Introduction
Bacterial abscess of the liver is relatively rare; however, it has been described since the time of Hippocrates (400 BCE), with the first published review by Bright appearing in 1936. In 1938, Ochsner’s classic review heralded surgical drainage as the definitive therapy; however, despite the more aggressive approach to treatment, the mortality remained at 60-80%.
The development of new radiologic techniques, the improvement in microbiologic identification, and the advancement of drainage techniques, as well as improved supportive care, have reduced mortality to 5-30%; yet, the prevalence of liver abscess has remained relatively unchanged. Untreated, this infection remains uniformly fatal.
The three major forms of liver abscess, classified by etiology, are as follows:
· Pyogenic abscess, which is most often polymicrobial.
· Amoebic abscess due to Entamoeba histolytica
· Fungal abscess, most often due to Candida species
Signs & symptoms
Fever with chills
Vomiting
Pain in the right side of upper abdomen
Sudden weight loss
Dark colour of urine
Pale or grey coloured stool
Diarrhoea
1)Infections in the liver
Bacterial liver abscess
Escherichia coli
Klebsiella pneumoniae
Staphylococcus aureus
Staphylococcus milleri
Amoebic liver abscess
Entamoeba histolytica
Fungal abscesses
Candida albicans
Aspergillus
Actinomyces
Eikenella corrodens,
Yersinia enterocolitica,
Salmonella typhi,
Brucella melitensis.
2)As secondary to infections like appendicitis, peritonitis, endocarditis etc
3)Associated with diseases like pancreatic cancer, colon cancer, inflammatory bowel disease, septicaemia, etc.
4) Trauma to the liver by injury/accident
Pathophysiology
Enterobacteriaceae are especially prominent when the infection is of biliary origin. Abscesses involving K pneumoniae have been associated with multiple cases of endophthalmitis.
The most frequently encountered anaerobes are Bacteroides species, Fusobacterium species, and microaerophilic and anaerobic streptococci. A colony is found is usually as the initial source of infection.
Staphylococcus aureus abscesses usually result from hematogenous spread of organisms involved with distant infections, such as endocarditis.
Staphylococcus 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.
Candida albicans occur in individuals with prolonged exposure to antimicrobials, hematologic malignancies, solid-organ transplants, and congenital and acquired immunodeficiency.
Pyogenic liver abscess is observed as the initial manifestation of underlying hepatocellular carcinoma in rare cases.
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.
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 micro abscess formation. These micro abscesses initially are multiple but usually coalesce into a solitary lesion.
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.
The right hepatic lobe is affected more often than the left hepatic lobe. 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.
Diagnosis
USG – abdomen
CT scan
MRI
Blood tests like TC, DC etc to check infection
ESR
Blood cultures
Antibiotics
Anti-pyretic pills
NSAID’s
Drainage therapy with insertion of a needle & a drainage catheter into the abscess to remove the pus.
Surgery and parenteral antibiotics in more severe cases.
Prognosis
Liver abscesses usually have a bad prognosis in general due to chance of multi-organ failure and delay in diagnosis & treatment. Pyogenic liver abscess is fatal, when left untreated. 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, including hepatic failure.
Bilirubin level greater than 3.5 mg/dL, encephalopathy, hypoalbuminemia, and multiple abscesses; all are independent factors that predict poor outcome in amoebic abscess
An underlying malignant aetiology and an Acute Physiology and Chronic Health Evaluation (APACHE II) score greater than 9 increases the relative mortality by 6.3-fold and 6.8-fold, respectively.
Complications
Pulmonary complications especially in amoebic abscess
Empyema resulting from contiguous spread or intrapleural rupture of abscess
Rupture of abscess with peritonitis afterwards
Endophthalmitis when an abscess is associated with K. pneumoniae bacteraemia
Disease & Ayurveda
Aabhyantaravidradhi
Nidana
Diet which is Heavy, Unsuitable, unwholesome, dry, and mixed with all other food items with opposite potency.
