Diagnostic approach of liver abscess

Liver abscess is an infection of parasitic or bacteria into the liver parenchyma which causes encapsulation of suppurative material surrounded by inflammatory tissue. Liver abscess is an important health problem especially in low-middle income countries. It is not easy to diagnose liver abscess due to non-specific clinical signs. This case report, we presenteda 46-year-old man who was hospitalized with suspected pulmonary infection. However, in the course of the patient's disease, we found a liver abscess.

Demographic, Clinical, Laboratory and Management Profile in Patients of Amoebic Liver Abscess from Northern India

Background: Amoebic liver abscess (ALA) is a serious extra-intestinal manifestation of amoebiasis and a major problem in developing countries. Due to rapid urbanization, improved sanitation and hygiene in India, there has been a shift in disease epidemiology towards non-communicable disease, but recent changes in epidemiological and clinical pattern in ALA are not well studied. Aim: To evaluate recent demographic, clinical, laboratory and management profile in patient with ALA. Methods: It is a prospective observational study conducted in the Department of Gastroenterology, SMS medical college, Jaipur, Rajasthan from June 2018 to December 2020. A predesigned semi structured questionnaire consisting of socio-demographic factors, risk factors, clinical, laboratory and management profile was used to collect data. Result: A total 508 patients of amoebic liver abscess were analysed. Median age of presentation was 40 years, majority were males (90.4%) with chronic alcoholism (44.1%) and belonging to lower socio-economic class. Abdominal pain, fever and anorexia were the most common symptoms. A majority had right lobe involvement (77.6%) and solitary abscess in 67.5%. Most of the small liver abscesses (68%) were managed by medical treatment alone. Percutaneous needle aspiration was done in 62.6% patients, mostly for abscess size 5-10 cm (93%) with 90% success. A total of 24.6% patients underwent percutaneous catheter drainage, all successfully done. Intraperitoneal rupture was seen in 10% patient. Mortality was 1.5%. Conclusion: This is one of the largest cohorts of ALA which shows that a majority of cases are males from lower socioeconomic status with history of significant alcohol intake. Early initiation of a combined therapeutic approach leads to early symptomatic improvement, fewer complications and better outcomes.

Sociodemographic and Clinical Profile of Amoebic Liver Abscess observed at a Tertiary Referral Hospital over 10 Years

Aim: To study the sociodemographic factors, clinical features and treatment outcome of patients with amebic liver abscess. Methods: Prospective analysis of 163 consecutive patients with liver abscesses (mean age 39.5 years, 140 males). Amoebic aetiology was determined by various combinations of history of dysentery, radiological appearance, aspirated pus study, amebic serology, colonoscopy findingsand response to treatment. Sociodemographic factors associated with amoebic liver abscess included education, income, eating hygiene and alcohol consumption. All patients were treated with fine needle pus aspiration and intravenous metronidazole for at least 7 days. Results: 109(63.9%) abscesses were treated in the first 5 years. Antecedent diarrhoea was present in 27 (16.6%). 146 patients (89.6%) took nitroimidazoles frequently. Jaundice, mostly mild, occurred in 35%.E. histolytica was demonstrated in stool in 11 patients (6.7%) and in aspirated pus in 35 patients (21.5%). Serology was positive (>1:160) in 53(32.5%) patients and was related to abscess size > 10 cm, presence of amoeba in pus and stool and positive colonoscopy findingsbut not to the number of abscesses. Colonoscopy revealed colitis in 21(12.9%) and caecal mass in 7(4.3%). All patients had prompt symptom relief with treatment without recurrence. 80% belonged to the lower middle class hailing from rural areas. 128(78.5%), all males, consumed 60 – 80 ml indigenously brewed liquor daily and they had poor personal and eating hygiene with higher antibody levels. 32 patients (19.6%) drank potable water. Conclusion: Though decreasing, amebic liver abscess continues to afflict heavy alcohol drinkers of lower socioeconomic strata, living in unhygienic conditions. Alcohol might influence seropositivity. Aspiration irrespective of size gives a lasting cure.

