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Liver Abscess
JohannaLou andYoungK.Hong
55
Concept
In the 1930s, these were mainly diagnosed in adults in their
20–30s as a complication of untreated appendicitis. As antibiotics became more effective, they are more commonly
found in adults in their 50–60s related to either biliary disease or cryptogenic. Liver abscesses are divided into three
categories based on their etiology: pyogenic (bacterial),
amoebic, or fungal.
Way Question May BeAsked?
A 57-year-old male with a history of type II diabetes mellitus
and rheumatoid arthritis on chronic hydrocortisone presents
to the Emergency Department with fever, chills, malaise, and
dull right upper ank pain. He recently underwent an esophagogastroduodenoscopy (EGD) for reux. His CT scan
showed multiple liver abscesses and a small right-sided pleural effusion. What is your next step?
How toAnswer?
Full History
• Location and quality of pain
• Recent abdominal infections, remote diarrheal illness
• Recent instrumentation (upper or lower endoscopy)
• History of malignancy
• Immunosuppressive conditions (HIV, chronic steroid
use): increases the risk of fungal abscess
• Social history: intravenous drug use, travel history
J. Lou · Y. K. Hong (*)
Department of Surgery, Cooper University Healthcare,
Camden, NJ, USA
e-mail: lou-johanna@cooperhealth.edu;
Hong-young@cooperhealth.edu
Full Physical Exam
• Fever
• Abdominal exam: RUQ tenderness, liver enlargement
• Lymphadenopathy
Diagnostic Tests
• Labs: leukocytosis, LFTs (elevated alkaline phosphatase)
• Amoebic antigen testing (more sensitive than antibody
serology)
• Hepatitis tests
• Pregnancy test in females
• Ultrasound of RUQ
• CT scan of abdomen/pelvis with intravenous contrast
Surgical Treatment
• NPO, IVF
• IV antibiotics with streptococcal, gram-negative, and
anaerobic coverage until cultures result
• Cultures
• For pyogenic abscess
– Percutaneous aspiration vs. drainage with catheter
placement if >5cm
– Prolonged IV antibiotics if multiple small abscesses
not amenable to drainage
– Partial hepatectomy is equivalent to open irrigation
and drain placement
– Repeat imaging in 4–6weeks
• For amoebic abscess (Entamoeba histolytica)
– Treat colonic amebiasis as a source
– Oral metronidazole +cyst eradication (oral paromo-
mycin or diiodohydroxyquin)
– Aspiration and drainage ONLY when unresponsive to
antibiotics alone
• For fungal abscess
– Highest risk of death
– Early empiric antifungal coverage (amphotericin B or
micafungin)
– Percutaneous drainage
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_55
175
176
J. Lou and Y. K. Hong
Common Curveballs
• History of malignancy
• Concomitant intra-abdominal infections: diverticulitis,
appendicitis
• History of IVDU, HIV
• The patient has multiple abscesses
• Abscess communication with large bile duct
• Ruptured amoebic abscess
Clean Kills
• Missing the diagnosis
• Not ruling out an amoebic abscess
• Missing a biopsy of the abscess wall to rule out
malignancy
• Not checking for other abdominal sources as underlying
etiology
• Mixing up treatment of echinococcal cysts and amoebic
abscess (echinococcal/hydatid cysts are identied by
electrophoresis and initially treated with mebendazole)—
surgery rst causes anaphylaxis
Words ofWisdom
Liver abscesses are rare but deadly if not diagnosed earlier.
Pyogenic liver abscesses are the most common type seen in
the United States. Amoebic liver abscesses are caused by the
parasite Entamoeba histolytica and are endemic to tropical
low- and middle-income countries. Fungal abscesses are
associated with immunosuppression and have the greatest
mortality. Treatment centers around early antimicrobials and
percutaneous drainage (except for amoebic abscesses), with
open drainage or resection reserved for severe refractory
cases.
Acute Cholecystitis
JohannaLou andYoungK.Hong
56
Way Question May BeAsked?
A 43-year-old woman presents to the Emergency Department
with right upper quadrant pain that woke her up from sleep
about 9h ago. The pain started after she had a bacon cheeseburger for dinner, and it radiated to her stomach. She felt
nauseous and vomited once while waiting in the ED.She has
had similar episodes, which always resolve after a few hours.
On exam, she appears uncomfortable but nontoxic. Her
abdomen is soft with RUQ tenderness and a positive
Murphy’s sign.
