Welcome to today's podcast episode on hepatic infections. I'm your host. I'm Tom Basch, a research fellow at Cincinnati Children's Hospital Medical Center. Along with Stay Current, we are sharing knowledge to improve child health around the globe. In this episode, we will be exploring the types, presentation, diagnosis and management of various hepatic infections with Doctor Alex Boondock. It's not the longest topic, um, and I'm trying to hit the high points. He's a pediatric surgeon at Cincinnati Children's Hospital, and throughout this podcast we will use a few imaging that will help us understand the cases. If you want to follow along and check them out, they're below in the description on the Stay Current app. We're starting out with a case. A seven year old girl goes to her pediatrician's office with a one-week history of a diminished appetite and right upper quadrant fullness, but the kid isn't jaundiced, there's no lymphadenopathy, there's nothing really else to reveal. Besides subjective fever, she's been well. What do you guys want to do next? Let's make a pit stop first and go to do some labs. We sent some blood samples, and labs are relatively unremarkable. It's important to understand. And the way things can look inside the liver, and that really helps you understand what your possibilities are here. In this patient's ultrasound, there's a hypoaquaic circular structure in a solid organ in the right upper quadrant. The lining is simple or looks smooth and simple, and it looks like it shadows posteriorly, all right? So based on those conclusions, you would say that this is probably a simple fluid-filled structure. And in the axial image, we see a simple cystic hepatic structure in the right lobe that is water weight, has no solid component, it doesn't appear complex, and the wall is smooth. This is the reason we want to make note of all these things mentally, right, because not only does it inform your differential, but it also informs the prognosis of how you're going to follow the patient or if you're going to be forced to do something about it. We know that this child has no symptoms as a result of the cyst. So what should be on the differential here? Maybe it could be a vascular malformation. What would you see on a vascular malformation? Usually mixed density. It has flow in it. It could be a myeloma. It could be a choliocal cyst, a weird presentation of Karoli. What else? What about inherited diseases? That would be autosomal dominant polycystic kidney disease with hepatic manifestations. There's an entity also known as autosomal dominant polycystic liver disease, but From a clinical perspective, if it doesn't manifest as some kind of liver insufficiency, it's not, you would just follow it. You wouldn't really have much else to do. Are there any primary cystic malignancies of the liver? And then there's a very rare entity that I've seen once, also known as a ciliated foregu cyst. That's essentially a variant on a bronchogenic cyst. And so similarly with a bronchogenic cyst, you have to follow those long-term and consider intervening on them for risk of malignancy down the road. So here's information about the simple cyst, predominantly in women, especially symptomatic cysts. One study I looked at said that in symptomatic, simple hepatic cysts, it's a 1 to 9 predominant. Welcome to today's podcast episode on hepatic infections. I'm your host. I'm Tom Basch, a research fellow at Cincinnati Children's Hospital Medical Center. Along with Stay Current, we are sharing knowledge to improve child health around the globe. In this episode, we will be exploring the types, presentation, diagnosis and management of various hepatic infections with Doctor Alex Boondock. It's not the longest topic, um, and I'm trying to hit the high points. He's a pediatric surgeon at Cincinnati Children's Hospital, and throughout this podcast we will use a few imaging that will help us understand the cases. If you want to follow along and check them out, they're below in the description on the Stay Current app. We're starting out with a case. A seven year old girl goes to her pediatrician's office with a one-week history of a diminished appetite and right upper quadrant fullness, but the kid isn't jaundiced, there's no lymphadenopathy, there's nothing really else to reveal. Besides subjective fever, she's been well. What do you guys want to do next? Let's make a pit stop first and go to do some labs. We sent some blood samples, and labs are relatively unremarkable. It's important to understand. And the way things can look inside the liver, and that really helps you understand what your possibilities are here. In this patient's ultrasound, there's a hypoaquaic circular structure in a solid organ in the right upper quadrant. The lining is simple or looks smooth and simple, and it looks like it shadows posteriorly, all right? So based on those conclusions, you would say that this is probably a simple fluid-filled structure. And in the axial image, we see a simple cystic hepatic structure in the right lobe that is water weight, has no solid component, it doesn't appear complex, and the wall is smooth. This is the reason we want to make note