TREATMENT DIFFICULTIES WITH LIVER ABSCESS IN PREGNANCY A RARE CASE REPORTTREATMENT DIFFICULTIES WITH LIVER ABSCESS IN PREGNANCY A RARE CASE REPORT

Liver abscess in pregnancy is a rare entity and can be a life threatening condition. Here we present A case of amoebic liver abscess in 25 years old lady in of pregnancy, with highlights on treatmentthird trimester difficulties which we had faced in the management and timely intervention leads to good fetomaternal outcome

Liver abscess: demographic, clinical, biochemical, imaging and microbial spectrum

Background: Liver abscesses are localized suppurative destruction of liver tissue due to infections of either bacterial (Pyogenic) or protozoa (Amoebic). Historically; pyogenic liver abscess has been described since the time of hippocrates (400 BC). Despite the more aggressive approach to treatment, the mortality rate remained at 60-80%.Methods: This Cross-sectional analytical study carried out at Department of Medicine, Al-Tibri Medical College Hospital, Karachi, from June 2017 to December 2018. All participants of either gender with diagnosis of liver abscess were included in this prospective study. Patients with co morbidities like malignancy, autoimmune disease or on immunosuppressive treatment for any reason were excluded from the study. Following confirmation of the diagnosis; different characteristics of either type of liver abscess like demographic, clinical features, biochemical and imaging findings were evaluated.Results: Data of 73 subjects, 65(89.0%) males and 08(11.0%) females were analyzed with mean age was 45.42±14.518 years. Fifty-four (73.97%) patients had pyogenic liver abscess while amoebic liver abscess was found in 19(26.03%) subjects. Clinically, the most common symptom was abdominal pain, found in 66(90.4%) subjects, followed by fever in 61(83.6%), hepatomegaly in 47(64.4%), jaundice in 18(24.7%) and vomiting in 10(13.7%) cases. Demographics and clinical features are shown in (Table 1).Conclusions: Local trends have been changing and majority of liver abscess were of pyogenic liver abscesses. Clinically, clear differentiation between two types of abscesses is not possible always but few manifestations like typical symptoms, raised alkaline phosphatase and leucocytosis may be helpful.

Las citoquinas en el absceso hepático amebiano: un ejemplo de investigación inmunología en el ámbito clínico / Cytokines in amoebic liver abscess: an example of immunological research within the clinical scope

Resumen El propósito de esta revisión es resaltar la importancia de la investigación en el área de la inmunología y su aplicación en el ámbito clínico. En una primera parte se presentan los descubrimientos más importantes que ayudaron a dilucidar los principales procesos fisiológicos involucrados en las enfermedades y de esta manera ayudaron a redireccionar la investigación en el área de la inmunología. Seguido, se describe un ejemplo de investigación básica relacionada con el papel de las citocinas en el absceso hepático amebiano, mostrando el trabajo de varios grupos de investigación en el mundo, con el objetivo de entender la respuesta inmune contra el parásito. Lo anterior nos permite argumentar la relevancia que tiene la investigación inmunológica dentro del contexto clínico.

Abstract The purpose of this review is to highlight the importance of research in immunology and its application in the clinical setting. The first part presents the most important discoveries that helped to elucidate the main physiological processes involved in the diseases and in this way helped to redirect research in immunology. Then, we describe an example of basic research related to the role of cytokines in the amoebic liver abscess, showing the work of several research groups in the world, with the aim of understanding the immune response against the parasite. This allows us to argue the relevance of immunological research within the clinical context.

