细菌性肝脓肿

Bacterial liver abscess refers to the invasion of suppurative bacteria into the liver, causing local liver tissue inflammation, necrosis, liquefaction, and accumulation of pus to form an abscess. The abscess is often multiple, and solitary abscesses are not uncommon; the right liver is more common than the left liver; bilateral involvement is also common; the size of the abscess is not uniform; some may become chronic liver abscesses.
Bacterial liver abscess is more common in rural areas, related to unhygienic living habits. Common pathogenic bacteria include Escherichia coli, Shigella, anaerobic bacteria, Staphylococcus aureus, and Streptococcus; it is generally a mixed infection of various bacteria. The ways bacteria enter the liver are:
1. Biliary tract system: This is the main route, often caused by calculi or biliary roundworms, leading to suppurative cholangitis. The suppurative bile flows upwards along the bile duct and causes liver abscess.
2. Hematogenous infection: Infection in any part of the body causes bacteria to enter the liver with the blood circulation.
3. Lymphatic system: Infection of adjacent organs, bacteria return to the liver through the lymphatic system. Of course, whether bacteria entering the liver can cause liver abscess not only depends on the number and virulence of the bacteria, but also on the body's resistance and local liver conditions. With the improvement of diagnostic and therapeutic levels, the current treatment effect of the disease is very satisfactory.

　　The occurrence of complications in bacterial liver abscess often aggravates the condition and confuses clinical signs, leading to misdiagnosis.

　　Common complications include abscess rupture and penetration into adjacent organs. Penetration into the pleural cavity can cause empyema and pleural bronchial fistula, or penetration into the peritoneal cavity, pericardial cavity; sometimes it can also penetrate into the stomach, duodenum, colon, kidney, pancreas; a few cases can penetrate into the inferior vena cava, hepatic vein, thoracic duct, or abdominal wall, etc., and may also cause embolism, thrombosis, and abscess formation in other parts. Liver hemorrhage caused by the rupture of intraluminal blood vessels and the excretion of bile is rare.

1. The onset is acute, often with chills, high fever, nausea, vomiting, anorexia, fatigue, and in severe cases, jaundice may occur.
2. Pain in the liver area or accompanied by right shoulder radiation pain.
3. The right lower quadrant is full, the intercostal skin is呈凹陷性水肿，the right upper abdominal muscles are tense, the liver is enlarged, and there is tenderness and pain in the liver area when percussion is performed.

　　Bacterial liver abscess is a secondary disease. If the primary focus is treated early and attention is paid to treatment, the disease can be prevented. Even in the early stage of liver infection, if a large amount of antibiotics is given in time and systemic supportive therapy is strengthened, the formation of liver abscess can be prevented.

　　细菌性肝脓肿患者的预后与其年龄、体质、原发病、脓肿数目、治疗开始的早晚、治疗的彻底性和有无并发症等密切相关。年幼及老年患者的预后较青壮年者差，病死率也高。多发性肝脓肿的病死率明显高于单发性肝脓肿。140例多发性肝脓肿中死亡106例(75.7％)，而117例单发性肝脓肿中死亡仅28例(23.9％)。病菌的种类与毒性对肝脓肿的预后也有密切关系。由大肠埃希杆菌、葡萄球菌、链球菌、铜绿假单胞菌等细菌引起的肝脓肿病死率较高，对多种药物不敏感的菌种感染者预后也差。全身情况较差和营养不良及有明显肝功能损害者，如低蛋白质血症和高胆红素血症时，病死率更高。有并发症的肝脓肿，如膈下脓肿、脓肿破入腹腔导致弥漫性腹膜炎、胆道出血，或合并脓胸或肺脓肿时，病死率增高。相反，单发性脓肿症状轻微无并发症者，预后良好。因此，对细菌性肝脓肿治疗的要求是早期诊断，早期治疗，及时使用有效的抗生素，有效的排脓，彻底处理原发病灶以及加强全身支持治疗等，可大大降低病死率。

