Ranson

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Liver abscess

TREATMENT — Treatment of pyogenic liver abscess should include drainage and antibiotic therapy.

Drainage — Drainage techniques include CT-guided or ultrasound-guided percutaneous drainage (with or without catheter placement), surgical drainage, or drainage by endoscopic retrograde cholangiopancreatography (ERCP).

For single abscesses with a diameter ≤5 cm, either percutaneous catheter drainage or needle aspiration is acceptable [20-23]. Drainage catheters should remain in place until drainage is minimal (usually up to seven days). Repeat needle aspiration may be required in up to half of cases if a catheter is not left in situ [20,21].
For percutaneous management of single abscesses with diameter >5 cm, catheter drainage is preferred over needle aspiration. These principles were illustrated in a trial of 60 patients with pyogenic liver abscess treated with antibiotics and percutaneous drainage via catheter or needle aspiration [23]. Among patients with an abscess diameter >5 cm, treatment was successful in 100 percent of patients treated with catheter drainage compared with 50 percent of patients with needle aspiration. Successful outcomes were observed for all patients with abscess ≤5 cm, regardless of drainage modality.
For single abscesses with diameter >5 cm, some favor surgical intervention over percutaneous drainage [24,25]. The efficacy of this approach was suggested in a retrospective study of 80 patients with abscess >5 cm managed with percutaneous or surgical drainage; there was no difference in mortality, morbidity, duration of fever or complication rates. However, the rate of treatment failure was lower with surgical drainage (7 versus 28 percent).
Surgical drainage is also appropriate in the following circumstances:

• Multiple abscesses
• Loculated abscesses
• Abscesses with viscous contents obstructing the drainage catheter
• Underlying disease requiring primary surgical management
• Inadequate response to percutaneous drainage within seven days

Multiple or loculated abscesses may be successfully managed by percutaneous drainage; this was illustrated in a retrospective study of patients with pyogenic liver abscess [26]. Successful percutaneous drainage was achieved in the setting of multiple abscesses (22 of 24 patients) and multiloculated abscesses (51 of 54 patients) [26].
Endoscopic retrograde cholangiopancreatography (ERCP) can be useful for drainage of liver abscesses in patients with previous biliary procedures whose infection communicates with the biliary tree [11,27].

Antibiotics — No randomized controlled trials have evaluated empiric antibiotic regimens for treatment of pyogenic liver abscess. Treatment recommendations are based upon the probable source of infection and should be guided by local bacterial resistance patterns if known. (See 'Microbiology' above.)

Empiric broad-spectrum parenteral antibiotics should be administered pending abscess gram stain and culture results. We suggest one of the following regimens (table 1):

• Monotherapy with a beta-lactam/beta-lactamase inhibitor, such as ampicillin-sulbactam (3 g every six hours) OR piperacillin/tazobactam (4.5 g every six hours) OR ticarcillin-clavulanate (3.1 g every six hours)
• A third generation cephalosporin such as ceftriaxone (1 to 2 g IV every 24 hours) PLUS metronidazole (500 mg IV every 8 to 12 hours)

For patients with beta-lactam intolerance, alternative empiric regimens include:

• A fluoroquinolone (eg, ciprofloxacin 400 mg IV every 12 hours or levofloxacin 500 mg or 750 IV daily) PLUS metronidazole (500 mg IV every 8 to 12 hours)
• Monotherapy with a carbapenem, such as imipenem (500 mg every six hours) OR meropenem (1 g every 8 hours) OR ertapenem (1 g daily)

Regardless of the initial empiric regimen, the therapeutic regimen should be revisited once culture and susceptibility results are available. Recovery of more than one organism should suggest polymicrobial infection including anaerobes, even if no anaerobes are isolated in culture. In such circumstances, anaerobic coverage should be continued.

Duration of therapy — There are no randomized controlled trials evaluating the optimal duration of therapy. This is typically determined by the extent of infection and the patient's clinical response to initial management. Patients with abscess(es) that are difficult to drain or slow to resolve on follow-up imaging usually require longer courses of therapy.