How toAnswer
Full History
• The classic presentation of the ve F’s: fat, fertile, forty,
female, family history
• A careful history of timing, character, and duration of
pain: constant RUQ abdominal pain, lasts longer than
4–6h
– Distinguish between biliary colic=temporary impac-
tion of a gallstone in the gallbladder neck causing postprandial abdominal pain, nausea/vomiting that resolves
within hours
• Associated with nausea, vomiting
• Typically, after a fatty meal
– They may have had previous shorter, less severe
episodes
• Prior surgical history: Roux-en-Y gastric bypass may
have an internal hernia
• Last menstrual cycle
Full Physical Exam
• Fever
• Unstable hemodynamics would be concerning for a more
severe inammatory process
• Positive Murphy’s sign: cessation of inspiration with palpation over gallbladder
Diagnostic Tests
• Labs including CBC, complete metabolic panel: leukocytosis with neutrophil predominance
• Liver function tests: mild elevation in transaminases, bilirubin less than 1
• Normal amylase and lipase
• Urinalysis
• Pregnancy test in females
• RUQ ultrasound: gallstones with gallbladder wall thickening >4mm, pericholecystic uid, normal CBD diameter (<8mm)
– First line, noninvasive and inexpensive, sensitivity
>70–80%
• Hepatobiliary iminodiacetic acid (HIDA): diagnostic if
there is no visualization of the gallbladder at 60min
– Gold standard with sensitivity and specicity >95%
– Good at distinguishing biliary colic and nonbiliary
pain
– False positives seen in chronic cholecystitis and fast-
ing patients
• CT scan: may see cholelithiasis, thickened and enhancing
gallbladder wall, pericholecystic uid
– Mainly used to exclude nonbiliary causes of abdomi-
nal pain
• MRCP: good for diagnosing choledocholithiasis
Surgical Treatment
J. Lou · Y. K. Hong (*)
Department of Surgery, Cooper University Healthcare,
Camden, NJ, USA
e-mail: lou-johanna@cooperhealth.edu;
Hong-young@cooperhealth.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_56
• NPO, IVF
• Broad-spectrum IV antibiotics
• OR for laparoscopic possible open cholecystectomy on
index admission for mild and most moderate cases
177
178
J. Lou and Y. K. Hong
• Laparoscopic cholecystectomy
– Access the abdomen with the Hassan or Veress tech-
nique at the umbilicus
– Position and identify the gallbladder with a 30°
laparoscope
– Two additional 5mm ports in the RUQ parallel to the
subcostal margin and one 10–12 mm port in the
epigastrium
– Position patient reverse Trendelenburg and right side
up
– Place OGT or NGT to suction
– Retract the dome of the gallbladder cephalad above the
liver
– Dissect off any adhesions to expose the triangle of
Calot (cystic duct, common hepatic duct, and inferior
edge of the liver)
– Clear off fat until a critical view of safety is obtained
(cystic artery and duct are only two structures entering
the triangle)
– Double clip and divide the cystic artery and duct
– Use electrocautery to dissect the gallbladder off the
cystic plate
– Once free, remove the gallbladder with an endo catch
bag through the largest port
• Open cholecystectomy
– Either upper midline or right subcostal incision two
ngerbreadths below the costal margin
– Begin with the fundus and dissect the posterior wall of
the gallbladder off the cystic plate with Bovie or other
energy devices
– Retract laterally once the infundibulum is free to
approach the cystic duct and artery
– Clip and divide both structures
• If needed, both procedures can be performed with an
intraoperative cholangiogram
• If too unstable or poor medical candidate, interventional
radiology can be consulted for a percutaneous cholecystostomy tube
Common Curveballs
• RUQ pain is an atypical presentation of acute coronary
syndrome
– Differential: GERD, gastritis, gastroenteritis, peptic
ulcer disease, bowel obstruction (if history of RNY, it
may be internal hernia), hepatitis, mesenteric ischemia, perforated appendicitis, pneumonia
• If choledocholithiasis, can do pre- or post-operative
ERCP versus intraoperative cholangiogram
• The patient has comorbidities that make them a poor surgical candidate
• The patient has a dilated CBD
• The patient has elevated bilirubins
• The gallbladder is gangrenous and begins falling apart
during your laparoscopic dissection
• Bile is seen in the liver bed when inspecting for
hemostasis
• Aberrant biliary or vascular anatomy
• Patient will be status post a gastric bypass or duodenal
switch and may be asked to describe how to perform pre
or postoperative ERCP
Clean Kills
• Missing the diagnosis
• Missing possible choledocholithiasis
• Not taking patients to surgery for appropriate surgical
candidate
• Taking severe or unstable patient for a laparoscopic
cholecystectomy
• Ordering HIDA scan with ejection fraction
• Not performing a cholangiogram if unsure of anatomy
Words ofWisdom
Acute cholecystitis typically presents with RUQ pain, fever,
and leukocytosis. First-line imaging is an RUQ ultrasound,
showing cholelithiasis, gallbladder wall thickening, and pericholecystic uid. Antibiotics should be started at the time of
diagnosis. For mild and moderate acute cholecystitis, urgent
laparoscopic cholecystectomy is the treatment of choice,
with rapid conversion to open if unable to obtain the critical
view of safety. Intraoperative cholangiogram is a valuable
adjunct to help dene the biliary anatomy and identify choledocholithiasis or biliary injury.
