Percutaneous catheter drainage of amoebic liver abscess

Amebic liver abscess: Clinico-radiological findings and interventional management

In its classic form, amebic liver abscess (ALA) is a mild disease, which responds dramatically to antibiotics and rarely requires drainage. However, the two other forms of the disease, i.e., acute aggressive and chronic indolent usually require drainage. These forms of ALA are frequently reported in endemic areas. The acute aggressive disease is particularly associated with serious complications, such as ruptures, secondary infections, and biliary communications. Laboratory parameters are deranged, with signs of organ failure often present. This form of disease is also associated with a high mortality rate, and early drainage is often required to control the disease severity. In the chronic form, the disease is characterized by low-grade symptoms, mainly pain in the right upper quadrant. Ultrasound and computed tomography (CT) play an important role not only in the diagnosis but also in the assessment of disease severity and identification of the associated complications. Recently, it has been shown that CT imaging morphology can be classified into three patterns, which seem to correlate with the clinical subtypes. Each pattern depicts its own set of distinctive imaging features. In this review, we briefly outline the clinical and imaging features of the three distinct forms of ALA, and discuss the role of percutaneous drainage in the management of ALA.

Enhanced Drainage Protocol in Large Amoebic Liver Abscess

Background  Amebic liver abscess (ALA) contributes significantly to morbidity and mortality in patients of the developing world. Even though medical management is the primary modality of treatment, 15% of the cases are refractory and require intervention for drainage. Pigtail catheterization is inefficient and results in a long duration of hospital stay. So, we conducted a prospective observational study to determine the efficacy and safety of drainage of large ALA using a wide bore 24 French (Fr) drain compared with a conventionally used 10 Fr pigtail catheter. Materials and Methods  A single center prospective observational study was conducted over a period of 5 years and data of 122 patients was collected. After starting empirical medical therapy, patients underwent drainage of ALA with either a 10 French pigtail or a 24 Fr drain. The primary outcome variables were resolution of clinical symptoms such as fever and pain in abdomen, length of hospital stay, and resolution of abscess on imaging at day 3. Secondary outcome was complications related to the procedures. Results  Data of 122 patients was collected. Males constituted a vast majority (96%) of the study population and the fifth decade was the most common age group involved. Alcoholics had a higher chance of developing a large ALA. Sixty-eight patients underwent drainage of the ALA using a 24 Fr drain which resulted in faster resolution of symptoms (2.4 vs. 5.1 days, p -value 0.033), a shorter duration of catheter in situ (6.4 vs. 13.2, p -value 0.011), and a faster drainage of ALA (residual volume at day 3; 177 vs. 212 mL, p -value 0.021). Twenty-eight patients had a biliary communication of which 26 required therapeutic endoscopic retrograde cholangiopancreatography. Conclusion  In patients with a large ALA, placement of a wide bore 24 Fr catheter hastens recovery of the patients when compared with drainage with a standard 10 Fr pigtail catheter. Placement of a biliary stent serves as a useful adjunct for their management and it may obliviate the need for a major biliary diversion surgery.

Percutaneous catheter drainage of uncomplicated amoebic liver abscess: prospective evaluation of a clinical protocol for catheter removal and the significance of residual collections

INTRODUCTION

Patients with amoebic liver abscess (ALA) may require percutaneous catheter drainage (PCD). Once the PCD output is substantially reduced or has ceased along with clinical recovery, residual collections on radiological evaluation may concern the treating physicians. The prevalence and significance of such collections is unknown, and the subsequent approach how to tackle them is unclear.

METHODS

Consecutive patients with one or more uncomplicated ALAs requiring drainage were prospectively enrolled from 3 hospitals and managed based on a standard approach. Catheter removal was attempted after the patients fulfilled all 4 of the following criteria: disappearance of abdominal pain, absence of fever for at least 48 h, an improving trend of TLC (documented on 2 consecutive reports), and catheter drain output of < 10 ml/day for at least 2 consecutive days.