Useful clinical indicators to follow are temperature, white blood cell count and serum C-reactive protein. Follow-up imaging should only be performed in the setting of persistent clinical symptoms or if drainage is not proceeding as expected; radiological abnormalities resolve much more slowly than clinical and biochemical markers. Among 102 pyogenic liver abscess patients in Nepal, the mean time to ultrasonographic resolution of abscesses <10 cm was 16 weeks; mean time to resolution for abscesses >10 cm was 22 weeks [28].
Drainage catheters should remain in place until drainage is minimal (usually up to seven days). If percutaneous needle aspiration was performed without catheter placement, repeat aspiration may be required in up to one-half of cases [20,21].
Antibiotic therapy should be continued for four to six weeks [29]. Patients who have had a good response to initial drainage should be treated with two to four weeks of parenteral therapy, while patients with incomplete drainage should receive four to six weeks of parenteral therapy. The remainder of the course can then be completed with oral therapy tailored to culture results [22,23]. If culture results are not available, reasonable empiric oral antibiotic choices include amoxicillin-clavulanate alone or a fluoroquinolone (ciprofloxacin or levofloxacin) plus metronidazole.

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Clinical Outcomes and Prognostic Factors of Cancer Patients with Pyogenic Liver Abscess.

Chen SC, Lee YT, Tsai SJ, Lai KC, Huang CC, Wang PH, Chen CC, Lee MC.

Source

Institute of Medicine, Chung Shan Medical University, Taichung, 40201, Taiwan.

Abstract

PURPOSE:

Pyogenic liver abscess (PLA) of cancer patients often has a poor prognosis, but corresponding prognostic factors are less investigated. This study aimed to identify predictors of mortality in cancer patients with PLA.

PATIENTS AND METHODS:

Medical records of 85 consecutive cancer patients (46 with hepatobiliary pancreatic cancer, 14 with gastrointestinal cancer, and 25 with non-digestive system cancer) having PLA who were admitted to two university hospitals were retrospectively reviewed. The predictors of mortality were determined using Cox regression model.

RESULTS:

The overall case fatality rate was 33%. In multivariate analysis, the greater Acute Physiology and Chronic Health Evaluation II score (P = 0.028), multiloculated abscess (P = 0.025), and polymicrobial infection (P = 0.003) were associated with mortality. In subgroup analysis of the 25 patients with multiloculated abscess undergoing percutaneous catheter drainage as primary treatment, the case fatality rates of patients with a solitary smaller abscess (size < 5 cm), those with a solitary larger abscess (size > 5 cm), and those with larger multiple abscesses were 0%, 36%, and 85%, respectively (P = 0.002; using χ (2) for trend).

CONCLUSIONS:

The advanced disease stage, multiloculated abscess, and polymicrobial infection posed a greater mortality risk in cancer patients with PLA. Moreover, an early surgical approach should be considered for cancer patients having large, multiloculated complex PLAs.

PMID:

21826544

[PubMed - as supplied by publisher]

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Current management of pyogenic liver abscess: surgery is now second-line treatment.

Mezhir JJ, Fong Y, Jacks LM, Getrajdman GI, Brody LA, Covey AM, Thornton RH, Jarnagin WR, Solomon SB, Brown KT.

Source

Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA.

Abstract

BACKGROUND:

The objective of this study was to examine the current treatment for liver abscess and to assess the factors associated with failure of percutaneous drainage.

STUDY DESIGN:

Records of 58 patients with pyogenic hepatic abscess, from 1998 to 2009, were examined. Clinicopathologic variables were analyzed as predictors of failure of percutaneous drainage using multivariable logistic regression. The results of surgical intervention after failure of percutaneous treatment were also examined.