Cirrhosis
ClaraZhu andYoungK.Hong
57
Way Question May BeAsked?
A 60-year-old male presents to the hospital with complaints
of “yellowed eyes” and signicant abdominal distention. He
undergoes a CT scan, which demonstrates a recanalized
umbilical vein and simple abdominal uid. During his hospitalization, he required multiple paracentesis for recurrent
ascites.
How toAnswer?
Full History
• Hepatitis exposure
• Alcohol use
• Tobacco use
• Weight loss
• Family cancer history
• History of varices
• Upper or lower GI bleeding
Full Physical Examination
• Scleral icterus
• Jaundice of the skin
• Fluid wave
• Caput medusa
• Encephalopathy
Diagnostic Tests
• Labs including CBC, BMP, LFTs, INR, prealbumin,
albumin
• Calculation of Model for End-Stage Liver Disease
(MELD) score with consideration for transplant referral
above 14
C. Zhu · Y. K. Hong (*)
Department of Surgery, Cooper University Healthcare,
Camden, NJ, USA
e-mail: Zhu-clara@cooperhealth.edu;
Hong-young@cooperhealth.edu
• Calculation of Child–Pugh score
• Esophagogastroduodenoscopy (EGD) for screening of
esophageal varices every 6months. EGDs should also be
performed for emergent upper GI bleeding, especially in
patients with a known history of cirrhosis
• The right upper quadrant duplex allows for detecting
hepatic arterial or venous thrombus during the workup of
elevated LFTs. CT scan with IV contrast can also quickly
provide information about vascular thrombosis and ductal
dilation, though it will not include data on ow
• MRI is the best test for the characterization of hepatic
lesions that appear in cirrhotic patients
Need routine surveillance for the progression of hepato-
cellular carcinoma (HCC).
Surgical Procedure
• The transjugular intrahepatic portosystemic shunt (TIPS)
has been adopted to treat refractory ascites and upper GI
variceal bleeding, though it has an increased risk of
encephalopathy. This is typically performed by interventional radiology.
• Surgical portosystemic shunts should be considered for
those with unfavorable anatomy for TIPS, those who have
encephalopathy, do not have access to TIPS, or those who
have failed TIPS and require a bridge to transplant.
Common Curveballs
• The patient has limited social resources, precluding regular screening
• No interventional radiologist is available for the performance of TIPS
• GI bleed in a cirrhotic patient
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_57
179
180
C. Zhu and Y. K. Hong
Clean Kills
• Not performing adequate resuscitation for acute decompensation of liver cirrhosis
• Not involving gastroenterology colleagues for medical
optimization of cirrhosis
• Not evaluating the severity of liver cirrhosis (MELD,
Child–Pugh)
Words ofWisdom
Patients with cirrhosis are at high risk of surgical morbidity
and mortality. The rst step in managing cirrhosis is medical
optimization where possible, which often includes the
involvement of a multidisciplinary team. TIPS is indicated
where patients have refractory ascites and recurrent GI
bleeding, though TIPS will worsen hepatic encephalopathy.
Surgical shunts are used with less frequency but may be displayed in select patients with cirrhosis.
Gallbladder Cancer
ClaraZhu andYoungK.Hong
58
Concept
Very rare with fewer than 20,000 cases each year in the
United States. Often mimics typical gallbladder symptoms
and seen on nal pathology reports. The depth of invasion is
critical for deciding on next steps.
Way Question May BeAsked?
A 63-year-old male presents for elective cholecystectomy
for biliary colic. On nal pathology, he was found to have a
gallbladder mass consistent with adenocarcinoma.
How toAnswer?
