Hepatobilier Pemicu 4

Ryan Putra 405080212

Computed tomography (CT) scan findings of liver abscess are shown. A large, septated abscess of the right hepatic lobe is revealed. Abscess was successfully treated with percutaneous drainage and antimicrobial therapy.

Computed tomography (CT) scan findings of liver abscess are shown. A large anterior abscess involving the left hepatic lobe is revealed. Abscess was successfully treated with percutaneous drainage and antimicrobial therapy.

 The 3 major forms of liver abscess, classified by etiology, are as follows: Pyogenic abscess, which is most often polymicrobial, accounts for 80% of hepatic abscess cases in the United States. Amebic abscess due to Entamoeba histolytica accounts for 10% of cases. Fungal abscess, most often due to Candida species, accounts for less than 10% of cases.

Pathophysiology
The liver receives blood from both systemic and portal circulations. Increased susceptibility to infections would be expected given the increased exposure to bacteria. However, Kupffer cells lining the hepatic sinusoids clear bacteria so efficiently that infection rarely occurs. Multiple processes have been associated with the development of hepatic abscesses

Underlying etiology of 1086 cases of liver abscess compiled from the literature.

 Appendicitis was traditionally the major cause of liver abscess. As diagnosis and treatment of this condition has advanced, its frequency as a cause for liver abscess has decreased to 10%. Biliary tract disease is now the most common source of pyogenic liver abscess (PLA). Obstruction of bile flow allows for bacterial proliferation. Biliary stone disease, obstructive malignancy affecting the biliary tree, stricture, and congenital diseases are common inciting conditions. With a biliary source, abscesses usually are multiple, unless they are associated with surgical interventions or indwelling biliary stents. In these instances, solitary lesions can be seen.

 Infections in organs in the portal bed can result in a localized septic thrombophlebitis, which can lead to liver abscess. Septic emboli are released into the portal circulation, trapped by the hepatic sinusoids, and become the nidus for microabscess formation. These microabscesses initially are multiple but usually coalesce into a solitary lesion.

 Microabscess formation can also be due to hematogenous dissemination of organisms in association with systemic bacteremia, such as endocarditis and pyelonephritis. Cases also are reported in children with underlying defects in immunity, such as chronic granulomatous disease and leukemia. Approximately 4% of liver abscesses result from fistula formation between local intra-abdominal infections.

 Despite advances in diagnostic imaging, cryptogenic causes account for a significant proportion of cases; surgical exploration has impacted this minimally. These lesions usually are solitary in nature. Penetrating hepatic trauma can inoculate organisms directly into the liver parenchyma, resulting in pyogenic liver abscess. Nonpenetrating trauma can also be the precursor to pyogenic liver abscess by causing localized hepatic necrosis, intrahepatic hemorrhage, and bile leakage. The resulting tissue environment permits bacterial growth, which may lead to pyogenic liver abscess. These lesions are typically solitary.

 Pyogenic liver abscess has been reported as a secondary infection of amebic abscess, hydatid cystic cavities, and metastatic and primary hepatic tumors. It is also a known complication of liver transplantation, hepatic artery embolization in the treatment of hepatocellular carcinoma, and the ingestion of foreign bodies, which penetrate the liver parenchyma. Trauma and secondarily infected liver pathology account for a small percentage of liver abscess cases.

 The right hepatic lobe is affected more often than the left hepatic lobe by a factor of 2:1. Bilateral involvement is seen in 5% of cases. The predilection for the right hepatic lobe can be attributed to anatomic considerations. The right hepatic lobe receives blood from both the superior mesenteric and portal veins, whereas the left hepatic lobe receives inferior mesenteric and splenic drainage. It also contains a denser network of biliary canaliculi and, overall, accounts for more hepatic mass. Studies have suggested that a streaming effect in the portal circulation is causative.