RESULTS:

Fifty-one patients (88%) had a history of malignancy including pancreas (36%), cholangiocarcinoma (17%), colon (12%), and gallbladder (10%). Recent hepatic artery embolization or radiofrequency ablation preceded development of abscess in 13 patients (22%). Fifteen patients (26%) had evidence of biliary tract communication, and 14 of 15 (93%) of these patients had concomitant biliary tract obstruction. Percutaneous drainage was successful in 38 patients (66%) with a median drain dwell time of 26 days (range 3 to 319 days). Five patients (9%) required operative intervention and 2 of these patients (3% overall) died postoperatively from septic complications. Fifteen patients (26%) died with percutaneous drains in place; 9 (60%) of these patients died of cancer progression without evidence of sepsis. Independent predictors of failure of percutaneous drainage included abscesses containing yeast (p = 0.003) and communication of the abscess cavity with the biliary tree (p = 0.02).

CONCLUSIONS:

Pyogenic hepatic abscess was treated successfully in the majority of patients with advanced malignancy, although mortality remained high. The presence of yeast and communication with an untreated obstructed biliary tree were associated with failure of percutaneous drainage. The need for surgical salvage was associated with a high mortality.
Copyright (c) 2010 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

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Current Management of Pyogenic Liver Abscess: Surgery is Now Second-Line Treatment

Presented at the American College of Surgeons 95^th Annual Clinical Congress, Chicago, IL, October 2009.

James J. Mezhir MD^a, Yuman Fong MD, FACS^{a, ,} , Lindsay M. Jacks MS^c, George I. Getrajdman MD^b, Lynn A. Brody MD^b, Ann M. Covey MD^b, Raymond H. Thornton MD^b, William R. Jarnagin MD, FACS^a, Stephen B. Solomon MD^b and Karen T. Brown MD^b

^a Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY
^b Department of Interventional Radiology, Memorial Sloan-Kettering Cancer Center, New York, NY
^c Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, NY

Received 13 November 2009; 

revised 26 February 2010; 

accepted 3 March 2010. 

Available online 29 April 2010.

Background

The objective of this study was to examine the current treatment for liver abscess and to assess the factors associated with failure of percutaneous drainage.

Study Design

Records of 58 patients with pyogenic hepatic abscess, from 1998 to 2009, were examined. Clinicopathologic variables were analyzed as predictors of failure of percutaneous drainage using multivariable logistic regression. The results of surgical intervention after failure of percutaneous treatment were also examined.

Results

Fifty-one patients (88%) had a history of malignancy including pancreas (36%), cholangiocarcinoma (17%), colon (12%), and gallbladder (10%). Recent hepatic artery embolization or radiofrequency ablation preceded development of abscess in 13 patients (22%). Fifteen patients (26%) had evidence of biliary tract communication, and 14 of 15 (93%) of these patients had concomitant biliary tract obstruction. Percutaneous drainage was successful in 38 patients (66%) with a median drain dwell time of 26 days (range 3 to 319 days). Five patients (9%) required operative intervention and 2 of these patients (3% overall) died postoperatively from septic complications. Fifteen patients (26%) died with percutaneous drains in place; 9 (60%) of these patients died of cancer progression without evidence of sepsis. Independent predictors of failure of percutaneous drainage included abscesses containing yeast (p = 0.003) and communication of the abscess cavity with the biliary tree (p = 0.02).

Conclusions

Pyogenic hepatic abscess was treated successfully in the majority of patients with advanced malignancy, although mortality remained high. The presence of yeast and communication with an untreated obstructed biliary tree were associated with failure of percutaneous drainage. The need for surgical salvage was associated with a high mortality.

Abbreviations: OR, odds ratio; PD, percutaneous drainage; PLA, pyogenic liver abscess

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HRS

Hepatorenal syn.：Cr>1.5, CCr<40

Type I：rapid, <2wks, Cr>2.5, CCr<20à2~3 months

Type II：slow, diuretic-resistant ascitesà6 months

Tx: Midodrine, Octreotide, Albumin, Liver transplantation

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Ranson's score

血糖兩百年５５

乳酸脫氫３５０

白血球高破萬六

ＯＴ轉胺２５０

血比容降１０％

鈣８鹼４氧６０

血中尿素高過５

外補輸液給６升

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Amylase D/D

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GI bleeding (Washington Manual)

S/S

1.     Hematemesis

2.     coffee-ground emesisà aspiration of blood or coffee-ground material from NG  tube suggest an upper GI source of blood loss

