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Surgical Management of Infectious Processes of the Liver

Surgical Management of Infectious Processes of the Liver. Houssam G. Osman, M.D. HPB surgery Associate Director, HPB Fellowship Methodist Dallas Medical Center, Dallas ACOS: In-Depth Review - 2014 Kansas C ity, MO. PYOGENIC LIVER ABSCESS. Secondary to bacterial infection

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Surgical Management of Infectious Processes of the Liver

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  1. Surgical Management of Infectious Processes of the Liver Houssam G. Osman, M.D. HPB surgery Associate Director, HPB Fellowship Methodist Dallas Medical Center, Dallas ACOS: In-Depth Review - 2014 Kansas City, MO

  2. PYOGENIC LIVER ABSCESS • Secondary to bacterial infection Etiology / route of dissemination • Biliary : cholangitis , ERCP • Portal: intra-abdominal; appendicitis, diverticulitis • Arterial: IVDU, pneumonia, endocarditis • Adjacent organ: cholecystitis • Direct trauma: after ablation on TACE Keep underlying tumor at the back of your mind specially if you don’t find a source!

  3. PYOGENIC LIVER ABSCESS Clinical presentation • Fever • Abdominal pain • Nausea, vomiting, weight loss • Sepsis

  4. PYOGENIC LIVER ABSCESS Diagnostic workup • Labs: leukocytosis and elevated LFTs • US • CT • MRI • Blood culture • Workup for source

  5. PYOGENIC LIVER ABSCESS Treatment: • Antibiotics - IV - prolong course • Percutaneous approach - drain placement - aspiration (may need multiple trips to IR) • Surgical drainage/debridement/resection - failure of percutaneous approach - intra-peritoneal rupture - need for operative intervention to address other abdominal process

  6. HYDATID LIVER DISEASE • Echinococcusspecies • Humans become accidental intermediate hosts when they become infected after ingesting ova passed in dog feces¹ • Liver is the most common involved organ² • It may take months to years for individual to become symptomatic after infection ¹William R. Jarnagin and Leslie H. Blumgart, MD. Blumgart's Surgery of the Liver, Pancreas and Biliary Tract, 5th Edition ²Shaw JM, Bornman PC, Krige JEJ: Hydatid disease of the liver. S Afr J Surg. 44:70-77 2006

  7. HYDATID LIVER DISEASE Potential complication • Rupture - peritoneal cavity - pleural space - biliary tree • Secondary infection • Mass effect Corona M et al, Case report: Percutaneous treatment of multiple honeycomb-like liver hydatid cysts (type III CE2, according to WHO classification). Indian J Radiol Imaging. 2012 Jan;22(1):23-6. doi: 10.4103/0971-3026.95399.

  8. HYDATID LIVER DISEASE Clinical presentation • Asymptomatic • RUQ pain • Allergic reaction and anaphylactic shock

  9. HYDATID LIVER DISEASE Diagnostic work up • Laboratory - eosinophilia > 3% ¹ - LFTs may be normal - serology; electrophoresis, ELIZA • CT/MRI - multiple types -hydatid sand, honeycomb ¹Pitt HA, et al.: Management of hepatic echinococcosis in Southern California. Am J Surg William R. Jarnagin and Leslie H. Blumgart, MD. Blumgart's Surgery of the Liver, Pancreas and Biliary Tract, 5th Edition

  10. HYDATID LIVER DISEASE Treatment • Conservative - asymptomatic small cyst < 5 cm¹ • Surgery - conservative - radical - avoid spillage • Percutabeous • Medication (Albendazole) - perioperative - definitive ¹Buttenschoen K, Buttenschoen D: Echinococcusgranulosus infection: the challenge of surgical treatment. Langenbecks Arch Surg. 388:218-230 2003

  11. AMEBIC LIVER ABSCESS • Entamoebahistolytica • Most common extra-intestinal location • Fecal-oral transmission Killed Napoleon!!

  12. AMEBIC LIVER ABSCESS Presentation • Asymptomatic • Abdominal pain and fever Unlikely to have concomitant colitis

  13. AMEBIC LIVER ABSCESS Diagnosis: • US • CT • Serology ? Role of aspiration William R. Jarnagin and Leslie H. Blumgart, MD. Blumgart's Surgery of the Liver, Pancreas and Biliary Tract, 5th Edition Courtesy Professor A.K. El Dory, Ain Shams University, Cairo.

  14. AMEBIC LIVER ABSCESS Treatment: • Metronidazole • Therapeutic aspiration - imminent rupture - failure or contraindication of medical treatment - secondary bacterial infection

  15. LIVER FLUKE Fasciolahepatica • Fecal-oral transmission • Inhabit hepatocytes, bile duct, and gallbladder • Presentation: abdominal pain, fever, hemobilia • Diagnosis: CT, serology • Treatment - Triclabendazole - ERCP if biliary obstruction

  16. LIVER FLUKE Clonorchissinensis • Fecal –oral transmission • Oriental cholangiohepatitis • CT, serology • Praziquantel

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