of all these things mentally, right, because not only does it inform your differential, but it also informs the prognosis of how you're going to follow the patient or if you're going to be forced to do something about it. We know that this child has no symptoms as a result of the cyst. So what should be on the differential here? Maybe it could be a vascular malformation. What would you see on a vascular malformation? Usually mixed density. It has flow in it. It could be a myeloma. It could be a choliocal cyst, a weird presentation of Karoli. What else? What about inherited diseases? That would be autosomal dominant polycystic kidney disease with hepatic manifestations. There's an entity also known as autosomal dominant polycystic liver disease, but From a clinical perspective, if it doesn't manifest as some kind of liver insufficiency, it's not, you would just follow it, you wouldn't really have much else to do. Are there any primary cystic malignancies of the liver? And then there's a very rare entity that I've seen once, also known as a ciliated foregu cyst. That's essentially a variant on a bronchogenic cyst. And so similarly with a bronchogenic cyst, you have to follow those long-term and consider intervening on them for risk of malignancy down the road. So here's information about the simple cyst, predominantly in women, especially symptomatic cysts. One study I looked at said that in symptomatic, simple hepatic cysts, it's a 1 to 9 predominance, male to female. I'm not sure why. They're more often noted in the right lobe. It is probably just a mass issue because right lobe is larger than the left. Symptomatic ones are definitely larger and complications can occur, but they are very rare. So what should we do? I would probably tend to. See the kid back more likely every year just to make sure that there aren't any symptoms or nothing else is weird is going on. So when would you be concerned? And there are hints that might push us more towards worrying about malignancy, like weight loss, night sweats, coagulopathy, or looking more sick. Right, if you ended up having abnormal LFTs or other lab values, and if symptoms changed and you re-imaged it and it grew, what are some things that you might have seen on imaging that might be concerning to you? What features would make you worried? Calcification. septations, and maybe a thicker rim would make some surgeons worry. So here we left you an algorithm in the description to manage the simple hepatic cystic disease. This algorithm is for adult patients, so this may not be necessarily completely apples and oranges. But this is an algorithm to managing simple hepatic cystic disease. They use the size cutoff for concern as 4 centimeters. So, if it's asymptomatic and it's less than 4 centimeters, by this algorithm, You're not even gonna follow up with imaging. If you have right upper quadrant symptoms or their issues, or patients with a greater than 4 centimeter size cyst, you need to go in detail. Then really digging down and trying to make sure we understand, is the symptoms of abdominal fullness or pain, early satiety, those kinds of things, are they truly related to this thing? And if you say, Yes, then you're thinking about an intervention. And so what are our two options for intervention? Retrospective data that is out there would suggest that aspiration and sclerosis, believe it or not, has a pretty low recurrence rate somewhere quoted in the low single digit range, whereas surgical cysts on roofing and then packing it or burning it. With the argon or packing it with omentum in a whole range of series, anywhere from a 0 to 14% recurrence rate, with complications to include post-op bleeding, development of an abscess, or maybe one of the more complex ones would be a bile leak. And this sclerosis is 70% ethanol. The recurrence rate is relatively low, according to their study. There's some level of persistent symptomatology also in the low single digits. And then you run the risk of ethanol toxicity. This is just perhaps a framework to think about how you would approach a cyst that is truly symptomatic. And here's our next lesion. This one has at least 4 or 5 septations. It is still relatively smooth, but maybe a little more regular than the last one. Borders are still predominantly fluid-filled, and again, if you want to follow along, check out these imagings, they're below in the description on the Staycorn app. So this is representative of a mucinous. Cystic neoplasm, very similar in histologic appearance to the mucinous cystic neoplasm of the ovary. It often occurs more in adults and females, and it's often symptomatic, that it's a true neoplasm rather than a simple cyst. It is important to differentiate whether or not it is a non-invasive version or associated with an invasive carcinoma. And sometimes it is very difficult to tell on axial imaging or ultrasound. And oftentimes it's not a great idea to biopsy this thing because you can seed the peritoneum, you can seed the tract, especially if it's an invasive carcinoma. And certainly the treatment for that is resection. Fortunately, this is exceedingly rare. And next, we have echinococcal cysts as another entity on the