The liver fluke:Chronic hepatic abscess associated with fascioliasis

The liver fluke Fasciola hepatica has a digenetic lifecycle, requiring water snails as intermediate host. Man becomes an accidental final host after the ingestion of loof – typically watercress – that is contaminated with infectious metacercariae.The metacercariae exist in the human upper gastrointestinal tract, penetrate the intestinal wall, and migrate through the visceral peritoneum, finally boring their way through the liver capsule. The young flukes migrate from the subcapsular parenchyma to the biliary tree were the hermaphrodite adult flatworms can reside for years, giving rise to obstructive jaundice, cholangitis, or cholangiocarcinoma. In many locations such as Portugal, the Nile delta, northern Iran, parts of China, and the Andean highlands of Ecuador, Bolivia, and Peru, infections rates are high enough to make fascioliasis a serious public health concern....read more..

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Hepatobiliary and Pancreatic: Chronic hepatic abscess associated with fascioliasis

T-J Yen1, C-H Hsiao2, R-H Hu3, -L Liu4, C-H Chen1
Article first published online: 17 FEB 2011
DOI: 10.1111/j.1440-1746.2011.06679.x

Journal of Gastroenterology and Hepatology
Volume 26, Issue 3, page 611, March 2011

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A woman, aged 36, had investigations as part of a health screen. She denied any significant symptoms. Although she is currently living in Taiwan, she was born in Burma and had travelled extensively through South East Asia. She had the dietary habit of ingestion of raw vegetables. Screening blood tests including liver function tests were normal. Tumor markers were within the reference range and she had negative serological tests for hepatitis B and C. An ultrasound study showed a large hepatic mass and this was followed by a contrast-enhanced computed tomography scan. There was a lobulated mass, 9 cm in diameter, in the right hepatic lobe that was well-demarcated and showed spotty peripheral calcification. Furthermore, the lesion did not enhance in either the arterial, portal venous or delayed phases.

The portal venous phase is shown in Figure 1.

A liver biopsy showed granulation and necrotic tissue without evidence of malignancy. She was treated with a right hepatectomy. The mass contained granulation-like tissue with turbid yellow fluid. Histological sections revealed several unembryonated eggs, 100–150 µm in maximum diameter, that seemed likely to be related to infection with Fasciola hepatica (Figure 2). She was not treated with antihelminthic drugs as stool specimens were negative for eggs and for Fasciola hepatica antigens.

Figure 1

Figure 2

The three major liver flukes that infect humans are Clonorchis, Opisthorchis and Fasciola. Fasciola has a more complex lifestyle that includes an hepatic phase as well as a biliary phase. In the hepatic phase, developing flukes remain within the liver for 6 to 9 weeks. This phase is often asymptomatic but, with major infections, symptoms can include fever, upper abdominal pain, hepatomegaly and urticaria. Most patients also have a high eosinophil count in peripheral blood. Mature flukes in the bile duct can persist for up to 10 years and are occasionally symptomatic with biliary pain, cholangitis and pancreatitis. The development of a chronic liver abscess appears to be extremely rare but could develop because of prominent hepatic inflammation or because of an unusual chronic form of cholangitis. In the above case, the latter would appear more likely as eggs are only produced by mature flukes within the biliary system. http://onlinelibrary.wiley.com/doi/10.1111/j.1440-1746.2011.06679.x/full

Also See Video and Text; What The Heck Is Liver Rot? Its A Fluke

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Liver Abscess: Complications and Causes

Liver Abscess
Saturday, October 2, 2010, 9:56

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Liver abscess can result from the dissemination of a bacterial or fungal infections of the digestive tract through the portal vein, the biliary infection or by direct extension from adjacent infection.

The three major forms of liver abscesses, are classified by etiology: Piogene-abscesses, mostly polymicrobial, have more than 80% of liver abscesses Abscesses due to Entamoeba histolytica-ameobice, counts 10% of liver abscesses -Fungal abscesses, most commonly due to Candida species counts below 10% of cases.