3.     Melena, black sticky stoolàupper GI

4.     Hematochezia, bloody stoolàlow GI

5.     patients with lower GI bleeding have less hemodynamic compromise compared to those with upper GI bleeding

6.     Disorders of coagulation: liver disease, von Willebrand disease, vitamin K deficiency, and DIC

7.     Medications: warfarin, heparin, aspirin, NSAID, clopidogrel (Plavix), thrombolytic agents, antithrombotic agents such as glycoprotein IIb/IIIa receptor antagonists (abciximab [ReoPro], eptifibatide [Integrilin], tirofiban [Aggrastat]), direct thrombin inhibitors

PE, LAB

1.     Color of stool

2.     NG aspirate

3.     Intravascular volume and hemodynamic status: a sudden increase in pulse rate or decrease in BP may be an early indicator of recurrent or ongoing blood loss

4.     orthostatic hemodynamic changes: drop in SBP >10 mm Hg, rise in HR >15 bpmàloss of 10% to 20% of the circulatory volume;
supine hypotension suggests a >20% loss
BP <100 mm Hg or HR >100 bpmàthat requires urgent volume resuscitation

5.     CBC, PT/PTT, Blood group, cross-matching of 2~4 units of blood, liver function tests, serum creatinine

Diagnosis

1.     Esophagogastroduodenoscopy (EGD): high diagnostic accuracy, therapeutic capability, and low morbidity

2.     Colonoscopy: performed within the initial 24 hours is greatest

3.     early diagnostic endoscopy does not reduce mortality, therapeutic endoscopy reduces transfusion requirements, need for surgery, and length of hospital stay

4.     Anoscopy

5.     Push enteroscopy: evaluation of the proximal small bowel

6.     Capsule endoscopy

7.     Single- and double-balloon enteroscopy

8.     Intraoperative enteroscopy

9.     TRBC scanning: positiveàrequire invasive intervention, high in-hospital morbidity

10.    Arteriography: localization and potential therapy, when bleeding > 0.5 mL/min

TX

1.     Restoration of intravascular volume

2.     Oxygen administration

3.     Transfusion should be continued until hematocrit reaches ≥25%; patients with cardiac or pulmonary disease may require transfusion to a hematocrit of ≥30%

4.     Correction of coagulopathy: Discontinuation of the anticoagulant, FFP 4U,
Vit-K (10 mg SC or IM) may be indicated for prolonged PT from warfarin or hepatobiliary disease, but takes several hours to days,
Protamine infusion (1 mg antagonizes ~100 units of heparin) can be used for immediate reversal of anticoagulation from heparin
Platelet infusion may be indicated when the platelet count is <50,000/m m³

5.     Airway protection

6.     Nonvariceal upper GI bleeding: IV PPI or oral high-dose PPI (omeprazole, 40 mg PO bid) reduce the rate of recurrent bleeding and the need for surgery. Mortality is reduced in peptic ulcer bleeding, but not other causes. PPI therapy, oral or IV, is better than IV histamine-2 receptor antagonist (H₂RA) therapy

7.     Variceal bleeding:
--octreotide infusion should be initiated immediately (50- to 100-mcg bolus, followed by infusion at 25 to 50 mcg/hr), and continued for 3 to 5 days.
--Vasopressin (0.3 units/min IV, titrated by increments of 0.1 units/min q30 min until hemostasis is achieved, side effects develop, or the maximum dose of 0.9 units/min is reached), rarely used because of significant cardiovascular complications including cardiac arrest and myocardial infarction
--Nitroglycerin is administered only if the systolic BP is >100 mm Hg, at a dose of 10 mcg/min IV, increased by 10 mcg/min q10-15 min until the systolic BP falls to 100 mm Hg or a maximum dose of 400 mcg/min is reached

8.     Antibiotic: fluoroquinolone (norfloxacin or ciprofloxacin), ceftriaxone (1 g/d) for patients with advanced cirrhosis or when quinolone-resistant

9.     Therapeutic endoscopy within 12 to 24 hours, single dose of erythromycin (250 mg IV) administered 30 to 60 minutes prior to upper endoscopy may induce gastric emptying of clots and debris, and improve visualization