Excess physical exercise & sexual intercourse
Holding natural urges like urine, faeces, vomiting, cough etc.
Diet which causes & aids infection & inflammation
Purvaaroopa
Not mentioned
Samprapti
Due to the causative factors, the doshas get vitiated individually or together and generates aabhyantaravidradhi or abscess inside the abdomen. In this, all the three doshas are involved in most cases. The vitiated doshas vitiate all dhatus and supportive tissues like Twak, rakta, mamsa, medas, asth, snayu, kandara etc. The vitiated doshas can get lodged in any of the following 10 sites in abdomen to produce aabhyantara vidradhi.
Naabhi – navel
Vasti – Urinary bladder
Yakrit – Liver
Pleeha -Spleen
Kloma – Pancreas
Hrdaya – Heart
Kukshi – Abdomen
Vankshana – Groin
Vrkka – Kidney
Guda – Rectum
After the sthaanasamsraya, these doshas produce a heavy swelling or cyst which is painful and inflammatory in nature.
Lakshana
There is general and specific lakshanas of aabhyantaravidradi depending upon its site of development.
General lakshanas are:
Cyst/bulged up tissue
Pain (Severe and unbearable)
Pus discharge
Specific lakshana of aabhyantaravidradhi in
yakrit
swaasa difficulty in breathing
kukshi
maarutakopanam (abnormal movement of Vaayu/gas formation)
kukshiparswaamsaarti(pain in abdomen, sides and shoulder)
aatopajanma(abnormal sounds from abdomen with gas trouble)
Divisions
- Baahyam
Aabhyantaram
- Vaatikam
Paittikam
Kaphajam
Thridoshajam
Raktajam
Kshatajam
Prognosis
Kashtasadhyam
Chikithsa
Samana
Soolaharalepanam
Sodhana
Virechanam
Bhedanam and drainage of pus
Commonly used medicines
Guggulupanchapalachoornam
Dasamoolapanchakoladi kashayam
Brands available
AVS Kottakal
AVP Coimbatore
SNA oushadhasala
Vaidyaratnam oushadhasala
Home remedies
No home remedy is suggested for liver abscess as it is a condition of medical emergency
Diet
- To be avoided
Minimise the intake of Salt and oil as a part of diet.
Heavy meals and difficult to digest foods – cause indigestion.
Junk foods- cause disturbance in digestion and reduces the bioavailability of the medicine
Carbonated drinks – makes the stomach more acidic and disturbed digestion
Refrigerated and frozen foods – causes weak and sluggish digestion by weakening Agni (digestive fire)
Milk and milk products – increase kapha and cause respiratory problems
Curd – causes vidaaha and thereby many other diseases
- To be added
Light meals and easily digestible foods
Green gram, soups.
Freshly cooked and warm food processed with cumin seeds, ginger, black pepper, ajwain etc
Behaviour:
Quit alcohol/smoking/narcotics.
Avoid sedentary lifestyle. Be active.
Better to avoid exposure to excessive sunlight wind rain or dust.
Maintain a regular food and sleep schedule.
Avoid holding or forcing the urges like urine, faeces, cough, sneeze etc.
Avoid day sleep.
Yoga
Vigorous exercises are not allowed in inflammatory liver abscess conditions.
Only stretching, moderate walking, and mild cardio exercises are advised. Also, specific yogacharya including Ardhamathsyentrasana, Dhanurasana, Gomukhasna and naukasana is recommended. Pain, the strength of the patient, range of movement and flexibility must be considered while doing every exercise.
Sookshma sandhi vyayama (warming up small joints) is advised.
Regular exercise helps improve bioavailability of the medicine and food ingested and leads to positive health.
Yoga can maintain harmony within the body and with the surrounding system.
Ardhamathsyentrasana
Dhanurasana
gomukasana
Naukasana
All the exercises and physical exertions must be decided and done under the supervision of a medical expert only.
Research articles
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