Liver abscess - Different modalities of treatment and its outcome

Background: Liver abscesses, both amoebic and pyogenic, is an important cause of morbidity and mortality in our country. It is a common condition in tropical countries. The primary mode of treatment of amoebic liver abscess is medical ; however many cases may need different type of surgical management. In the present study of liver abscess of different etiology, the following treatment modalities such as aspiration, percutaneous catheter drainage, laparoscopic drainage and open surgical procedure have been studied. Methods: A retrospective study was conducted from September 2007 to October 2008 on 50 liver abscess patients at Rajendra Institute of Medical sciences, Ranchi. Medical records were analysed for different modalities of treatment for amoebic liver abscess. Results: The mean age of patients was 39 years. Most of them were male alcoholics. Solitary abscess was found in right lobe of liver in 80% of cases. Most common presentation was right upper quadrant pain and fever. Abscesses were mainly amoebic. Percutaneous needle aspiration was done in 30%, 41% underwent USG guided pig tail catheter drainage and 5% of patients underwent for surgical interventions for peritonitis following ruptured liver abscess. The overall mortality rate seen in amoebic liver abscess was 7% in our series. Conclusions: Liver abscess is a very common condition in India and Amoebic liver abscess is more common than pyogenic liver abscess. More commonly occurs in young alcoholic males and most common presenting feature is right hypochondrial pain followed by fever. Most common sign include tender hepatomegaly. Ultrasound abdomen is the best method for diagnosis and intervention and in a few cases laparoscopic drainage or open surgical intervention required.

Amoebic Liver Abscess in Newly Detected HIV Infection

Amoebic Liver Abscess (ALA) is a most commonextraintestinal manifestation of amoebiasis which ismost commonly present with high grade fever withright upper quadrant abdominal pain. Here we present acase of 32 year male patient newly diagnosed as PeopleLiving with HIV/AIDS (PLHIV) with ALA. Patientwas treated with Metronidazole (500 mg 8 hourly) andtherapeutic drainage.

Image Guided Management of Various Liver Abcess

ackground: Amoebic liver abscess is an important cause of inflammatory space occupying lesion of liver in the tropics. The primary aim of our study is to study the clinical presentations, investigations, diagnosis and management of amoebic liver abscess. Methods: All patients diagnosed with liver abscess in Hi-Tech Medical and hospital, Bhubaneswar, Odisha, over a period of two years from September 2014 to September 2016.After obtaining clearance and approval from the institutional ethical committee, detailed history of all patients is taken with thorough clinical examination; required Investigations were done and entered into a proforma during their stay and follow up. Therapeutic aspiration reserved for the following cases where: Size of abscess is more than 5 cm in diameter (125ml). When pain and fever persist for more than 3 to 5 days after starting Antiamoebic therapy. Four clinical variables-abdominal pain, fever, anorexia, and hepatomegaly-were assessed on daily basis. Finally, The patients were asked to visit for reassessment once a month for 3 months. Results: A total of 30 patients of amoebic liver abscess were included and studied during the time period. Out of 30 patients of liver abscess, 14 patients gave history of alcohol consumption, comprising 47% of the study population. than 5 cms were treated conservatively. In Patients treated by percutaneous aspiration, 12 were having cavities ranging 11-25 cms and 5 with cavities ranging 6-10 cms. 60% of patients were treated by ultrasound guided percutaneous aspiration and 40% of patients were treated by conservative management. Conclusion: Ultrasonography helps in early diagnosis and reducing morbidity and mortality. It also confirms the site, size and number of amoebic liver abscess and knowing the prognosis.

Amoebic colitis with liver abscess

moebiasis is a parasitic infection caused by the intestinal protozoan Entamoeba histolytica, most prevalent in developing countries. It results in 40,000 to 100,000 deaths each year from amoebic colitis and extra intestinal infections. Amoebic liver abscess (ALA) is the most common extra intestinal site of infection with an incidence of between 3% and 9% of all cases of amoebiasis. Ultrasound which has a sensitivity of more than 90% for detecting ALA is highly recommended as an initial investigation followed by serological demonstration of circulating antibodies specific to Entamoeba histolytica.