一、实验室检查
1.血白细胞总数及中性粒细胞计数增高，50％有贫血，90％以上有血沉加速。肝功能有一定损害，大部分患者碱性磷酸酶明显升高，转氨酶仅中度升高，约半数胆红素升高，低蛋白血症明显者预后欠佳。
2.肝穿刺 可在触痛点最明显的肋间穿刺，针进入皮肤及肌层后，让患者吸一大口气，再尽量呼出并屏息片刻，将针大部刺入肝内，立即抽出内芯，抽吸肝内容，抽取的脓液做细菌培养(阳性率高)。需要时做血培养，但阳性率低。
3.肝脓液培养 细菌检出率为20％～50％，致病菌与感染途径有关，从胆道和门静脉侵入的多为大肠埃希菌或其他革兰阴性杆菌；从肝动脉侵入的多为球菌，特别是葡萄球菌。其他尚有肠链球菌与溶血性链球菌、铜绿假单胞菌、变形杆菌、粪产碱杆菌、产气杆菌等，还有部分为混合感染。有报道细菌性肝脓肿中36％～45％为厌氧菌感染，约25％患者为需氧、厌氧菌混合感染，以往的无菌性脓肿多数为厌氧菌引起，若常规采用厌氧菌培养技术可提高培养阳性率。厌氧菌中常见者为脆弱类杆菌、巨核梭形杆菌、微需氧链球菌等。
4.血培养 同时做血培养可有致病菌生长，部分与脓液培养的致病菌相同，血培养阴性可能是细菌不经血行感染或已使用抗生素影响培养结果。
II. Other auxiliary examinations
1. X-ray examination X-ray examination can detect the enlargement of liver shadows. If the abscess is located in the right lobe of the liver, it can be observed that the diaphragm is elevated, movement is restricted, the costodiaphragmatic angle is blurred, or there is a small amount of pleural effusion, lower lobe pneumonia, or atelectasis in the right lower lobe. Sometimes, a gas-liquid level may appear in the abscess location, which often suggests that the abscess is caused by a gaseous bacterial infection. The abscess in the left lobe of the liver can cause compression of the gastric cardia and the lesser curvature of the stomach. When there is diaphragmatic movement restriction, disappearance of the costodiaphragmatic angle, and a small amount of pleural effusion, it is also necessary to consider whether there is an abscess below the diaphragm.
1. Ultrasound examination It can be found that there is a typical liquid echo dark area or liquid level in the abscess location. This examination, in addition to assisting in clinical diagnosis, can also help understand the location, size, and depth from the body surface of the abscess cavity, so as to determine the optimal puncture point and needle insertion direction and depth, or provide access options for surgical drainage. However, ultrasound often finds it difficult to detect multiple liver abscesses smaller than 1 cm, and attention should be paid to this in clinical diagnosis. From the perspective of ultrasonography, it needs to be distinguished from other cystic lesions. Generally, the wall of liver cysts is neat and clear, and the density inside the cyst is uniform. However, the wall of liver abscesses is irregular and the boundaries are unclear, and there are often multiple echo areas inside the cavity.
2. CT examination CT examination can detect the size and shape of the abscess, showing the exact location of the abscess in the liver, providing clear and direct imaging data for clinical physicians to perform abscess puncture and surgical drainage. The main manifestation is the appearance of a low-density area in the liver, with CT values slightly higher than those of liver cysts, with the boundaries not very clear. Sometimes, mass shadows can appear within the low-density area. After the contrast agent is injected, the peripheral enhancement is obvious, and the boundaries become clearer. The typical manifestation of enhanced scanning is the annular enhancement (target sign) of the abscess wall, which strongly suggests that the abscess has formed.
3. MRI examination Due to the presence of edema in the early stage of liver abscess, it has the characteristics of long T1 and T2 relaxation times during MRI examination. On the T1-weighted image, it appears as an indistinct low signal intensity area, while on the T2-weighted image, the signal intensity increases. After the abscess forms, the abscess is a low intensity signal area on the T1-weighted image; the abscess wall, which is inflammatory granulation connective tissue, has a lower signal intensity but slightly higher than that of the abscess; the inflammatory edema of the liver tissue surrounding the abscess wall forms a slightly lower signal intensity focus than the abscess wall ring. On the T2-weighted image, the signal intensity of the abscess and edematous tissue increases significantly, and there is a slightly lower signal intensity annular abscess wall in between.

