2. 3.5 year old female of weight 13kg came with Abdomen pain 4 days Fever 4days According to the mother the child was alright 5 days back when she suddenly started having sharp right sided pain which was intermittent & lasted for 1-2hours. The pain was not associated with meals or any other factor. It decreased with analgesics but didn’t subside. Fever was documented 102-103 with shivering. It was intermittent without any specific timings & was relieved by Brufen. She was taken to Saifee hospital & an Ultrasound was done which was normal. She was advised Rocephin(Ceftriaxone) & then next day another doctor prescribedCefspanDs (Cefixime) instead. There was anorexia but no constipation. There was no noticeable weight loss. No associated vomiting, diarrhea or micturationcomplaint. Case
3. Past hx Admitted 2-3 times for AGE /RTI Vaccination-complete Birth hx- 1st baby Normal vaginal delivery at hospital No complication. Developmental- appropriate for age Nutritional Breast fed & top feed till 6months Weaning @ 6mth with cerelac Currently eats with family
4. Examination Oriented toxic looking child, Irritable & crying in pain. J0 A+ C0 K0 E0 L0 D0 Vitals- 101F , 113min, 116/71 Abdomen- tense abdomen, tender on right side Guarding –ve Appendicularsigns –ve No visceral findings. Gut sounds –audible Resp- Bl air entry, NVB Cvs- s1 +s2 CNS – Intact
15. A liver abscess is a pus-filled mass inside or attached to the liver. Types There are three major forms of liver abscess, classified by etiology: Pyogenicliver abscess, which is most often polymicrobial, accounts for 80% of hepatic abscess cases in the United States. Amoebic liver abscess due to Entamoebahistolytica accounts for 10% of cases. Fungal abscess, most often due to Candida species, accounts for less than 10% of cases. Causes Abdominal infections- appendicitis, diverticulitis, biliary tract Blood borne infections Trauma to liver Invasive procedures- Endoscopy In children, mostly seen along with Immune deficiency, malnutrition or trauma. Introduction
16. The liver receives blood from both systemic and portal circulations. Increased susceptibility to infections would be expected given the increased exposure to bacteria. Biliary tract disease is now the most common source of pyogenic liver abscess (PLA). Obstruction of bile flow allows for bacterial proliferation due to stones, malignancy, congenital anamolies or stricture. Infections in organs in the portal bed can result in a localized septic thrombophlebitis, which can lead to liver abscess. Microabscess formation can also be due to hematogenous dissemination of organisms in association with systemic bacteremia, such as endocarditis and pyelonephritis. Penetrating hepatic trauma can inoculate organisms directly into the liver parenchyma, resulting in pyogenic liver abscess Pathogenesis
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19. Enterobacteriaceae are especially prominent when the infection is of biliary origin. The most frequently encountered anaerobes are Bacteroides species and anaerobic streptococci. Staphylococcus aureus abscesses usually result from hematogenous spread of organisms involved with distant infections, such as endocarditis. Amebic liver abscess is most often due to E histolytica. Liver abscess is the most common extraintestinal manifestation of this infection. Fungal abscesses primarily are due to Candida albicans and occur in individuals with prolonged exposure to antimicrobials, hematologic malignancies, solid-organ transplants, and congenital and acquired immunodeficiency. Cases involving Aspergillus species have been reported. Other organisms reported in the literature include Actinomyces species, Eikenellacorrodens, Yersiniaenterocolitica, Salmonella typhi, and Brucellamelitensis.