10.    Variceal ligation or banding is the endoscopic therapy of choice for esophageal varices, lower rates of rebleeding and fewer complications compared to sclerotherapy

11.    Transjugular intrahepatic portosystemic shunt (TIPS) à
expandable metal stent deployed between the hepatic veins and the portal vein
Indications: refractory variceal bleeding unresponsive to variceal ligation or sclerotherapy, bleeding from gastric varices in portal hypertension
screening for shunt stenosis with duplex Doppler ultrasound

12.    Emergent total colectomy for massive, unlocalized, colonic bleeding
Total or partial colectomy for diverticular bleeding
Splenectomy for bleeding gastric varices from splenic vein thrombosis
Shunt surgery (portacaval or distal splenorenal shunt)
  (a) fails endoscopic or pharmacologic therapy,
  (b) unable to return for follow-up visits,
  (c) high risk of death from recurrent bleeding
     (cardiac disease or difficulty in obtaining blood products)
  (d) lives far from medical care



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Ranson Criteria

Table 4 Ranson Criteria for Severity Assessment in Acute Pancreatitisa

Alcoholic Pancreatitis Nonalcoholic Pancreatitis On admission Age >55 yr >70 yr WBC count >16,000/mcL >18,000/mcL Blood glucose >200 mg/dL >220 mg/dL LDH >350 International Units/L >400 International Units/L AST >250 units/L >440 units/L During the first 48 hr of admission Fall in hematocrit >10% >10% Serum calcium <8 mg/dL <8 mg/dL Base deficit >4.0 mEq/L >5.0 mEq/L Increase in blood urea >5 mg/dL >2 mg/dL Fluid sequestration >6 L >6 L Arterial PO2 <60 mm Hg <60 mm Hg

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complication of TAE

Complication of Transcatheter Arterial Embolization

1.      Liver injury:

--Acute liver failure

--liver abscess

--intrahepatic biloma

--liver infarction

--multiple intrahepatic aneurysm

2.      Extrahepatic injury

--cholecystitis or GB infarction

--splenic infarction

--GI mucosa lesion

--tumor rupture

--variceal bleeding

3.      Other

--dissection or perforation of celiac a.

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cirrhosis

liver cirrhosis complication:
1.portal vein HTN
2.ascites
3.SBP
4.liver failure
5.hepatoma


decompensated cirrhosis(Child B, C):
1.Alb decrease
2.Bil increse-->jaundice if >2
3.Ascites
4.PT prolong
5.Encephalopathy

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HCC

HCC診斷：

1.      lession>2cm

2.      AFP>200

3.      兩種image

HCC治療：

A.      Child A, B：

a.      single：

1.      移植：<6.5 cm

2.      開刀：ascites OK、Bil<2、if Child A
      ICG<15可大範圍切除，否則須再評估

3.      局部(PEIT、RFA)禁忌如下
a.多於 3個、大於5 cm、beside vital organs(e.g. Gall bladder--for PEIT and RFA or main trunk of blood vessel--for RFA)、PLT<8萬 or prolonged P>5

4.      TAE禁忌如下：

Absolute：

a.      Total occlusion of the portal trunk

b.      Presence of encephalopathy

c.       Serium bilirubin level >3.0 mg/dL

d.      uncooperative patient

Relative：

a.      Uncontrollable ascites

b.      Recent variceal bleeding

c.       Portal vein occlusion in right main branch

d.      Arterio-Venous shunt or Arterio-Portal shunt

e.      AST> 300 U/L, or ALT> 300 U/L or LDH >425 U/L

f.        Thrombocytopennia(platelet<50000/uL)

g.      Coagulopathy (PT prolongation > 3 sec. or INR > 1.5 )

b.      Multiple：

1.      移植：<4cm

2.      開刀：<3顆、<4.5cm

3.      局部：<3顆、<5cm

4.      TAE：

B.      Child C：

a.      No Portal Invasion

1.      移植：<4cm

2.      局部：<3顆、<5cm

3.      TAE

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