ABSCESSES OF THE LIVER

What is a liver abscess?

What are the types of liver abscess?

What is the most common location of abscess in the liver?

Abscess (collection of pus) in the liver parenchyma

Pyogenic (bacterial), parasitic (amebic), fungal

Right lobe left lobe

What are the two most common types?

Bacterial (most common in the United States) and amebic (most common worldwide)

What are the three most common bacterial organisms affecting the liver?

What are the most common sources/causes of bacterial liver abscesses?

What are the signs/ symptoms?

What is the treatment?

Gram negatives: E. coli, Klebsiella, and Proteus

Cholangitis, diverticulitis, liver cancer, liver metastasis

Fever, chills, RUQ pain, leukocytosis, increased liver function tests (LFTs), jaundice, sepsis, weight loss

IV antibiotics (triple antibiotics with metronidazole), percutaneous drainage with CT scan or U/S guidance

What are the indications for operative drainage?

Multiple/loculated abscesses or if multiple percutaneous attempts have failed

What is the risk of surgical removal of echinococcal (hydatid) cysts?

When should percutaneous drainage be performed?

What is the treatment?

Rupture or leakage of cyst contents into the abdomen may cause a fatal anaphylactic reaction

Never; may cause leaking into the peritoneal cavity and anaphylaxis

Mebendazole, followed by surgical resection; large cysts can be drained and then injected with toxic irrigant (scoliocide) into the cyst unless aspirate is bilious (which means there is a biliary connection) followed by cyst removal

C h a p t e r 53

Portal

Hypertension

358 Section II / General Surgery

Describe drainage of blood from the superior hemorrhoidal vein.

Where does blood drain into from the IMV?

Where does the portal vein begin?

What are the (6) potential routes of portal–systemic collateral blood flow (as seen with portal hypertension)?

To the IMV, the splenic vein, and then the portal vein

Into the splenic vein

At the confluence of the splenic vein and the SMV

1.Umbilical vein

2.Coronary vein to esophageal venous plexuses

3.Retroperitoneal veins (veins of Retzius)

4.Diaphragm veins (veins of Sappey)

5.Superior hemorrhoidal vein to middle and inferior hemorrhoidal veins and then to the iliac vein

6.Splenic veins to the short gastric veins

What percentage of patients with cirrhosis develop esophageal varices?

How many patients with cirrhosis develop portal hypertension?

What is the most common physical finding in patients with portal hypertension?

What are the associated CLINICAL findings in portal hypertension (4)?

Chapter 53 / Portal Hypertension 359

40%

Approximately two thirds

Splenomegaly (spleen enlargement)

1.Esophageal varices

2.Splenomegaly

3.Caput medusae (engorgement of periumbilical veins)

4.Hemorrhoids

Varices

Splenomegaly

Caput medusae

Hemorrhoids

What other physical findings are associated with cirrhosis and portal hypertension?

What is the name of the periumbilical bruit heard with caput medusae?

Spider angioma, palmar erythema, ascites, truncal obesity and peripheral wasting, encephalopathy, asterixis (liver flap), gynecomastia, jaundice

Cruveilhier-Baumgarten bruit

360 Section II / General Surgery

What constitutes the portal– systemic collateral circulation in portal hypertension in the following conditions:

Esophageal varices?

Caput medusae?

Retroperitoneal varices?

Hemorrhoids?

Coronary vein backing up into the azygous system

Umbilical vein (via falciform ligament) draining into the epigastric veins

Small mesenteric veins (veins of Retzius) draining retroperitoneally into lumbar veins

Superior hemorrhoidal vein (which normally drains into the inferior mesenteric vein) backing up into the middle and inferior hemorrhoidal veins

What is the “rule of 2/3” of portal hypertension?

2/3 of patients with cirrhosis will develop portal hypertension

2/3 of patients with portal hypertension will develop esophageal varices

2/3 of patients with esophageal varices will bleed from the varices

In patients with cirrhosis and known varices who are suffering from upper GI bleeding, how often does that bleeding result from varices?

Chapter 53 / Portal Hypertension 361

Only 50% of the time

What are the signs/symptoms?

What is the mortality rate from an acute esophageal variceal bleed?

Hematemesis, melena, hematochezia

50%

What is the initial treatment of variceal bleeding?

As with all upper GI bleeding: large bore IVs 2, IV fluid, Foley catheter, type and cross blood, send labs, correct coagulopathy (vitamin K, fresh frozen plasma), / – intubation to protect from aspiration

What is the diagnostic test of choice?

EGD (upper GI endoscopy)

Remember, bleeding is the result of varices only half the time; must rule out ulcers, gastritis, etc.

If esophageal varices cause bleeding, what are the EGD treatment options?

1.Emergent endoscopic sclerotherapy: a sclerosing substance is injected into the esophageal varices under direct endoscopic vision

2.Endoscopic band ligation: elastic band ligation of varices

What are the pharmacologic options?

Somatostatin (Octreotide) or IV vasopressin (and nitroglycerin, to

avoid MI) to achieve vasoconstriction of the mesenteric vessels; if bleeding continues, consider balloon (Sengstaken-Blakemore tube) tamponade of the varices, -blocker

What is a SengstakenBlakemore tube?

What is the next therapy after the bleeding is controlled?

Tube with a gastric and esophageal balloon for tamponading an esophageal bleed (see page 268)

Repeat endoscopic sclerotherapy/banding

What is a “partial shunt”?

What is a Warren shunt?

Shunt that directly decompresses the portal vein, but only partially

Distal splenorenal shunt with ligation of the coronary vein—elective shunt procedure associated with low incidence of encephalopathy in patients postoperatively because only the splenic flow is diverted to decompress the varices

What is a contraindication to the Warren “selective” shunt?

Define the following shunts: End-to-side portocaval shunt

Side-to-side portocaval shunt

Synthetic portocaval

H-graft

Chapter 53 / Portal Hypertension 363

Ascites

“Total shunt”—portal vein (end) to IVC (side)

Side of portal vein anastomosed to side of IVC—partially preserves portal flow (“partial shunt”)

“Partial shunt”—synthetic tube graft from the portal vein to the IVC

(good option for patients with alcoholism; associated with lower incidence

of encephalopathy and easier transplantation later)

What is the most common perioperative cause of death following shunt procedure?

What is the major postoperative morbidity after a shunt procedure?

Hepatic failure, secondary to decreased blood flow (accounts for two thirds of deaths)

Increased incidence of hepatic encephalopathy because of decreased portal blood flow to the liver and decreased clearance of toxins/metabolites from the blood

What lab value roughly correlates with degree of encephalopathy?

What medications are used to treat hepatic encephalopathy?

Serum ammonia level (Note: Thought to correlate with but not cause encephalopathy)

Lactulose PO, with or without neomycin PO