20. Fever (±shivering/chills) Malaise Abdominal pain (Right upper quadrant most commonly but maybe generalised) Nausea, Vomiting Anorexia Weight loss Cough or hiccoughs due to diaphragmatic irritation Symptoms
21. Fever Right upper quadrant /epigastric tenderness with or without palpable mass Jaundice A pleural or hepatic friction rub can be associated with diaphragmatic irritation Signs
23. Lab investigations CBC Neutrophilleukocytosis Anemia of chronic disease LFTs Hypoalbuminemia and elevation of alkaline phosphatase (most common) Elevations of transaminase and bilirubin levels (variable) Blood cultures are positive in roughly 50% of cases Cultureof abscess fluid should be the goal in establishing microbiologic diagnosis. Enzymeimmunoassay should be performed to detect E histolytica in patients either from endemic areas or who have traveled to endemic areas. Diagnostics
25. CT demonstrates a heterogeneous lesion with irregular margins and possibly peripheral contrast enhancement. Internal septations are common. Ultrasonographic evaluation reveals hypoechoic masses with irregularly shaped borders. Internal septations or cavity debris may be detected
26. Percutaneous needle aspiration Under CT scan or ultrasound guidance, needle aspiration of cavity material can be performed Percutaneous catheter drainage Percutaneous drainage has become the standard of care and should be the first intervention considered for small cysts. Procedures
27. Medical Antibiotics are not generally used as a single modality unless under certain circumstances where the patient is unable to undergo invasive procedure or has multiple abscesses that can’t be drained or be operated. Given as adjuvant therapy along with drainage. Treatment
28. Empirical therapy is started suspecting the common organisms until the culture is reported.
29. Duration of treatment Short courses For 2weeks after the drainage have been reported, but recurrence was reported Recommended Solitary lesions, 4-6wks for adequately drained lesions Multiple abscesses may require upto 12 weeks of therapy.
30. Surgical Indications cysts >5cm Signs of shock/perotinitis Failure of previous drainage attempt Complicated multilocular, thick-walled abscess with viscous pus. Types Open surgery- Transperitoneal approach Posterior transpleural approach Laproscopic Postoperative complications recurrent pyogenic liver abscess, intra-abdominal abscess, hepatic or renal failure, and wound infection.
31. Sepsis Empyema Peritonitis from rupture into the pleural or peritoneal spaces, and retroperitoneal extension Complications
32. Etiology, Presentation and Management of Liver Abscessesat the Children’s Hospital LahoreHUMA ARSHAD CHEEMA,1 ANJUM SAEED2Address For Correspondence: Dr. HumaArshadCheema Professor and Head of the Department, Division of PediatricGastroenterology-Hepatology, The Children’s Hospital and the Institute of Child Health, Lahore Background: Liver abscess is a common problem among children. The purpose of this study is to describe the etiology,different management strategies and outcome of children with liver abscess in Children’s Hospital Lahore. Patients and Methods: This study included 38 children with liver abscess seen during two-year period, from September 2004 to September 2006 at the Children’s Hospital and Institute of Child Health, Lahore. Diagnosis was made on history,examination and investigations. Ultrasound and CT scan were the main diagnostic tools. Results: Out of 38 patients, 33 children underwent aspiration and remaining 5 were managed conservatively. Eight aspiratesyielded positive culture for various organisms. Three patients were positive for E.Coli, 2 for Staph Aureus, and 1 each case of Klebsiella and Pseudomonas. One patient had multiple micro-abscesses and was also positive for typhidotIgM. Another patient was positive for acid fast mycobacterium tuberculosis. All patients recovered from their abscesses. There was no mortality reported. Conclusions: In our pediatric population, liver abscess are mostly caused by pyogenic organisms. Amebic etiology was not proven in any case. Majority of liver abscesses can be satisfactorily treated by aspiration and /or percutaneous image guided drainage with satisfactory outcome. Key Words: Liver abscess, children.
33. Introduction Hepatic abscess is not an uncommon problem in children living in poor hygienic conditions in third world countries. Although the majority of intra-abdominal abscesses are notlocalized to an organ, the liver is most commonly involved when a visceral abscess occurs.1 It could result as a complicationof various intra-abdominal infections; by hematogenous spread via portal vein from the gastrointestinal tract;or, may develop after traumatic injury to the liver. The two most common varieties of liver abscess are pyogenic andamebic.2 Children presenting with liver abscess have variable clinical features like fever, right upper quadrant pain orthe features of associated disease and complications.3,4 Ultrasound is the main diagnostic tool and in some cases CTscan may be helpful.5,6 Treatment of patients is both medical and drainage of abscess, depending upon the size and locationof liver abscess. The purpose of this study was to describe the etiology,mode of management and outcome of children with liver abscesses. Patients and Methods This is a prospective descriptive study. It includes 38 childrenwith liver abscesses presenting to the Children's Hospital and Institute of Child Health, Lahore during a two-yearperiod from September 2004 to September 2006. Diagnosis was made on history, examination and investigations. Ultrasound and CT scan were the main diagnostic tools (Fig 1 & 2). A complete blood count, ESR, liver function tests coagulation profile and a chest x-ray was also done in all cases.All patients had 3 stool examinations and indirect Haemagglutination test for Entamebahistolytica.. Aspirated pus wassent for gram stain and culture. History and physical examination of these children were recorded on pre-designedform. Following management guidelines were followed. If abscess was less than 4cm in diameter and was not liquefied on ultrasound, only antibiotics were used. Same size abscess when liquefied was treated by aspiration alone. All abscessses which were liquefied and were more than 4cm had image guided insertion of mushroom-tipped catheter for drainage (Fig. 3). This was done under local anesthesia and sedation. Prothrombin and activated partial thromboplastin times were checked before aspiration or drainage. All patients received antibiotics. Aspirate was sent for cytology, culture and sensitivity.