Full History
• Any history of biliary symptoms
• Constitutional symptoms (fatigue, weight loss)
• Medical history
• Assessment of functional status
• Cancer History
• Substance use history (ETOH, smoking)
Full Physical Examination
• Abdominal exam
• Lymph node exam
– CT chest for evaluation of metastatic disease
• Pathology evaluation
– Evaluation of tumor extent into the wall of the gall-
bladder determines the extent of surgical resection
T1a: invades lamina propria
T1b: invades muscularis layer
T2a: invades perimuscular connective tissue on the
peritoneal side
T2b: invades perimuscular connective tissue on the
liver edge
T3: tumor penetrates serosa into one adjacent organ
Cystic duct margin
Surgical Management
Surgical treatment of gallbladder cancer remains the mainstay for treatment.
• T1a disease: cholecystectomy with negative cystic duct
margin.
• T1b and greater: extended cholecystectomy.
– Cholecystectomy with 2 cm of hepatic parenchyma
taken en bloc, along with hepatoduodenal, gastrohepatic, and retroduodenal lymph nodes, has equal outcomes of segment 4B/5 resection.
– If the cystic duct margin is positive, resection to nega-
tive margins may require biliary reconstruction.
Diagnostic Tests
• Laboratory studies, including LFTs, CBC, and lipase
– Serum bilirubin, alkaline phosphatase, liver enzymes
• CT with IV contrast with triple-phase contrast or MRCP
• Staging evaluation
– Tumor marker (CA 19-9)
C. Zhu · Y. K. Hong (*)
Department of Surgery, Cooper University Healthcare,
Camden, NJ, USA
e-mail: Zhu-clara@cooperhealth.edu;
Hong-young@cooperhealth.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_58
Common Curveballs
• For patients with suspected gallbladder mass on preoperative imaging, extended cholecystectomy should be performed upfront. No touch technique is recommended.
181
182
C. Zhu and Y. K. Hong
Clean Kills
• Failure to stage with cross-axial imaging, tumor markers
• Extensive hepatic resection can be utilized with advanced
local disease, but debulking has no role in management.
Leaving positive margins after extended cholecystectomy
is associated with a poor prognosis
• Offering major right hepatectomy or liver transplant
Words ofWisdom
Often seen incidentally on pathology reports for a patient
with acute or chronic cholecystitis. Gallbladder cancer has
an overall poor prognosis. For patients with resectable disease, efforts should be made to achieve an R0 resection,
which remains the mainstay of disease treatment. Gallbladder
cancer locally invades into the liver, rather than metastasizes
to distant parts of the body. For a T1a with negative cystic
duct margin, cholecystectomy is denitive resection.
Postcholecystectomy Syndrome
ConnorMagura, JessePowell, andLuisCardenas
59
Concept
Patients with postcholecystectomy syndrome have symptoms that are concerning for biliary pathologies such as biliary colic, cholecystitis despite having undergone a
cholecystectomy. Often this will include complaints of nausea, vomiting, heartburn, indigestion, changes to bowel habits, right upper quadrant abdominal pain, and referred pain.
PCS patients’ presenting symptoms can be found to be
attributed to another disease process or the workup can be
inconclusive while trying to evaluate the source of their discomfort, although the latter is diagnosis of exclusion.
Case Part 1
A 56-year-old female patient presents to the surgery clinic
following a cholecystectomy she underwent for acute cholecystitis while on vacation now complaining of ongoing intermittent right upper quadrant pain associated with nausea
and bouts of diarrhea as well as reux.
This vignette demonstrates a patient presenting with PCS
who requires a thorough evaluation to further understand her
symptomatology. A history and physical is critical as this
patient’s primary presentation may represent both biliary as
extrabiliary causes.
Common extrabiliary causes include diagnoses such as
reux, peptic ulcer disease, esophagitis, and pancreatitis and
can also include diagnoses as critical as masses and mesenteric ischemia.
Biliary causes can be broken down into early and late.
• Early causes are often involved with surgical complications such as biliary injury, retained cystic duct, CBD
stones.
C. Magura (*) · J. Powell · L. Cardenas
Division of Surgical Critical Care and Trauma, Department of
Emergency General Surgery, Christiana Care Hospital,
Newark, DE, USA
e-mail: connor.magura@christianacare.org;
jessie.l.powell@christianacare.org; lcardenas@christianacare.org
• Late causes occur months to years later and include etiologies such as recurrent CBD stones, bile duct strictures,
inamed cystic duct/gallbladder remnant, papillary stenosis, biliary dyskinesia.
Patients should be thoroughly screened for neurologic
and psychiatric diagnoses.
Who is at risk?
