Where does pus come from in the liver?
The liver receives blood not only through the artery, but also through the portal vein - from the entire intestine, so microbes come to it in several ways. The most common source is the bile ducts: with a stone, narrowing or tumor, the outflow of bile is disrupted, cholangitis develops, and the infection rises to the liver. The second route is through the portal vein for appendicitis, diverticulitis, and inflammatory bowel diseases. Less commonly, the pathogen is introduced with arterial blood during sepsis or enters directly during injury and after operations.
- Biliary tract - cholangitis, stones, strictures, duct tumors
- Portal route - appendicitis, diverticulitis, inflammatory bowel disease
- Arterial route - for general purulent infection
- Contact - from the gallbladder or injury
- Amoebic abscess is a complication of intestinal amebiasis
- Suppuration of hydatid cyst of the liver
Who's at risk
An abscess rarely occurs in a completely healthy person: usually there is either a focus of infection in the abdomen or reduced body defenses. People with diabetes, cirrhosis, cancer, and those receiving chemotherapy or immunosuppressive drugs are especially vulnerable. The risk is increased by previous interventions on the bile duct: stenting, endoscopic manipulations, operations with anastomosis between the intestine and the duct. Amoebic abscess is associated with travel to regions with poor sanitary water conditions and previous intestinal infection.
- Gallstone disease and previous cholangitis
- Diabetes mellitus
- Liver cirrhosis and cancer
- Surgeries and endoscopic interventions on the bile ducts
- Reduced immunity, taking immunosuppressants
- Past intestinal amoebiasis
- Penetrating abdominal trauma
Symptoms
The classic combination is fever with chills and pain in the right hypochondrium, but in the elderly and people with diabetes the picture is blurred: only weakness, sweating, weight loss and low-grade fever. The pain is usually dull, bursting, intensifies with movement and deep inspiration, and can radiate to the right shoulder due to irritation of the diaphragm. With a large or ruptured abscess, shortness of breath, coughing and pain when breathing appear. Jaundice does not always occur and more often indicates a problem with the bile ducts.
- Temperature above 38 degrees, chills, night sweats
- Dull pain and heaviness in the right hypochondrium
- Referral of pain to the right shoulder and scapula
- Weakness, loss of appetite and weight
- Nausea, sometimes vomiting
- Liver enlargement, pain on pressure
- Jaundice due to damage to the bile ducts
Survey
The first step is an ultrasound of the liver: it is available and in most cases shows a cavity with heterogeneous contents. A clarifying method is computed tomography with intravenous contrast: it sees small and multiple lesions, evaluates the bile ducts and helps to find the source of infection. Tests show high leukocytosis, accelerated ESR, elevated C-reactive protein, and alkaline phosphatase often increases. Before starting antibiotics, a blood culture is taken, and during drainage, the contents are sent for culture to accurately select the drug.
- Ultrasound of the liver and gallbladder
- CT or MSCT of the abdominal cavity with contrast
- Complete blood count with ESR, C-reactive protein
- Liver tests, bilirubin, alkaline phosphatase
- Blood cultures before starting antibiotics
- Culture of abscess contents during drainage
- Analysis for amoebiasis if an amoebic abscess is suspected
Treatment
Treatment is always inpatient and consists of two parts: antibacterial therapy and removal of pus. Small lesions can sometimes be treated with broad-spectrum antibiotics alone, which are then changed based on culture results. If there is a cavity of more than a few centimeters, a percutaneous puncture is performed or drainage is installed under ultrasound or CT control - this is less traumatic and effective. Open surgery is needed for multiple, hard-to-reach or ruptured abscesses. Be sure to eliminate the source: stone in the duct, inflamed appendix, narrowing of the bile ducts.
- Hospitalization and intravenous antibiotics
- Correction of therapy based on culture results
- Percutaneous puncture or drainage under ultrasound and CT guidance
- Surgery if drainage is ineffective
- Eliminating the source of infection in the biliary tract or intestines
- For amoebic abscess - antiprotozoal drugs
- Control ultrasound until the cavity is completely closed