　　Bacterial liver abscess refers to an intrahepatic suppurative infection focus formed by the invasion of pyogenic bacteria into the liver. Clinically, it is mainly manifested as chills, high fever, liver pain, liver enlargement, and local tenderness. When there is systemic bacterial infection, especially intraperitoneal infection, bacteria can invade the liver. If the patient's resistance is weak, liver abscess may occur.

　　The dietary principles for bacterial liver abscess are:

　　Low-fat, high-nutrition, high-vitamin, and easy-to-digest diet.

　　Unsuitable foods for patients with bacterial liver abscess include:

　　1. Abstain from alcohol consumption

　　Since the main component of alcohol is alcohol, it has a direct damaging effect on the liver. If alcohol is consumed in large quantities, it will increase the burden on the liver, making the condition more severe. Therefore, alcohol should not be consumed in the diet of liver abscess patients.

　　2, Avoid eating ginger

　　The main components of ginger, volatile oil, gingerol, and safrole can cause liver cells of liver abscess patients to proliferate, necrose, and interstitial tissue hyperplasia, causing inflammatory infiltration and liver function. Therefore, ginger should be avoided by liver abscess patients.

　　3, Avoid eating garlic

　　Some components in garlic have a stimulating effect on the stomach and intestines, which can inhibit the secretion of intestinal digestive juices, affect appetite and the digestion of food, and worsen the symptoms of anorexia, aversion to greasy food, and nausea in liver abscess patients.

　　4, Avoid high-protein and high-fat foods

　　The yolks of eggs, fatty meat, and fried foods, etc., should not be eaten in large quantities by patients with liver abscess. It can be seen that the diet of liver abscess is similar to that of other liver diseases, mainly paying attention to low-fat foods, eating easily digestible foods, and eating nutritious foods, etc.

　　Bacterial liver abscess is a secondary disease. In fact, if the primary disease focus is treated early and emphasized, this disease can be prevented. For the treatment of this disease, traditional Chinese medicine is better, and traditional Chinese medicine focuses on the root cause of the disease, and Chinese herbal medicine has a mild nature, with relatively small刺激性 and side effects.

　　Bacterial liver abscess refers to a suppurative infection within the liver parenchyma. Clinically, it is characterized by fever, chills, upper right abdominal pain, and tenderness on percussion. The route of infection is mostly hematogenous. The right lobe accounts for the majority, and it can be multiple or solitary. Common bacteria include Staphylococcus aureus, Escherichia coli, Pseudomonas aeruginosa, and Proteus vulgaris, etc.

　　Bacterial liver abscess belongs to the category of 'Liver abscess', 'Hypochondriac pain', 'Jaundice' in traditional Chinese medicine. Because the liver and gallbladder are interrelated, the membrane is connected, and the seven emotions are internally depressed or angry to hurt the liver, leading to the liver losing its function of releasing, the gallbladder losing its cleanliness, and the stagnation of qi causing blood stasis. Clearing heat and transforming fire, the gallbladder is weak and cannot make decisions, the fire becomes more fierce, and thus liver abscess is formed.

　　First, differential diagnosis and treatment

　　1, Shiyi Disinfection Drink

　　Composition and Usage: Coptis 6g, rhubarb 3g, Scutellaria baicalensis, Gentiana scabra, Gardenia jasminoides, Bupleurum, Acacia catgut each 8g, Houttuynia cordata, Taraxacum mongolicum, Lonicera japonica each 15g, take one dose daily, decoct with clear water, and take in 2 to 3 doses.

　　Function and Pharmacology: Clear heat and detoxify, promote blood circulation and discharge pus. Clinical research results show that this prescription has definite efficacy in the treatment of bacterial liver abscess.