34. Results Thirty eight children were included in this study. Youngest child was 2 years old and oldest was 13.5 years. Thirty three patients were male and 5 were female. History of fever (100%) was present in all the patients. Second major presentation was abdominal pain (89%) and vomiting (33%).Two patients (5.26%) had jaundice. None of the patients had History of dysentery. On examination Anaemia (97%) and tender hepatomegaly (72%) were common findings Onlyoneof the patients had hemoglobin >9gm/dl (Range 4.3--9.6). Respiratory distress was seen in 4 patients (10.5%) with liver abscess that had infiltrated into the thoraciccavity. Only 2 patients with multiple abscesses had deranged liver function tests with elevated transaminases (97 & 120 units/dl) and mild hyperbilirubinemia (3.3 mg/dl, & .7 mg/dl) One of them had salmonella Typhi on blood culture. X-ray abdomen revealed elevation of right hemidiaphragm in 25 cases (65%). Tests for Entamoeba were negative in all patients. Thirty three of 38 children underwent percutaneous image guided aspiration and drainage Eight aspirates proved culture positive for various organisms Three patients were positive for E.Coli, 2 for Staph Aureus, 1 each for Klebsiellaand Pseudomonas, 1 patient had multiple microabscesses and was also positive for typhidotIgM and 1 patient was positive for acid fast mycobacterium tuberculosis. All patients responded to percutaneousdrainge and antibiotic therapy. 4 patients also required chest tube insertion as the abscess had ruptured there. Abscess cavity resolved in average 30 days. There was no mortality. No patient had amebiasis as the cause of liver abscess.
35. Discussion Hepatic abscess is not an uncommon problem in children living in poor hygienic conditions.1 Fever, right upper quadrant pain and vomiting were common presenting features. In a study done in UK fever is the most common finding at presentation, occurring in approximately 90 percent of patients.3,4 The majority of patients (55 to 74 percent) also have abdominal pain and/or tenderness. Ultrasound and CT scan are highly diagnostic for liver abscess.5,6 .Single abscess in right lobe is more common.7 Most patients had low hemoglobin, and high leukocyte count. But in some cases TLC count may be normal depends upon patient’s immunological response.8 Elevated right dome of diaphragm was common x-rays finding. Contrary to popular belief, most of liver abscesses in children in this third world country are pyogenic and not amebic in origin. Pyogenic liver abscess is more common than amebic in children as compared to adults.2,9 In our study most common organism was E.Coli but in other studies klebsilla and staph aureues are commonest organisms and there was not a single case of amebic abscess.10,11 Majority of these abscesses could be successfully managed by image guided aspiration / drain insertion with appropriate antibiotics. Open surgical drainage is rarely required Hepatic tubeculous abscess is rare but needs to be considered if patient is not responding to conventional treatment.12,13 Conservative management of smaller abscess (< 5 cm) is as effective. Percutaneous needle aspiration under ultrasound guidance was found best for non-complicated larger abscess (>5cm) as also proved by other studies.14 Conclusions The most common cause of liver abscess in our study was pyogenic and among pyogenic E.coli was the commonest organism but hepatic tuberculous abscess although rare should be considered if patient does not respond to conventional treatment. With good medical measures, safe and aseptic drainage of liver abscess complications can be reduced.
