1. Joint Hospital Surgical Grand Round Carmen C.W. Chu Department of Surgery, Pamela Youde Nethersole Eastern Hospital

2.  F/53 Philipino  Newly diagnosed Ca sigmoid  PET-CT : solitary liver metastasis at segment IV/V  For laparoscopic anterior resection + RFA  Intraop:  Multiple liver abscess  Anchovy sauce like pus

3.  Severe disease with 80-100% mortality if untreated  Infection of liver parenchyma  Infiltration by inflammation and pus formation

4. Bacterial -80% Amoebic – 10% Fungal Tuberculosis

5.  Biliary  Portal  Traumatic  Arterial  Cryptogenic

6.  ↑ incidence 13 to 20/100,000 hospital admissions  Improved imaging techniques  Aetiology:  Portal pyaemia due to appendicitis used to be the commonest cause  ↑ Biliary causes  ↓ Overall mortality 6-14%  ↑ Resistant strains and fungal infection  ↑ antibiotics use Barakate et al. Ann Surg. 1996

7. Gram- Negative AerobesGram Positive AerobesKlebsiellaStreptococcus Milleri Escherichia Coli Staphylococcus Aureus Pseudomonas AeruginosaEnterococcus spp. Proteus Gram-Negative AnaerobesGram-Positive Anaerobes BacteroidesClostridium FusobacteriumPeptostreptococcus

8. Braiteh. International Journal of Infectious Diseases 2005 Polymicrobial Cryptogenic non invasive Mono-microbial Cryptogenic invasive Mono- microbial Metastatic infection Rare Frequent DM10-25%15%70% Biliary/ GI Pathology 95%0.6%nil Mortality31-41%<0.5%11%

9. Drainage of pus Treatment of underlying pathology Antibiotics >6weeks

10.  Surgical drainage is the mainstay of treatment in pre- imaging and pre-antibiotics era  McFadzean reported success with percutaneous drainage in 1953  Percutaneous drainage by interventional radiology is effective in 75-90% McFadzean et al Br J Surg 1953 Giorgio et al. Radiology 1995

11. Percutaneous Catheter Drainage (PCD) Percutaneous Needle aspiration (PNA) Adv Continuous drainage Especially when re- accumulation is rapid Can treat multiple abscesses in same setting Avoids catheter related complications Disadv Catheter related complications Repeated aspiration required

13. Rajak (1998)Yu (2004)Zerem (2007) Sample Size25 vs 2532 vs 3230 vs 30 Size of liver abscess 336 vs 222 ml 6.15 vs 5.55 cm 7.4 vs 7.4cm Overall efficacy 100% vs 60%84% vs 97%100% vs 67% Rajak et al. AJR 1998 Yu et al. Hepatology 2004 Zerem et al AJR 2007

14.  F/73  Poorly controlled DM  Admitted for fever, deranged LFT  USG: Gas containing liver abscess

15. 14.8 x 10.3 x 16.7cm air containing multi-loculated abscess displacing hepatic veins over right lobe of liver

16. CT on D7 after drainage Right lobe liver abscess remained static in size

17. 3 days after second catheter drainage

18.  Present with rupture/peritonitis  Failure of non-operative treatment  Anatomatically not accessible  Complications of percutaneous drainage  Treatment of primary pathology Tan et al. Annals of Surgery 2005

19.  Pyogenic liver abscess remained a significant pathology and is potentially life threatening  Majority caused by bacterial infection  Amoeba, fungal and tuberculosis  Percutaneous drainage with antibiotics remained first line of treatment and is effective in up to 90% of selected cases  Surgery is indicated in selected cases