Epidemiology
United States The incidence of pyogenic liver abscess has essentially remained unchanged by both hospital and autopsy data. Liver abscess was diagnosed in 0.7%, 0.45%, and 0.57% of autopsies during the periods of 1896-1933, 1934-1958, and 19591968, respectively. The frequency in hospitalized patients ranges from 8-16 cases per 100,000 persons. Studies suggest a small, but significant, increase in the frequency of liver abscess.

Mortality/Morbidity
Untreated, pyogenic liver abscess remains uniformly fatal. With timely administration of antibiotics and drainage procedures, mortality currently occurs in 5-30% of cases. The most common causes of death include sepsis, multiorgan failure, and hepatic failur

Sex
While abscesses once showed a predilection for males in earlier decades, no sexual predilection currently exists. Males have a poorer prognosis from hepatic abscess than females.

Age
Prior to the antibiotic era, liver abscess was most common in the fourth and fifth decades of life, primarily due to complications of appendicitis. With the development of better diagnostic techniques, early antibiotic administration, and the improved survival of the general population, the demographic has shifted toward the sixth and seventh decades of life. Frequency curves display a small peak in the neonatal period followed by a gradual rise beginning at the sixth decade of life. Cases of liver abscesses in infants have been associated with umbilical vein catheterization and sepsis. When abscesses are seen in children and adolescents, underlying immune deficiency, severe malnutrition, or trauma frequently exists.

Signs and Symptoms

The most frequent symptoms of hepatic abscess include the following: Fever (either continuous or spiking) Chills Right upper quadrant pain Anorexia Malaise

Signs and Symptoms

Cough or hiccoughs due to diaphragmatic irritation may be reported.Referred pain to the right shoulder may be present. Individuals with solitary lesions usually have a more insidious course with weight loss and anemia of chronic disease. With such symptoms, malignancy often is the initial consideration. Fever of unknown origin (FUO) frequently can be an initial diagnosis in indolent cases. Multiple abscesses usually result in more acute presentations, with symptoms and signs of systemic toxicity. Afebrile presentations have been documented.

Physical Examination
Fever and tender hepatomegaly are the most common signs. A palpable mass need not be present. 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, may be present. A pleural or hepatic friction rub can be associated with diaphragmatic irritation or inflammation of Glisson capsule. Jaundice may be present in as many as 25% of cases and usually is associated with biliary tract disease or the presence of multiple abscesses.

Cause
Polymicrobial involvement is common, with Escherichia coli and Klebsiella pneumoniae being the 2 most frequently isolated pathogens. Reports suggest that K pneumoniae is an increasingly prominent cause.

 Enterobacteriaceae are especially prominent when the infection is of biliary origin. Abscesses involving K pneumoniae have been associated with multiple cases of endophthalmitis. The pathogenic role of anaerobes was underappreciated until the isolation of anaerobes from 45% of cases of pyogenic liver abscess was reported in 1974. Since that time, increasing rates of anaerobic involvement have been reported, likely because of increased awareness and improved culturing techniques. The most frequently encountered anaerobes are Bacteroides species, Fusobacterium species, and microaerophilic and anaerobic streptococci. A colonic source is usually the initial source of infection.

 Staphylococcus aureus abscesses usually result from hematogenous spread of organisms involved with distant infections, such as endocarditis. S milleri is neither anaerobic nor microaerophilic. It has been associated with both monomicrobial and polymicrobial abscesses in patients with Crohn disease, as well as with other patients with pyogenic liver abscess. 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, Eikenella corrodens, Yersinia enterocolitica, Salmonella typhi, and Brucella melitensis.

Workup
Laboratory Studies CBC count with differential
Anemia of chronic disease Neutrophilic leukocytosis

Liver function studies

Hypoalbuminemia and elevation of alkaline phosphatase (most common abnormalities) Elevations of transaminase and bilirubin levels (variable)

Blood cultures are positive in roughly 50% of cases. Culture of abscess fluid should be the goal in establishing microbiologic diagnosis. Enzyme immunoassay should be performed to detect E histolytica in patients either from endemic areas or who have traveled to endemic areas.