• All patients who undergo cholecystectomy with reported
incidence as high as 40%. Increased risk in females
between ages of 20 and 29.
• Patients who underwent urgent surgery have a higher risk
as well as those who suffered with prolonged preoperative
symptoms.
How to work up this patient?
• Laboratory studies including blood counts, metabolic
panel, and liver function test. Workup can also include
other studies to evaluate other relevant organs such as the
pancreas.
• Radiographic tests can be ordered but should include a
broad differential to possibly evaluate other intraabdominal etiologies as well as pulmonary concerns.
• A HIDA scan can be ordered if there is concern for possible biliary leak or concern for sphincter of Oddi
dysfunction.
Alternate Scenario
A 56-year-old female patient presents to the Emergency
department following the redevelopment of right upper
quadrant pain. She has had cramps right upper quadrant
pain beginning 3days after her cholecystectomy last week
for biliary colic but is now complaining of sharp focal right
upper quadrant pain. She additionally feels febrile and has
noticed that her eyes have become yellow. Her RUQ pain is
exactly how she felt before having her gallbladder removed
but the yellowing and fever she did not appreciate prior. On
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_59
183
184
C. Magura et al.
triage examination, she is found to be hypotensive tachycardic and febrile to 38.9.
This patient is presenting with subjective symptoms similar to her original presentation which led her to undergo a
cholecystectomy. These two clinical scenarios display a wide
variety of clinical presentations as the second scenario shows
a more critically ill patient that possibly has a diagnosis as
serious as cholangitis from a retained stone.
Pathophysiology ofPostcholecystectomy
Syndrome
The pathophysiology is believed to be secondary to the disruption of the normal physiology in the bile removal process,
more specically the alterations in bile ow. However, the
pathophysiology is truly not understood. As such, the gastroenterological symptoms are attributed to either biliary or
nonbiliary etiologies if determined.
Treatment Options
Therapies can be broken down to either pharmacologic or
procedural approaches. Treatment options for this syndrome
generally involve treating an underlying disease, if discovered. For patients with symptoms and no specic underlying
diagnosis, pharmacologic therapy can be pursued after completing a thorough diagnostic workup.
For patients with diarrhea, cholestyramine may be helpful. Treatment of associated reux symptoms is appropriate
in addition to standard workup for GERD.Patients who have
constipation can be considered for the use of stool bulking
and laxative agents.
If the patient is believed to have a biliary dyskinesia or
other biliary pathology driving PCS, ERCP is the mainstay
of procedural approaches as this will allow for intervention
such as sphincterotomy, dilation, stent placement, or retained
stone extraction if necessary in addition to diagnostic
workup.
These patients do require frequent follow-up, and it has
been documented that with attentive care, these patients nd
satisfactory symptom relief with long-term follow-up.
Pearls andPitfalls
• PCS is a syndrome of patient symptoms but there is fre-
quently an underlying diagnosis driving the symptoms.
• The differential is broad and patients must be evaluated
and treated as such.
• It is critical to evaluate patients for postoperative compli-
cations in the early postoperative course.
• When life-threatening and treatable diagnosis are ruled
out, treating patients symptoms is appropriate.
Clean Kills
• Failing to appropriately evaluate patient with thorough
history and physical
• Dismissal of patient symptoms
• Failure to workup patient for any other contributory diag-
nosis or surgical complication
• Lack of adequate follow up
Words ofWisdom
Postcholecystectomy syndrome is the presentation of
patients representing with symptoms akin to their original
presentation prompting their cholecystectomy. Thorough
history and physical is critical and a thorough workup and
treatment of any underlying disorders that may be contributing to their symptomatology. Failure to perform these aspects
of the patient’s care leads to poor patient’s satisfaction and
outcomes.
Bibliography
• An EUS can be a valuable tool in conjunction with possible ERCP. The EUS can be helpful in identifying any
other associated pathologies while performing an ERCP.
• MRCP also maintains an option for patients to evaluate
for biliary pathology if the individual cannot tolerate
ERCP.
Jaunoo SS, Mohandas S, Almond LM.Postcholecystectomy syndrome
(PCS). Int J Surg. 2010;8(1):15–7. ISSN 1743-9191. https://doi.
org/10.1016/j.ijsu.2009.10.008.
Soper N.Laparoscopic cholecystectomy. UpToDate; 2023.
Zackria R, Lopez RA.Postcholecystectomy syndrome. In: StatPearls.
Treasure Island, FL: StatPearls Publishing; 2023. https://www.ncbi.
nlm.nih.gov/books/NBK539902/.