Liver Abscess — MCQs
A 25 yr. old girl admitted as a case of septic abortion with tricuspid valve endocarditis. Vegetation from the valve likely to affect will be
Which of the following is NOT an indication for a liver biopsy?
Which of the following statements is true regarding amoebic liver abscess?
A patient presented with right hypochondriac pain. He had an episode of diarrhea 1 week prior. CT scan of the abdomen reveals a liver abscess of around 25 cc. What is the next step in management?
A 6-year-old child is brought with high fever with rigors for 5 days with pain in right hypochondrium. On examination, the patient is anicteric and tenderness is noted in right upper quadrant. What is the best investigation for this case?
The most common pathogenic organism causing pyogenic liver abscess in children is:
Obstruction of the hepatic vein by thrombosis or a membranous web is known as
All are used in the treatment of amoebic liver abscess except:
Pringle's manoeuvre is done to stop bleeding at:
Treatment of a symptomatic simple cyst of the liver is:
Liver Abscess Indian Medical PG Practice Questions and MCQs
Question 1: A 25 yr. old girl admitted as a case of septic abortion with tricuspid valve endocarditis. Vegetation from the valve likely to affect will be
- A. Lung (Correct Answer)
- B. Brain
- C. Spleen
- D. Liver
Explanation: ***Lung*** - Injected drug users often develop **tricuspid valve endocarditis**, which can lead to septic emboli lodging in the **pulmonary vasculature and causing lung damage** [2]. - Right-sided endocarditis, seen here with tricuspid valve involvement, typically embolizes to the **lungs**, causing symptoms such as **pneumonia, lung abscesses, or pulmonary infarcts** [3]. *Brain* - Emboli to the brain usually originate from the **left side of the heart**, such as the mitral or aortic valves, or from peripheral venous clots that paradoxically cross through a septal defect. - While possible in rare cases of paradoxical emboli, this is not the typical or most likely site for embolization from isolated tricuspid valve endocarditis. *Spleen* - **Splenic emboli** are more commonly associated with **left-sided endocarditis**, where vegetations can dislodge and travel systemically [1]. - While the spleen is part of the systemic circulation, it is not the primary target foremboli originating from the right heart. *Liver* - The liver receives blood from both the hepatic artery (systemic circulation) and the portal vein (gut circulation), but it is not a common site for embolization from **right-sided valvular endocarditis**. - Emboli from the right heart would first pass through the lungs before reaching the systemic circulation that supplies the liver.
Question 2: Which of the following is NOT an indication for a liver biopsy?
- A. Amoebic hepatitis (Correct Answer)
- B. Chronic hepatitis B and C
- C. Autoimmune hepatitis
- D. Wilson's disease
Explanation: ***Amoebic hepatitis*** - Liver biopsy is **not routinely indicated** for amoebic hepatitis as diagnosis is typically made through clinical history and serological tests. - The condition is usually managed with **medications** rather than requiring invasive procedures like a biopsy. *Wilson's disease* - Liver biopsy is important for assessing **copper accumulation** in Wilson's disease, establishing a diagnosis. - It may also provide information regarding the extent of **hepatocellular damage**. *Chronic hepatitis B and C* - In chronic hepatitis B and C, liver biopsy is crucial to evaluate the **degree of fibrosis** and hepatic inflammation. - It assists in determining the need for **antiviral therapy** and prognostication. *Autoimmune hepatitis* - Liver biopsy helps confirm the diagnosis of autoimmune hepatitis and assess the **severity of liver damage**. [1] - It also aids in monitoring the response to **immunosuppressive therapy**. [1] **Note on technique:** Percutaneous liver biopsy requires specific conditions for safety, such as cooperative patients and adequate coagulation profiles. [2]
Question 3: Which of the following statements is true regarding amoebic liver abscess?
- A. May rupture into the pleural cavity.
- B. Mostly involving the right lobe of the liver. (Correct Answer)
- C. For asymptomatic luminal carriers, metronidazole is the drug of choice.
- D. Multiple abscesses is less common than a single abscess.
Explanation: ***Mostly involving the right lobe of the liver*** - The **right lobe** of the liver is the most common site for an amoebic liver abscess due to its larger size and preferential blood flow from the portal venous system, which drains the intestines where *Entamoeba histolytica* resides. - The **superior mesenteric vein**, draining the cecum and ascending colon (common sites for amebiasis), primarily feeds the right hepatic lobe. *May rupture into the pleural cavity* - While rupture can occur, the **peritoneal cavity** is a more common site of rupture for amoebic liver abscesses. - Rupture into the pleural cavity or lung is less frequent but can lead to **empyema** or **bronchopleural fistula** [1]. *For asymptomatic luminal carriers, metronidazole is the drug of choice* - **Metronidazole** is effective against invasive amoebiasis (like liver abscess or dysentery) but is not the drug of choice for asymptomatic luminal carriers. - For **asymptomatic luminal carriers**, **luminal amebicides** such as **paromomycin** or **diloxanide furoate** are used to eradicate cysts from the intestine [1]. *Multiple abscesses is less common than a single abscess* - **A single amoebic liver abscess** is more common than multiple abscesses [1]. - Multiple abscesses are typically seen in disseminated disease or immunocompromised individuals, though even then a solitary lesion is more frequent.
