Abscess of the Liver.
Synonyms.—Suppurative Hepatitis; Hepatic Abscess.
Definition.—A circumscribed collection of pus in the substance of the liver.
Etiology.—Abscess of the liver results from the introduction into its substance of some irritant, usually infectious. It may enter directly from an injury, through the blood-vessels, and by way of the bile-ducts. The large, sing-le abscess, commonly known as the tropical abscess, because found in the hot climates, may occur idiopathically, although more frequently it is the result of dysentery. It occurs quite frequently among Europeans sojourning in India, who are addicted to the drink habit, and over-cat of rich, highly spiced foods. In this country, it occurs in the Southern States. The researches of Kartulis, Councilman, and Lafleur point strongly to the ameba coli as the causal agent, notwithstanding the fact that the ameba may be present, the feces well formed, no evidence of dysentery, and yet well-marked signs of hepatic abscess.
The frequency with which abscess follows injuries of the abdomen would suggest traumatism as a cause. Blows over the liver occur most often in boxers and railroad brakemen, and this class are more frequently affected. Injuries to the head have also been followed by abscess of the liver. Following the blow a toxin is generated and carried to the liver, which acts as the irritant.
Embolism of the portal vein or hepatic artery is a common cause of abscess of the liver, and may arise from a general pyernia or suppurative process in the region of the liver In this way abscesses may follow typhoid fever, appendicitis, dysentery, piles, and pelvic abscess, the infection being through the portal vein, and through the hepatic artery, in ulcerative endocarditis and gangrene of the lung.
Suppurative cholangeitis; suppuration of the bile-ducts, due to gall-stones; parasites, such as echinococci, lumbrici, distomi, or foreign bodies, nails, pins, needles, fishbones, etc., may give rise to abscess of the liver.
Pathology.—Large, Solitary, or Tropical Abscess.—These abscesses, while generally single, are occasionally multiple, and often coalesce, forming one immense ulcer, the size of a child's head, and may contain several quarts of pus.
The liver is'generally enlarged, the abscess electing the right lobe, and the convex side rather than the concave. Where the abscess is of long standing, there is connective tissue change in the neighboring parts, so that it becomes thick, tough, and somewhat cartilaginous.
The pus varies in character and may be grayish, mucoid, creamy, and often of a reddish-brown color. It may be sterile or rich in staphylococci or amebae coli.
In traumatic abscesses, the pus is more often sterile, is yellow, of a creamy consistency, or thin, icherous, and reddish-brown.
The abscess develops in the direction of the least resistance, working its way to the surface, and penetrates parts showing the least obstruction.
"Of three hundred cases reported by Waring, fifty-six per cent remained intact; sixteen per cent opened by operation; nine per cent ruptured through the lung; five per cent perforated the pleura; three per cent entered the colon. There are other instances where the abscesses entered into the hepatic and bile vessels, and into the gall-bladder, while Flexner has reported two cases of perforation into the inferior vena cava." (Osler.)
Nature sometime sets up an adhesive peritonitis, thus waning off the pus, which opens through the abdominal wall.
Multiple Pyemic or Embolic Abscesses.—When the abscess-producing material is carried to the liver by the portal vein, multiple abscesses usually arise in the liver, while the rest of the body remains free; while, if brought by the arteries, various other organs are also involved in the abscess formation. In multiple abscess, the liver is enlarged, smooth, and may present a normal appearance. At other times, small, white or yellowish-white spots appear beneath the capsule, showing the ulcer spots. On making a section, numerous small abscesses, varying in size from a pinhead to a California cherry, are seen, and contain pus of various quality, sometimes laudable, and again fetid, and of a reddish-brown color, due to staining from the bile, and various cocci are found in its contents. On probing these abscesses, they are found to open into the portal vein or its branches. In some cases the entire portal system within the liver may be involved. Occasionally suppurative cholangeitis occurs, usually the result of obstruction from gall-stones, the ducts and gall-bladder containing pus.
Symptoms.—They vary greatly, and may be so slight as to cause no suspicion of the true nature of the lesion till it is revealed by a post-mortem, showing death by a rupture of the organ, or by passing pus through the bowel or bronchi. Small abscesses may give rise to no other symptoms than pyemia.
Usually the forming stage is attended by headache, loss of appetite, and general malaise, with more or less chilly sensations. The temperature for a time may be subnormal, but with a well-marked rigor; the temperature runs up to 103° or 104°. Like septic fever in general, it is irregular, and may be either of an intermittent or remittent type.
Night-sweats are a common feature. In chronic cases there may be no fever, the temperature often being subnormal. The pain is located in the region of the liver, radiating to the back and right shoulder. When deep-seated, it is of a boring character, but when near to the surface, it is sharp and lancinating. With the advance of the disease, the enlargement of the liver crowds the diaphragm, irritating the right lung, and a hard, dry cough results, unless there is perforation of the lung, when there will be expectoration of a reddish-brown pus, resembling anchovy sauce.
Digestion is impaired, the tongue is covered from base to tip with a dirty, yellow coating. There is nausea and occasionally vomiting. Constipation alternates with diarrhea. As the result of faulty nutrition, the patient becomes emaciated, the skin is jaundiced or of a muddy color. With the further progress of the disease, typhoid symptoms appear, the tongue becomes dark-brown or black, is dry, sordes appear on the teeth and lips, the mind wanders, typhomania develops, and sometimes convulsions occur.
Physical Signs.—Inspection reveals marked fullness in the right hypochondrium, and if the abscess is located in the anterior portion of the right lobe, there will be a bulging of the ribs, the distention extending several inches below the costal margin.
Palpation reveals a large, round, hard tumor, and in son-fe cases fluctuation is noted.
Percussion.—There is increased dullness in all directions, but more pronounced upwards and to the right, in severe cases reaching as high as the fifth rib in front, and the scapula in the back. This extensive dullness upwards enables one to differentiate abscess from cancer, dullness in the latter case being downward.
The clinical symptoms of multiple abscess can not be separated from the above. The liver is enlarged and tender, and the skin more or less jaundiced.
Diagnosis.—In the early stage it is almost impossible to make a positive diagnosis, but when well advanced, the true nature of the disease is comparatively easy to discern. The enlargement of the liver, with pain and tenderness on pressure and fluctuation when superficial, the icteric or muddy color, emaciation. hectic fever, and night-sweats, can hardly be mistaken.
It is sometimes confounded with intermittent or remittent fever, but appropriate treatment soon relieves the latter, while the former is not benefited by remdies that overcome malarial fever. When in doubt, the aspirating needle should be used, and, if pus be found, the true nature is revealed.
Prognosis.—In pyemic or multiple abscess the prognosis is almost invariably unfavorable, and the single abscess is also grave, the mortality ranging from fifty to sixty per cent. Where the abscess is superficial, or when early recognized and promptly evacuated, the best results are obtained.
Treatment.—This is largely symptomatic, till the abscess points, when the treatment becomes surgical. The patient's strength should be maintained as far as possible, the stomach kept in good condition, the bowels not allowed to become constipated, the proper antiseptics administered, and the pain mitigated.
Echinacea, polymnia, Podophyllin, chionanthus, potassium chlorate, and muriatic acid will be the most prominent remedies indicated. The salines may be given if the bowels are constipated. The subnitrate or subgallate of bismuth when diarrhea prevails.
The diet should be nourishing but easily digested.
The Eclectic Practice of Medicine, 1907, was written by Rolla L. Thomas, M. S., M. D.