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General Surgery
Hepatic Abscess and Cystic Disease of the Liver
Built from Maingot's Abdominal Operations
What’s inside
8 sections · 190 slides
Overview
- Cystic lesions of the liver
- The seven lesions covered here
- Classification of cystic hepatic lesions
Pyogenic liver abscess
A pus-filled cavity in the liver caused by bacteria
- Pyogenic liver abscess defined
- How treatment changed over time
- Where the bacteria come from
- Six routes of infection to the liver
- Changing etiology of pyogenic liver abscess
- Biliary causes
- Bowel causes
- Spread from neighbouring disease and from injury
- Arterial and cryptogenic causes
- How often it happens
- Conditions that make it more likely
- Age pattern
- Predicting trouble in older patients
- Pyogenic liver abscess in children
- Predisposing factors for pyogenic liver abscess
- Number, size and site of the abscess
- Confirming the diagnosis by culture
- Which organisms grow
- Organisms isolated from pyogenic liver abscesses
- The organism follows the source
- Klebsiella pneumoniae liver abscess
- How patients present
- Less obvious presentations
- Symptoms of pyogenic liver abscess
- Signs and laboratory data in pyogenic liver abscess
- Blood tests
- Plain X-rays
- Gas-filled right lobe abscess on plain film
- Ultrasound
- Pyogenic liver abscess on ultrasound
- Blood vessels blocking the drainage path
- Computed tomography
- Pyogenic abscess on CT and drainage of a posterior abscess
- Liver abscesses on MRI
- Communicating abscess on cholangiogram
- Two things must be treated
- Antibiotic choice
- How long, and for whom
- Antibiotics for Klebsiella abscess
- Candidal liver abscess
- Antifungal choice
- Needle aspiration versus catheter drainage
- Recurrence guides the choice
- Right lobe abscess before and during drainage
- Shrinking cavity on sinogram and CT
- Surgical drainage
- Who still needs an operation
- Complications
- Complications of Klebsiella abscess
- Outcome
- Factors linked to a poor outcome
- Outcome of Klebsiella abscess
Amebic liver abscess
A single-celled parasite that eats its way into the liver
- Amebic liver abscess defined
- Two amoeba species
- From swallowed cyst to liver abscess
- What the abscess contains
- How common it is worldwide
- Who is at risk
- Age and sex pattern
- What happens in the bowel
- Amebic colitis
- How the liver is involved
- Making the diagnosis
- Typical symptoms
- Symptoms of amebic liver abscess
- Signs and laboratory data in amebic liver abscess
- Blood and stool tests
- Amebic versus pyogenic abscess
- Imaging in amebic abscess
- How slowly the scan clears
- Serology
- When to aspirate
- Better laboratory tests
- Drugs come first
- Metronidazole in practice
- Finish with a gut-acting drug
- Does aspirating help?
- When to drain anyway
- Percutaneous and surgical drainage
- Complications
- Paths of extension of amebic liver abscess
- Chest complications
- Rupture into pleura or bronchus
- Heart and brain complications
- Outcome
- Factors linked to a poor outcome in amebic abscess
Hydatid liver cyst
A tapeworm larva that builds a walled cyst inside the liver
- Hydatid disease defined
- Where the cysts settle
- Life cycle of the tapeworm
- Life cycle in detail
- Life cycle of Echinococcus granulosus
- How humans catch it and how fast cysts grow
- How common it is, and prevention
- How the cyst behaves
- The three layers of a hydatid cyst
- The pericyst
- The laminated membrane
- The germinal membrane
- Brood capsules and hydatid sand
- Daughter cysts
- Ectogenic vesiculation and E. multilocularis
- Clinical presentation
- Symptoms, signs and laboratory data in hydatid liver cysts
- Blood tests for hydatid disease
- Imaging
- The Gharbi classification
- Ruptured and calcified hydatid cysts on CT and ERCP
- Bile ducts opening into a hydatid cyst
- Differential imaging and character of hepatic cysts
- Reading the cyst comparison
- The rest of the imaging work-up
- Treatment principles
- Drug treatment
- The PAIR technique
- How percutaneous treatment became acceptable
- Results of percutaneous treatment
- Who can be treated percutaneously
- When not to puncture
- Complications of percutaneous treatment
- The risks that remain
- Surgery: the objectives
- Why cysts come back after surgery
- Scolicidal agents
- What the World Health Organization advises
- Open cyst evacuation
- Open cyst evacuation and pericystectomy
- Laparoscopic cyst evacuation
- Finishing the laparoscopic operation
- Laparoscopic results compared with open
- Pericystectomy step by step
- Pericystectomy in practice
- Liver resection and transplantation
- Choosing the operation in uncomplicated patients
- Choosing the operation in complicated patients
- Complications
- Rupture into the bile ducts
- Fistulae, retention cysts and free rupture
- Outcome
- Follow-up and mortality
Congenital liver cysts
Cysts present from birth: solitary simple cysts and polycystic liver disease
- Two kinds of congenital liver cyst
- How common simple cysts are
- Where simple cysts come from
- How simple cysts present
- Imaging simple cysts
- Large simple cyst compressing the hepatic veins
- Watching, and why aspiration fails
- Surgery for simple cysts
- Treatment options for congenital liver cysts
- Laparoscopic unroofing
- Polycystic liver disease
- How polycystic liver disease behaves
- Polycystic liver disease on CT
- Treating polycystic liver disease
- Limits of unroofing, and transplantation
Neoplastic liver cysts
Cystic tumours of the liver: cystadenoma and cystadenocarcinoma
- Cystic tumours of the liver
- Diagnosis and tumour markers
- Biliary cystadenoma
- Symptoms and imaging of cystadenoma
- Septated cystic liver tumor on ultrasound
- Liver cystadenoma at operation
- Liver cystadenoma after removal
- Why imaging alone is not enough
- Cyst fluid analysis
- Treatment of cystadenoma
- Treatment options for neoplastic liver cysts
- Cystadenocarcinoma
- Cystadenocarcinoma on CT
Traumatic liver cysts
A bile leak after liver injury that walls itself off
- Changing management of liver trauma
- How a traumatic cyst forms
- What a traumatic cyst is
- Traumatic hepatic cyst on CT and ultrasound
- Injury during gallbladder surgery
- Assessing a bile duct injury
- Treatment of traumatic cysts
Pulling it together
What to carry away from cystic disease of the liver
- Telling the four abscess-like lesions apart
- What each one needs
- Traps worth remembering
- References
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- Maingot's Abdominal Operations, 12th Edition