differential diagnosis for complex hepatic cystic disease. So this is the larval stage of a dog tapeworm. And the thought process here is that the ova of the parasite travels via the intestine through an enteral route through the portal vein. Most are single cysts. So what kind of things might you see that are esoteric on a physical exam? There might be some pleuritic pain because of the transit that can occur between the abdominal cavity and the thoracic cavity, which is absolutely frightening to me. When you listen to the liver, you can. Hear a rub. Here's a question for Dr. Bombach that everyone's thinking about. Why do you think all these diseases, including hepatic abscesses, are right lobe predominant? Is it mass related like we said before? The mass of the right lobe, right, is usually about 60% of the liver and the blood flow to the right lobe accordingly is bigger. So I think infectious agents preferentially head to the right liver. So that's typically where you're going to encounter these things. Now, treatment depends on the appearance of the cyst. Are their daughters? Cysts within the dominant cyst. Why is that? What is the most feared complication of anything you would do to intervene on this cyst? Rupture and causing anaphylaxis. If you spill the cysts, the cystic material can create an anaphylaxis, right? So how do we treat it? Regardless is both pre and post-operatively, you're going to treat the patient with an anti-parasitic albendazole. Then we talk about what are our options from a surgical and a percutaneous treatment. What do you usually do for surgery? Or how do you decide? I saw in some of the papers and some of the review articles was the WHO actually has a classification system for Haida disease and it grades it. You're more likely to spill or have complications, the more active daughter cysts you have in the lesion. So if the daughter cysts are more predominant, they don't really recommend the pair. PAIR or pair technique stands for puncture, aspiration, injection and re-aspiration. And it's used to treat cystic disease of liver. They favor open surgery, packing the abdomen, double suctions. Essentially it boils down to, are there active daughter cysts, in which case you have to be much more careful with your therapy. The next thing we'll talk very briefly about is ciliated hepatic foregot cyst. Only because I've actually seen one of these kids and following one of these kids. In the disease process, it's histologically analogous to a bronchogenic cyst, and it's a ciliated pseudostratified columnar epithelium, followed by smooth muscle, followed by connective tissue, followed by a fibrous capsule. It can transform into a frank malignant. into a squamous cell carcinoma. So we have a 15 year old husky young man who presented to the emergency department with moderate abdominal pain, mild jaundice, nausea, and anorexia. He had been previously seen by one of the partners and is awaiting for cholecystectomy. So from on physical exam, he's diaphoretic, high grade fevers, he's tachycardic, has mild pain. His bilirubin is elevated. His. Examinases are not, and his glucose and his white blood cell count are elevated. In imaging, there's an enhancing rumor around it and it's septd. What is your differential diagnosis? Could it be a your tumor? Could it be some strange manifestation of bacterial hepatitis? So, the demographics here would be for hepatic abscesses, at least in the summary from the score portal, 25% of hepatic abscesses occur in the first year of life. And 50% in the 1st 5 years of age, which is interesting. I wouldn't tell you that we see that many hepatic abscesses, probably due to aggressive surgical and antibiotic treatment of intraabdominal disease. How about risk factors? Instrumentation of the biliary tree, diabetes, strangely enough, proton pump inhibitor use has been cited or has been found in retrospectively to be a risk factor for. Hepatic abscess and chronic granulomatous disease and then certainly in patients who are immunosuppressed. And what are the types of organisms we should be suspicious for that type of an abscess? Believe it or not, E. coli and klepsyla would be the enteric gram-negative rods, and then you got a thing gram-pos coccy, which is usually Streph pyogenes and staph aureos. In the modern period, one author suggested staph. to be the most common, interestingly enough. And then there is a special strep species, strep malaria. Perhaps if you cultured that out of the abscess, you would be obligated to look for disseminated, specifically ocular and neuraxial infection as well. Then what are we going to do? How are we going to treat this one? Drain it, antibiotics. When would you leave a catheter? Or would you? Leave a catheter. Again, another treatment algorithm I saw in another paper said that if it's greater than 5 centimeters, they might have more propensity to leave a catheter rather than just aspirate and blast them with antibiotics. Again, that same author suggested 4 to 6 weeks of IV antibiotics and followed by 4 to 6 weeks of oral antibiotics. So be ready to readmit the kid for C. diff 3 months after tay.
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