Treatment
Medical Care Surgical Care Consultations

Medical Care
An untreated hepatic abscess is nearly uniformly fatal due to complications that include sepsis, empyema, or peritonitis from rupture into the pleural or peritoneal spaces, and retroperitoneal extension. Treatment should include drainage, either percutaneous or surgical. Antibiotic therapy as a sole treatment modality is not routinely advocated, though it has been successful in a few reported cases.
It may be the only alternative in patients too ill to undergo invasive procedures or in those with multiple abscesses not amenable to percutaneous or surgical drainage. In these instances, patients are likely to require many months of antimicrobial therapy with serial imaging and close monitoring for associated complications.

Antimicrobial treatment is a common adjunct to percutaneous or surgical drainage.

Surgical Care
Surgical drainage was the standard of care until the introduction of percutaneous drainage techniques in the mid 1970s. With the refinement of image-guided techniques, percutaneous drainage and aspiration have become the standard of care. Current indications for the surgical treatment of pyogenic liver abscess are for the treatment of underlying intra-abdominal processes, including signs of peritonitis; existence of a known abdominal surgical pathology (eg, diverticular abscess); failure of previous drainage attempts; and the presence of a complicated, multiloculated, thick-walled abscess with viscous pus. Shock with multisystem organ failure is a contraindication to surgery.

 Open surgery can be performed by 2 approaches.

A transperitoneal approach allows for abscess drainage and abdominal exploration to identify previously undetected abscesses and the location of an etiologic source. For high posterior lesions, a posterior transpleural approach can be used. Although this allows easier access to the abscess, the identification of multiple lesions or a concurrent intra-abdominal pathology is lost.

A laparoscopic approach is also commonly used in select cases. This minimally invasive approach affords the opportunity to explore the entire abdomen and to significantly reduce patient morbidity. A growing literature is defining the optimal population for this mode of intervention. A retrospective chart review compared surgery versus percutaneous drainage for liver abscesses greater than 5 cm. The morbidity was comparable for the 2 procedures, but those treated with surgery had fewer secondary procedures and fewer treatment failures. Postoperative complications are not uncommon and include recurrent pyogenic liver abscess, intra-abdominal abscess, hepatic or renal failure, and wound infection.

Consultations
Interventional radiology: Obtain a consultation as soon as the diagnosis is considered to allow rapid collection of cavity fluid and the potential for early therapeutic drainage of abscess. General surgery
Immediately seek a consultation with a general surgeon if the source of the abscess is a known underlying abdominal pathology or in cases with peritonitis. In cases undergoing percutaneous drainage, seek the involvement of a general surgeon if drainage of the abscess cavity is unsuccessful.

Gastroenterology involvement may be useful after successful drainage to evaluate for underlying gastrointestinal disease using colonoscopy or endoscopic retrograde cholangiopancreatography (ERCP). Infectious disease consultation should be considered in complicated cases and when the involved pathogens are unusual or difficult to treat, such as in fungal abscesses.

Antibiotics
Meropenem (Merrem)
Adult
1.0 g IV q8h

Pediatric
40 mg/kg IV q8h

Interaksi:
Probenecid may inhibit renal excretion of meropenem, increasing meropenem levels

Bactericidal broad-spectrum carbapenem antibiotic that inhibits cell-wall synthesis. Effective against most gram-positive and gram-negative bacteria. Has slightly increased activity against gram negatives and slightly decreased activity against staphylococci and streptococci species compared to imipenem.

 Imipenem and cilastatin (Primaxin)

Adult
Base initial dose on severity of infection, and administer in equally divided doses; dose may range from 250-500 mg IV q6h for maximum of 3-4 g/d Alternatively, 500-750 mg IM q12h or intra-abdominally

Pediatric
<12 years: Not established; 15-25 mg/kg/dose IV q6h suggested for > 3 months Fully susceptible organisms: Not to exceed 2 g/d IV Infections with moderately susceptible organisms: Not to exceed 4 g/d

For treatment of multiple organism infections in which other agents do not have wide-spectrum coverage or are contraindicated due to potential for toxicity.