A Prospective Comparative Study to evaluate drainage of liver abscess by 20 Fr PVC catheter versus 10 Fr pigtail catheter.

Background: Large liver abscess requires drainage by pigtail catheter. These catheters tend to get blocked frequently and thus takes long period of time to completely drain. So we wanted to study whether inserting a large bore catheter would drain the abscess faster thus decreasing the stay and requirement of antibiotics. Aim: To study the effectiveness of wide bore PVC catheter (20 Fr) in drainage of large peripheral liver abscess as compared to the use of pigtail catheter (10 Fr). Methods: The study was prospective comparative study done at a tertiary care hospital. Over a period of 22 months, 60 patients of amoebic liver abscess were assigned to undergo pigtail catheter drainage by 10 Fr. Versus wide bore 20 Fr PVC catheter drain and the outcomes were compared. Results: Use of wide bore (20 Fr) PVC catheter significantly decreased the duration of treatment, led to faster drainage of abscess and decreased incidence of recurrence in large amoebic liver abscess, as compared to pigtail catheter drainage by the standard 10 Fr pigtail catheter. Conclusion: 20 Fr PVC catheter is safe and efficacious for evacuating large solitary peripheral liver abscesses and should be preferred to narrow bore pigtail catheter.

Comparison of nested-multiplex, Taqman & SYBR Green real-time PCR in diagnosis of amoebic liver abscess in a tertiary health care institute in India.

Background & objectives: Amoebiasis is a common parasitic infection caused by Entamoeba histolytica and amoebic liver abscess (ALA) is the most common extraintestinal manifestation of amoebiasis. The aim of this study was to standardise real-time PCR assays (Taqman and SYBR Green) to detect E. histolytica from liver abscess pus and stool samples and compare its results with nested-multiplex PCR. Methods: Liver abscess pus specimens were subjected to DNA extraction. The extracted DNA samples were subjected to amplification by nested-multiplex PCR, Taqman (18S rRNA) and SYBR Green real-time PCR (16S-like rRNA assays to detect E. histolytica/E. dispar/E. moshkovskii). The amplification products were further confirmed by DNA sequence analysis. Receiver operator characteristic (ROC) curve analysis was done for nested-multiplex and SYBR Green real-time PCR and the area under the curve was calculated for evaluating the accuracy of the tests to dignose ALA. Results: In all, 17, 19 and 25 liver abscess samples were positive for E. histolytica by nested-multiplex PCR, SYBR Green and Taqman real-time PCR assays, respectively. Significant differences in detection of E. histolytica were noted in the real-time PCR assays evaluated (P<0.0001). The nested-multiplex PCR, SYBR Green real-time PCR and Taqman real-time PCR evaluated showed a positivity rate of 34, 38 and 50 per cent, respectively. Based on ROC curve analysis (considering Taqman real-time PCR as the gold standard), it was observed that SYBR Green real-time PCR was better than conventional nested-multiplex PCR for the diagnosis of ALA. Interpretation & conclusions: Taqman real-time PCR targeting the 18S rRNA had the highest positivity rate evaluated in this study. Both nested multiplex and SYBR Green real-time PCR assays utilized were evaluated to give accurate results. Real-time PCR assays can be used as the gold standard in rapid and reliable diagnosis, and appropriate management of amoebiasis, replacing the conventional molecular methods.

Clinical features and management of amoebic liver abscesses in a rural teaching hospital – A cross-sectional study, Sangareddy

Background: Liver abscess is a major health problem in tropical and subtropical regions. Aim: The present study aimed to evaluate the clinical profile, management of amoebic liver abscess patients. Materials and methods: A cross-sectional study was conducted in Department of Surgery MNR Medical College Hospital, Sangareddy over a period of 2 years from June 2014 to July 2016. A total of 100 patients with liver abscess were included in this study. Clinical examination, detail case history, ultrasonography reports, case management and outcome were recorded during study. Results: Among 100 patients, 88 were males and 12 were females. Majority of cases were belongs to the age group of 30 -40 years (45%). Most common clinical features of amoebic liver abscess was fever (89%), abdominal pain (78%) and diarrhoea (37%). The major signs were hepatomegaly (87%), right lobe abscess (68%), left lobe abscess (36%) and pleural effusion (18%). Mortality rate was 3% out of 100 patients.