Appendicitis was considered the most important cause of liver abscess formation. As the diagnosis and its treatment has improved, it remains the only cause in 10% of abscesses. Biliary tract disease is now the most common source piogene liver abscess. Obstruction allows bacterial proliferation. Gallstones, obstructive tumors affecting biliary tree and rare congenital diseases are conditions for the development of abscesses.

The clinical presentation most commonly for liver abscess include fever, chills, right upper quadrant pain, anorexia and malaise. Complications that may evolve through untreated abscess are sepsis, empyema continue dissemination of abscess or graft rupture, rupture of abscess with peritonitis and endophthalmitis, when an abscess is associated with bacteremia with Klebsiella pneumonia.

Single antibiotic therapy is not routinely indicated, although successful in some cases. It may be the only alternative for patients too ill to withstand an invasive intervention, or in cases with multiple abscesses, percutaneous drainage can not be. In these situations, patients will receive antibiotics for a period of several months, with careful monitoring of the development and deployment of any complications.
Surgical drainage was the standard for curative treatment, until the introduction of percutaneous drainage in 1970. Today, guided by imaging techniques, percutaneous drainage is the most widely used method for treating liver abscesses.

Left untreated an abscess in the liver is invariably fatal complications include sepsis, empyema, or peritonitis, by breaking into the pleural space or peritoneal abscess and retroperitoneal extension.

Pathogenesis of liver abscess
Piogenic abscess.
Piogene Bacteria can reach the liver by direct extension by contiguity to neighboring organs or the portal vein or hepatic artery. Clearance of bacteria through the port seems to be a normal phenomenon in healthy individuals, however, the proliferation of microorganisms, tissue invasion and abscess formation may occur in obstruction, poor perfusion or microembolizare.

In the biliary tree diseases.
Biliary diseases include 21-30% of reported cases of abscesses. Extrahepatic biliary obstruction leading to cholangitis and abscess formation is the most common cause and is usually associated with coledocolitiaza, malignant or benign tumors, or postsurgical strictures.

Bilio-enteric anastomoses (coledocoduodenostomia and coledocojejunostomia) were also associated with an increased incidence of abscess formation. Biliary complications (strictuirle) after liver transplantation are also causes of abscesses piogenis.

Port system infections.
Infectious processes originate from the abdomen to reach the liver through seeding or venous embolization. The restrictive use of antibiotics for intra-abdominal infections, piemia portal is now an uncommon cause liver abscesses, but still contains 20% of cases.

Appendicitis and pileflebitis are the predominant causes. Although any source of intra-abdominal abscess, such as acute diverticulitis, inflammatory bowel disease and intestinal perforation may lead to liver abscess and portal piemitis.

By disseminating marrow-via hepatic artery.
Infectious processes resulting in bacterial seeding of the liver in systemic cases of bacteremia, bacterial endocarditis, urinary sepsis after intravenous injection of drugs.
Penetrating wounds and hepatic necrosis by vascular damage inevitable laparoscopic procedures are recognized causes of liver abscesses. In addition, transarterial embolization and liver crioablations piogenis abscesses are new etiologies.

Cryptogenic etiology unknown.
In almost half of cases due to an abscess is found. Incidence is increased in patients with metastatic cancer. Patients with recurrent cryptogenic liver abscesses require careful investigation, and biliary and gastrointestinal.

Amoebic abscess.
Liver involvement results after the invasion of mesenteric venules with Entamoeba histolytica. Ameobis then enter the circulation and migrate up to the liver where it forms large abscesses typical. Protein Gal / GalNAc lectin is one that supports bacterial invasion. Abscess contains acellular proteinaceous debris that are considered to be a consequence of induced apoptosis and is surrounded by a ring trofozoizis that invade tissue.
Right hepatic lobe is most commonly affected because of the right lobe blood flow is supplemented predominantly superior mesenteric vein, while the left lobe is drained by the splenic vein.

http://www.procto-med.com/liver-abscess/