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Chapter: Medical Surgical Nursing: Assessment and Management of Patients With Hepatic Disorders

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Liver Abscesses

Two categories of liver abscess have been identified: amebic and pyogenic.

Liver Abscesses

Two categories of liver abscess have been identified: amebic and pyogenic. Amebic liver abscesses are most commonly caused by Entamoeba histolytica. Most amebic liver abscesses occur in thedeveloping countries of the tropics and subtropics because of poor sanitation and hygiene. Pyogenic liver abscesses are much less common but are more common in developed countries than the amebic type.

Pathophysiology

Whenever an infection develops anywhere along the biliary or GI tract, infecting organisms may reach the liver through the biliary system, portal venous system, or hepatic arterial or lymphatic system.

Most bacteria are destroyed promptly, but occasionally some gain a foothold. The bacterial toxins destroy the neighbor-ing liver cells, and the resulting necrotic tissue serves as a protec-tive wall for the organisms.

 

Meanwhile, leukocytes migrate into the infected area. The re-sult is an abscess cavity full of a liquid containing living and dead leukocytes, liquefied liver cells, and bacteria. Pyogenic abscesses of this type may be either single or multiple and small. Examples of causes of pyogenic liver abscess include cholangitis and ab-dominal trauma.

 

Clinical Manifestations

 

The clinical picture is one of sepsis with few or no localizing signs. Fever with chills and diaphoresis, malaise, anorexia, nau-sea, vomiting, and weight loss may occur. The patient may complain of dull abdominal pain and tenderness in the right upper quadrant of the abdomen. Hepatomegaly, jaundice, ane-mia, and pleural effusion may develop. Sepsis and shock may be severe and life-threatening. In the past, the mortality rate was 100% because of the vague clinical symptoms, inadequate di-agnostic tools, and inadequate surgical drainage of the abscess. With the aid of ultrasound, CT and MRI scans, and liver scans, early diagnosis and surgical drainage of the abscess have greatly reduced the mortality rate.

 

Assessment and Diagnostic Findings

 

Blood cultures are obtained but may not identify the organism. Aspiration of the liver abscess, guided by ultrasound, CT, or MRI, may be performed to assist in diagnosis and to obtain cultures of the organism. Percutaneous drainage of pyogenic abscesses is carried out to evacuate the abscess material and promote healing. A catheter may be left in place for continuous drainage; the patient must be instructed about its management.

Medical Management

Treatment includes IV antibiotic therapy; the specific antibiotic used in treatment depends on the organism identified. Continuous supportive care is indicated because of the serious condition of the patient. Open surgical drainage may be required if antibiotic ther-apy and percutaneous drainage are ineffective.

 

Nursing Management

 

Although the manifestations of liver abscess vary with the type of abscess, most patients appear acutely ill. Others appear to be chronically ill and debilitated. The nursing management depends on the patient’s physical status and the medical management that is indicated. For patients who undergo evacuation and drainage of the abscess, monitoring of the drainage and skin care are impera-tive. Strategies must be implemented to contain the drainage and to protect the patient from other sources of infection. Vital signs are monitored to detect changes in the patient’s physical status. Deterioration in vital signs or the onset of new symptoms such as increasing pain, which may indicate rupture or extension of the abscess, is reported promptly. The nurse administers IV antibiotic therapy as prescribed. The white blood cell count and other labo-ratory test results are monitored closely for changes consistent with worsening infection. The nurse prepares the patient for discharge by providing instruction about symptom management, signs and symptoms that should be reported to the physician, management of drainage, and the importance of taking antibiotics as prescribed.

 

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