A study on HLA-DR/DQ typing in adult Malay patients with acute amoebic liver abscess

Introduction: Amoebiasis is a parasitic disease caused by Entamoeba histolytica that may lead to death in developing countries. Few important risk factors have been identified in the development of amoebic liver abscess (ALA). There are limited reports that suggest an association between antigens of the major histocompatibility complex (MHC) particularly class II antigens and ALA development. This present work aimed at studying the possible association of HLA antigens with ALA and disease severity. Results of the study may serve as a guide for further immunological studies dealing with E. histolytica. Methods: This preliminary study involved two groups of subjects: 20 ALA patients in the experimental group and 40 healthy individuals in the control group. Cases were selected from adult Malay patients confirmed with ALA based on clinical signs and symptoms, radiological findings, microbiological findings and who were admitted to the medical or surgical ward, Hospital USM, Kelantan. Venous blood was obtained from each patient and HLA typing was then conducted using polymerase chain reaction specific primer sequence. Results: HLA DR12 was most frequently found in the healthy control and ALA groups at 40% and 55% respectively. HLA DQ7 and DQ8 were found to have the highest percentage in the ALA group at 65%. In the control group, HLA DQ8 (57.5%) had the highest percentage. Conclusion: HLA antigens play a role in acquisition of ALA and provide understanding of the disease outcome.

A comparative study of different modalities of treatment of liver abscess.

Objective: To compare the effectiveness of conservative medical treatment versus minimal invasive surgical techniques like percutaneous catheter drainage (PCD) and percutaneous needle aspiration (PNA) in the management of liver abscess. Material and methods: All patients with liver abscess who were admitted in Surgery from October 2013 to June 2014 were included in this study and were exposed to four different treatment modalities. The patients were first treated with combination of medicine (Option-A). If they failed to respond to this treatment then they were subjected to ultrasound guided aspiration (Option -B). If Option - B failed they were exposed to pig tail catheter placement (Option -C). Final option was surgical drainage (Option - D) if it was rupture liver abscess and if the patient presented with co morbid conditions like septicaemia and peritonitis.PNA was repeated every third day if the cavity size had not declined to 50% of the original for up to three times. Persistence of cavity or of clinical symptoms was considered failure of treatment. Results: Out of 51 patients, 14 patients responded to drug therapy alone. 34 patients required ultrasound guided aspiration and Pig tail catheter placement and 3 patients required open surgical drainage. A combination of drug therapy and ultrasound guided needle aspiration was effective for majority of 83% patients Duration of hospital stay was similar in the two groups. Conclusion: Minimal surgical interventions like PCD and PNA are better than conservative treatment for the management of liver abscesses of size >5 cm, in terms of duration to attain clinical relief and duration for which parenteral antibiotics are needed. Pyogenic liver abscess are less common than amoebic liver abscess. Right lobe of the liver is most commonly involved in both types of abscesses. Radio-imaging techniques like ultrasonography (US) and computerized tomography (CT) are the modalities of choice for investigation purposes. Treatment modalities of these abscesses, first emphasizes on medical treatment, but if it is unsuccessful then only the surgical intervention should be taken up. Laparotomy and Drainage or Laparoscopic Drainage remains the standard of care for ruptured liver abscess.

Nature Heals: Spontaneous Resolution of Liver Abscess through Hepato-colic Fistula.