　　2, Lonicera Decoction for Disinfection

　　Composition and Usage: Lonicera japonica 30g, raw gypsum, raw earth, red peony, Flos forsythiae purple, Flos eriobotryae, Taraxacum mongolicum each 15g. Peony, Bupleurum, Anemarrhena, Scutellaria baicalensis, Corydalis each 10g. Rhubarb 5g, Asarum 2g, take one dose daily, decoct with clear water, and take in 3 doses.

　　Function and Pharmacology: Clear the liver and detoxify, cool the blood, and eliminate boils. Clinical practice shows that adding blood circulation and blood stasis drugs to the basis of heavy use of heat-clearing and detoxifying drugs can promote the limitation and absorption of inflammation, so that the initial abscess can be dispersed or the severity can be reduced from serious to mild.

　　3, Qingzi脓疡散

　　Composition and Usage: Indigo 3g, purple herb, cold water stone each 9g, myrrh, tooth soap each 6g. Take one dose daily, decoct with clear water, and take 100ml to 200ml of juice in 3 doses.

　　Function and Pharmacology: Clear heat and detoxify, activate blood circulation and remove blood stasis, drain pus and reduce swelling. Clinical observations have shown that this medicine can improve blood circulation in the lesion, reduce its pathological damage, and promote inflammation absorption. It is an effective and good prescription for bacterial liver abscess.

　　Two, Review of Differential Diagnosis and Treatment

　　The key pathogenesis of this disease is heat-toxin stasis, obstruction of the liver meridian, and the formation of abscesses due to fermentation. Treatment should focus on clearing heat and detoxifying, and unblocking blood stasis to drain pus. In the convalescent period, it is important to strengthen the body and expel toxins, and to resolve abscesses and drain pus. Clinically, it is possible to combine活血化瘀 (activating blood circulation and removing blood stasis) to promote inflammation absorption on the basis of large doses of clearing heat and detoxifying, and to select formulas and medicines according to the severity of the syndrome, the balance of pathogenic and healthy qi and blood, and the degree of heat-toxin stasis.

　　Three, Commonly Used Traditional Chinese Medicines:

　　1. Longdan Xiegan Oral Liquid

　　Main Ingredients: Gentiana macrophylla, Scutellaria baicalensis, Gardenia jasminoides, Alisma orientale, Plantago asiatica, Prunus serotina, Angelica sinensis, Rehmannia glutinosa, Bupleurum chinense, Glycyrrhiza uralensis.

　　Function and Pharmacology: Clear the liver and gallbladder, promote diuresis and remove dampness-heat. Studies have shown that this product has antibacterial and anti-inflammatory effects, can significantly reduce the body's response to histamine, indirectly affect capillary dilation and permeability, increase fluid excretion, and remove 'damp-heat' inside the body, has anti-allergic effects, and can also promote the enhancement of macrophage phagocytic function, promote lymph transformation, and enhance immune function.

　　Dosage and Administration: 5ml to 10ml per time, 3 times a day, taken orally

　　2. Qinggan Lidian Oral Liquid

　　Main Ingredients:茵陈、栀子、防己、金银花、厚朴。

　　Function and Pharmacology: Clear heat, promote diuresis and detoxify, relieve distension. It can reduce pathological damage to the liver, and at the same time, Phellodendron amurense has a diuretic effect, which can promote the excretion of inflammatory exudates in the body, so it can be used for the treatment of bacterial liver abscess.

　　Dosage and Administration: 5ml to 10ml per time, 2 times a day, taken orally

　　3. Yiqing Capsules

　　Main Ingredients: Rhubarb, Scutellaria baicalensis, etc.

　　Function and Pharmacology: Clear heat and dry dampness, purge fire and detoxify, resolve blood stasis and stop bleeding. Pharmacological studies have shown that this medicine has anti-inflammatory, antipyretic, and analgesic effects, and also has antibacterial and antiviral effects. It can promote platelet aggregation, increase platelet count, and thus play a hemostatic effect. In addition, its choleretic effect is significant, and it also has an anti-hepatic injury effect.

　　Dosage and Administration: 2 capsules per time, 3 times a day, taken orally. Dosage for children should be reduced accordingly.