Question 4: A patient presented with right hypochondriac pain. He had an episode of diarrhea 1 week prior. CT scan of the abdomen reveals a liver abscess of around 25 cc. What is the next step in management?
- A. PAIR
- B. Surgery
- C. Medical therapy (Correct Answer)
- D. Percutaneous drainage
Explanation: ***Medical therapy*** - This is the appropriate next step for a **small liver abscess** of 25 cc (approximately 2.9 cm diameter). - Current evidence-based guidelines recommend **medical therapy alone** for abscesses **<5 cm in diameter**. - The preceding diarrheal episode suggests **amebic liver abscess**, which responds excellently to **metronidazole** with drainage reserved for non-responders. - Success rate with medical therapy alone for small abscesses is **>85%**. - Percutaneous drainage is reserved for: abscesses >5 cm, failed medical therapy (no improvement in 4-7 days), left lobe location, or imminent rupture. *Percutaneous drainage* - This would be indicated for **larger abscesses (>5 cm)**, left lobe abscesses, or if medical therapy fails after 4-7 days. - For a **small 25 cc abscess**, immediate drainage is unnecessary and carries procedural risks without added benefit. - Drainage should be considered if fever persists beyond 72 hours of appropriate antibiotics or clinical deterioration occurs. *PAIR* - **PAIR (Puncture, Aspiration, Injection, Re-aspiration)** is specifically for **hydatid cysts**, not pyogenic or amebic liver abscesses. - Injecting scolicidal agents would be inappropriate and potentially harmful in non-hydatid pathology. *Surgery* - Surgical drainage is reserved for **complicated cases**: ruptured abscess, multiple/loculated collections failing percutaneous drainage, or thick-walled abscesses. - A small, uncomplicated 25 cc abscess does not warrant surgical intervention as first-line management.
Question 5: A 6-year-old child is brought with high fever with rigors for 5 days with pain in right hypochondrium. On examination, the patient is anicteric and tenderness is noted in right upper quadrant. What is the best investigation for this case?
- A. SGOT/LFT
- B. CECT
- C. Serology
- D. USG (Correct Answer)
Explanation: ***USG*** - A **ultrasound** is the preferred initial investigation, especially in children, for evaluating abdominal pain in the **right hypochondrium** with fever. - It can effectively identify common causes like **cholecystitis**, **hepatitis**, or **liver abscess**, which fit the clinical presentation. *SGOT/LFT* - **Liver function tests (LFTs)** like SGOT/AST and SGPT/ALT provide information about liver inflammation or damage but do not help localize the pathology. - They are useful for assessing liver function but are not the primary diagnostic tool to identify the cause of the pain or fever. *CECT* - **Contrast-enhanced computed tomography (CECT)** is a more advanced imaging technique, often used after initial screening or when ultrasound findings are inconclusive. - It involves radiation exposure and contrast risks, making it less suitable as a first-line investigation for a child with these symptoms. *Serology* - **Serological tests** detect antibodies or antigens related to specific infections (e.g., viral hepatitis) but do not provide immediate anatomical information. - While they can confirm an infectious cause, they cannot identify the source of the pain or rule out other non-infectious pathologies immediately.
Question 6: The most common pathogenic organism causing pyogenic liver abscess in children is:
- A. Klebsiella
- B. Entamoeba Histolytica
- C. H Influenzae
- D. Staphylococcus aureus (Correct Answer)
Explanation: ***Staphylococcus aureus*** - **Staphylococcus aureus** is the **most common cause of pyogenic liver abscess in children**, particularly in neonates and young children. - It typically reaches the liver via hematogenous spread from a primary focus (umbilical infection, skin infections, or bacteremia). - S. aureus causes a more acute presentation with high fever, toxicity, and potential for multiple abscesses. - Treatment requires drainage and anti-staphylococcal antibiotics. *Klebsiella* - **Klebsiella pneumoniae** is the most common cause of pyogenic liver abscess in **adults**, especially in East Asian populations. - While it can occur in children, it is significantly less common than S. aureus in the pediatric age group. - It is associated with diabetes mellitus and can cause metastatic complications like endophthalmitis. *Entamoeba Histolytica* - This protozoan causes **amoebic liver abscess**, which is non-pyogenic and has a different pathophysiology. - Common in endemic tropical regions and presents with a more subacute course. - Diagnosed by serology and responds to metronidazole, unlike bacterial pyogenic abscesses. *H Influenzae* - **Haemophilus influenzae** can cause invasive infections in children, particularly meningitis and epiglottitis. - It is a rare cause of pyogenic liver abscess in children, especially since widespread Hib vaccination. - When it occurs, it's usually in the context of bacteremia in unimmunized children.