Rupture of a liver abscess is a fairly common phenomenon in surgical practice. It is commoner in developing countries like India. Sites of rupture often predict the clinical course of the patient and affect the natural history of the disease, more common being the pleural and peritoneal cavity. Rupture into the bowel with fistulization is a rare phenomenon in liver abscess. Hepato-colic fistulae are being encountered following radiofrequency ablation for hepato cellular carcinoma. This occurring in the setting of liver abscess is highly uncommon. We report the first ever case in English literature, wherein an amoebic liver abscess was complicated by the occurrence of a hepato-colic fistula. The patient was a 48-year-old male who had a liver abscess in a background of alcoholic liver disease. On further investigation, he was found to have abnormal communication between the abscess cavity and the hepatic flexure of the colon. He was managed conservatively followed by spontaneous closure of the fistula.

A clinical study on amoebic liver abscess.

Background: Amoebic liver abscess presents with severe pain and high grade fever and if not diagnosed and treated promptly, may lead to complications and mortality. Aim and objectives: The objective of the present study was to estimate the incidence, need for aspiration and prognosis. The diagnosis was based on clinical features, positive Elisa test, ultrasonography, aspiration of anchovy sauce from the liver lesion, isolation of E. Histolytica (cyst/trophozoite) from the stool of the patient. Result: We had 65 cases in the study. There were 52 males & 13 females with a ratio of 4:1. Solitary abscess was found in 48(73.8%) patients which are located as follows; right lobe(43), left lobe(2) and in both lobe(3). 9% were aspirated at presentation due to their size or position. Only 4 (2%) were aspirated at first follow-up on third day due to non resolution of pain or fever or increase in size. All the patients are responded to standard treatment of metronidazole. Amoebic liver abscess is a common diagnosis in our setup. Conclusion: Clinical background and sonogram give a reasonable suggestion about amoebic etiology. If initial aspiration is not indicated due to size larger than10 cm or proximity to surface, conservative treatment with oral or intravenous metronidazole is successful.

Fatal case of amoebic liver abscess in a child

We reported a case of amoebic liver abscess (ALA) in a 6-year-old Malaysian boy who presented with fever, lethargy, diarrhoea and right hypochondriac pain. On admission he was diagnosed with perforated acute appendicitis and a laparotomy was done. After surgery he developed acute respiratory distress. Ultrasonography, chest X-Ray and CT scan revealed two ALAs in the posterior segment of right lobe of liver, pleural effusion and collapsed consolidation of lungs bilaterally. Percutaneous liver abscesses drainage was done and intravenous Metronidazole was started. PCR carried out on the pus from the abscess was positive for Entamoeba histolytica. Patient however succumbed to the infection one week after admission.

Fatal case of amoebic liver abscess in a child

We reported a case of amoebic liver abscess (ALA) in a 6-year-old Malaysian boy who presented with fever, lethargy, diarrhoea and right hypochondriac pain. On admission he was diagnosed with perforated acute appendicitis and a laparotomy was done. After surgery he developed acute respiratory distress. Ultrasonography, chest X-Ray and CT scan revealed two ALAs in the posterior segment of right lobe of liver, pleural effusion and collapsed consolidation of lungs bilaterally. Percutaneous liver abscesses drainage was done and intravenous Metronidazole was started. PCR carried out on the pus from the abscess was positive for Entamoeba histolytica. Patient however succumbed to the infection one week after admission.

Inferior vena cava thrombosis in a case of amoebic liver abscess: Is hypercomplementemia responsible for this rare entity.

Among the liver abscesses, thrombosis of the inferior vena cava (IVC) has been reported mainly in amoebic liver abscess (ALA) caused by Entamoeba histolytica (E.H). It is an unusual complication especially in paediatric age group. Association of hypercomplementemia and IVC thrombosis has not been discussed previously. Published data suggest that E.H can activate the complement system and can cause hypercomplementemia. A very few studies suggest that complement activation and hypercomplementemia are associated with thrombus formation. We describe a paediatric case of ALA complicated by IVC thrombosis extending to the right atrium and discuss the possible role of hypercomplementemia in causation of IVC thrombosis in cases of ALA.