba histolytica.
Definition
The development of liver abscesses is thought to follow
Aetiology/pathophysiology
bacterial infection elsewhere in the body.
E.histolyticaisaprotozoanthatinfectsthelargeintestine.
The infection water is food borne and is most common
Aetiology/pathophysiology in parts of the world with poor sanitation, e.g. Far East
Enteric Gram negative and anaerobic organisms, e.g. and Africa. Ingestion of the cysts results in the release
Strep. milleri.Infection may reach the liver by the portal of trophozoites in the intestine, which are thought to
vein from a focus of infection drained by the portal vein, invade through the mucosa gaining entry to the portal
e.g. diverticulitis, appendicitis, infected haemorrhoids. blood system and then spread to the liver.
Infection may also result from a generalised septicaemia
or direct spread from the biliary tree. Clinical features
The onset of symptoms may be sudden or insidious.
Clinical features Symptoms include right upper quadrant pain, anorexia,
Symptoms and signs range from mild to severe, often nausea, weight loss and night sweats. Tender hepatic en-
the symptoms are less marked in elderly patients, with largement without jaundice is usual. Basal pulmonary
a mild fever with or without pain and hepatomegaly. In collapse and pleural effusion may occur.
severe cases patients present with upper abdominal pain,
Complications
swinging fever, anorexia, malaise and weight loss.
Rupture, secondary infection and septicaemia. Meta-
static brain abscesses have been reported.
Macroscopy/microscopy
Maybe single or multiple lesions ranging from a few
Investigations
millimetres to several centimetres in size.
Ultrasound or CT of the abdomen can show the abscess.
Blood tests include blood culture and serological tests.
Investigations
Guided aspiration and stool ova, cyst and parasite exam-
Ultrasound scan is useful for screening, and pus may be
ination may demonstrate the organism.
aspiratedforcultureunderitsguidance.Furtherimaging
may include CT or MRI of the abdomen. Blood cultures, Management
liver function tests and inflammatory markers should Treated with metronidazole. Percutaneous aspiration is
be sent. A raised alkaline phosphatase may be the only used in resistant cases.
marker.
Hydatid disease
Management
Repeated ultrasound guided aspirations may be re- Definition
quired. Extensive, difficult to approach abscesses are A tapeworm infection of the liver common in sheep rear-
drained by open surgery, with soft pliable drains. ing areas such as Greece, Australasia and Wales.