Question 7: Obstruction of the hepatic vein by thrombosis or a membranous web is known as
- A. Plummer Vinson Syndrome
- B. Budd-Chiari syndrome (Correct Answer)
- C. Caroli's disease
- D. Schatzki's ring (esophageal narrowing)
Explanation: ***Budd-Chiari syndrome*** - **Budd-Chiari syndrome** is specifically defined as the obstruction of outflow from the liver due to occlusion of the **hepatic veins** or the suprahepatic inferior vena cava [1]. - This obstruction can be caused by **thrombosis** or a **membranous web**, leading to hepatomegaly, ascites, and abdominal pain [1]. *Schatzki's ring (esophageal narrowing)* - A **Schatzki's ring** is a benign circumferential stenosis of the distal esophagus, typically at the **squamocolumnar junction**. - It primarily causes **dysphagia** (difficulty swallowing) for solids and has no relation to hepatic vein obstruction. *Plummer Vinson Syndrome* - **Plummer-Vinson syndrome** is a rare condition characterized by the triad of **iron deficiency anemia**, **dysphagia** (due to esophageal webs), and **glossitis**. - It involves the **upper gastrointestinal tract** and is unrelated to liver or hepatic venous outflow obstruction. *Caroli's disease* - **Caroli's disease** is a rare congenital disorder characterized by multifocal, segmental dilatation of the **intrahepatic bile ducts**. - It is associated with recurrent **cholangitis** and an increased risk of cholangiocarcinoma, but does not involve hepatic vein obstruction.
Question 8: All are used in the treatment of amoebic liver abscess except:
- A. Diloxanide furoate (Correct Answer)
- B. Metronidazole
- C. Emetine
- D. Chloroquine
Explanation: ***Diloxanide furoate*** - This drug is primarily a **luminal amebicide**, meaning it acts in the intestines to eliminate cysts and trophozoites and is used to treat **asymptomatic cyst carriers**. - It is not effective against **extraintestinal forms** of amebiasis, such as an **amebic liver abscess**, where trophozoites are found in tissues. *Metronidazole* - **Metronidazole** is the drug of choice for treating **amebic liver abscess** and other **extraintestinal amebiasis** due to its excellent tissue penetration and amebicidal activity. - It effectively kills **trophozoites** in the liver and other tissues, leading to resolution of the abscess. *Emetine* - **Emetine** (or its derivative, dehydroemetine) is a potent **tissue amebicide** and can be used in the treatment of **amebic liver abscess**, especially when metronidazole is contraindicated or ineffective. - However, its use is limited by significant **cardiotoxicity**, requiring careful monitoring. *Chloroquine* - **Chloroquine** possesses some **amebicidal activity**, particularly against trophozoites in the liver, making it useful as an adjunct or alternative in the treatment of **amebic liver abscess**. - It is often used in combination with other amebicides or in cases where metronidazole alone is insufficient.
Question 9: Pringle's manoeuvre is done to stop bleeding at:
- A. Hepatoduodenal ligament (Correct Answer)
- B. Splenic artery
- C. Renal artery
- D. Left gastric artery
Explanation: ***Hepatoduodenal ligament*** - **Pringle's manoeuvre** involves clamping the **hepatoduodenal ligament** to temporarily occlude the hepatic artery and portal vein, which are the main blood supply to the liver. - This maneuver is used during **liver surgery** to control or prevent bleeding from the liver parenchyma. *Splenic artery* - The **splenic artery** supplies the spleen and is not directly occluded by Pringle's manoeuvre. - Bleeding from the splenic artery would require direct clamping or **ligation** of that vessel, not compression of the hepatoduodenal ligament. *Renal artery* - The **renal artery** supplies the kidney and is located in the retroperitoneum, far from the liver and the hepatoduodenal ligament. - Pringle's manoeuvre has no effect on blood flow to the kidneys. *Left gastric artery* - The **left gastric artery** supplies the stomach and is a branch of the celiac trunk, which is proximal to the points of compression in Pringle's manoeuvre. - While it is part of the systemic circulation, Pringle's manoeuvre is specific to the blood supply entering the liver via the hepatoduodenal ligament, not individual gastric vessels.
Question 10: Treatment of a symptomatic simple cyst of the liver is:
- A. Percutaneous drainage
- B. Deroofing (Correct Answer)
- C. Aspiration
- D. Cystoenterostomy
Explanation: ***Deroofing*** - **Deroofing** (or fenestration) is the standard surgical treatment for symptomatic simple liver cysts. - This procedure involves **excising a portion of the cyst wall**, allowing permanent drainage into the peritoneal cavity and preventing recurrence. *Percutaneous drainage* - While sometimes used for initial diagnosis or symptom relief, **percutaneous drainage alone** of a simple cyst often leads to recurrence because the cyst wall remains intact and continues to produce fluid. - It is typically reserved for **patients who are not surgical candidates** or as a temporary measure. *Cystoenterostomy* - **Cystoenterostomy** involves creating a communication between the cyst and a loop of bowel (e.g., jejunum). - This procedure is generally reserved for **complex or large cysts** that are unresectable or in specific situations like pancreatic pseudocysts, and carries higher risks than deroofing for simple cysts. *Aspiration* - **Aspiration** is a temporary measure, similar to percutaneous drainage without sclerosing agents. - It almost always results in **recurrence** as the secretory lining of the cyst remains intact.
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