 Cefuroxime (Ceftin)
Adult
500 mg PO bid for 20 d

Pediatric
Children: 250 mg PO bid for 20 d Adolescents: Administer as in adults

Second-generation cephalosporin maintains gram-positive activity that first-generation cephalosporins have; adds activity against Proteus mirabilis, Haemophilus influenzae, Escherichia coli, Klebsiella pneumoniae, and Moraxella catarrhalis. Condition of patient, severity of infection, and susceptibility of microorganism determine proper dose and route of administration.

 Cefotetan (Cefotan)
Adult
1-2 g IV/IM q12h for 5-10 d

Pediatric
20-40 mg/kg/dose IV/IM q12h for 5-10 d

Second-generation cephalosporin indicated for infections caused by susceptible gram-positive cocci and gram-negative rods. Dosage and route of administration depends on condition of patient, severity of infection, and susceptibility of causative organism.

 Cefoxitin (Mefoxin)
Adult
1-2 g IV q6-8h

Pediatric
Infants and children: 80-160 mg/kg/d IV divided q4-6h; higher doses for severe or serious infections; not to exceed 12 g/d

Second-generation cephalosporin indicated for grampositive cocci and gram-negative rod infections. Infections caused by cephalosporin-resistant or penicillin-resistant gram-negative bacteria may respond to cefoxitin.

 Cefaclor (Ceclor)
Adult
250-500 mg PO q8h

Pediatric
20-40 mg/kg/d PO divided q8-12h; not to exceed 2 g/d

Second-generation cephalosporin indicated for infections caused by susceptible gram-positive cocci and gram-negative rods. Determine proper dosage and route based on condition of patient, severity of infection, and susceptibility of causative organism.

 Clindamycin (Cleocin)
Adult
150-450 mg/dose PO q6-8h; not to exceed 1.8 g/d 600-1200 mg/d IV/IM divided q6-8h, depending on degree of infection

Pediatric
8-20 mg/kg/d PO as hydrochloride and 8-25 mg/kg/d as palmitate divided tid/qid 20-40 mg/kg/d IV/IM divided tid/qid

Lincosamide for treatment of serious skin and soft tissue staphylococcal infections. Also effective against aerobic and anaerobic streptococci (except enterococci). Inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes causing RNA-dependent protein synthesis to arrest.

 Metronidazole (Flagyl)
Adult
Loading dose: 15 mg/kg or 1 g for 70-kg adult IV over 1 h Maintenance dose: 6 h following loading dose; infuse 7.5 mg/kg or 500 mg IV for 70-kg adult over 1 h q6-8h; not to exceed 4 g/d

Pediatric
15-30 mg/kg/d PO divided bid/tid for 7 d, or 40 mg/kg once; do not exceed 2 g/d

Imidazole ring-based antibiotic active against various anaerobic bacteria and protozoa. Used in combination with other antimicrobial agents (except for Clostridium difficile enterocolitis).

Antifungal agents
Amphotericin B (AmBisome)
Adult
3-5 mg/kg/d IV of liposomal amphotericin B over approximately 120 min

Pediatric
Administer as in adults

Produced by a strain of Streptomyces nodosus; can be fungistatic or fungicidal. Binds to sterols, such as ergosterol, in the fungal-cell membrane, causing intracellular components to leak with subsequent fungal-cell death.

 Fluconazole (Diflucan)
Adult
150 mg PO once or 400 mg/d, depending on severity of infection

Pediatric
3-6 mg/kg/d PO for 14-28 d or 6-12 mg/kg/d, depending on severity of infection

Synthetic oral antifungal (broad-spectrum bistriazole) that selectively inhibits fungal cytochrome P-450 and sterol C-14 alphademethylation.