RESULTS

A total of 110 patients (mean age 46.6 ± 10.5 years, 93.6% males, 89.1% alcoholics) underwent PCD placement; 69 patients (69/110; 62.7%) met all 4 criteria within 5 days of PCD placement (optimal response) and had an uncomplicated course. Patients with suboptimal responses (41/110; 37.3%) were evaluated for local and systemic complications; the appearance of fresh collections (5/110; 4.5%), abscess rupture (2/110; 1.8%), bile leakage (3/110; 2.7%), cholangitis (2/110; 1.8%), thrombophlebitis (2/110; 1.8%) and hospital-acquired infections (2/110; 1.8%) were diagnosed and treated accordingly. Ultimately, PCD removal (based on the fulfilment of all 4 criteria) was universally successful after a median of 5 days (IQR, 4-9 days). None of the patients had symptom recurrence after PCD removal, although residual collections were still seen in 97.3% of patients at the time of PCD removal and in 92.1% and 84.9% of patients available for follow-up at 1 and 3 months, respectively.

CONCLUSION

Based on our clinical protocol, PCD removal in ALA can be successfully expedited even in the presence of residual collections. An inability to fulfill all 4 criteria within 5 days of PCD placement warrants further evaluations for local and systemic complications that require additional therapeutic measures.

Liver Abscess in Children-experience From a Single Tertiary Care Center of North India: Etiology, Clinical Profile and Predictors of Complications

BACKGROUND

Liver abscess (LA), a common problem in children in the tropics, is believed to be mostly pyogenic (PLA), sometimes amebic (ALA). We aimed to analyze the clinical profile, etiology, risk factors for complications, management and outcomes of LA in children.

METHODS

The details of 81 children with LA managed in a tertiary set up over a period of 3 years were analyzed. A comparison of different parameters was performed with respect to etiology and complications.

RESULTS

ALA, PLA and mixed infection LA were diagnosed in 40 (49.4%), 32 (39.5%) and 9 (11.1%) children. The triad of fever, hepatomegaly and right upper quadrant tenderness was seen in 65 (80.2%). Coagulopathy was observed in 60 (77%) and jaundice in 12 (14.8%). Majority (71.6%) had a single LA in the right lobe (69%). Conservative, percutaneous needle aspiration, percutaneous catheter drainage and surgical drainage were done in 11.1%, 3.7%, 82.7% and 2.5%, respectively. Forty-three (53.1%) had complicated LA with rupture in 55.8% and vascular thrombosis in 16.2%. Children with complicated LA had higher alanine transaminase, prolonged prothrombin time/international normalized ratio, low serum protein and albumin levels (P < 0.05). Median duration of follow-up was 2 months and mean time to resolution of LA was 48.5 ± 18 days.

CONCLUSIONS

ALA is the commonest cause of pediatric LA in endemic regions and is difficult to differentiate from PLA clinically. Percutaneous catheter drainage is safe and effective modality for the management of LA in children. A higher alanine transaminase, prolonged prothrombin time/international normalized ratio and low serum albumin levels (<3 g/dL) at presentation identify complicated LA.

Prospective randomized comparative study of percutaneous catheter drainage and percutaneous needle aspiration in the treatment of liver abscess

BACKGROUND

This study aimed to assess the effectiveness and safety of percutaneous needle aspiration (PNA) and percutaneous catheter drainage (PCD) in the treatment of liver abscess.

METHODS

A prospective randomized study was conducted in the Department of Surgery, JN Medical College, Aligarh Muslim University, Aligarh, UP, India, between February 2018 and August 2019, after getting approval from the institutional ethics committee. A total of 543 patients with liver abscess were randomized into two groups using computer-generated randomization method. Appropriate details regarding patients' clinico-demographic profile and investigations were also collected. The effectiveness of either treatment was measured in terms of duration of intravenous antibiotic, clinical improvement, reduction in the size of cavity, treatment success rate, duration of hospital stay including long-term outcomes such as sonographic resolution of cavity and recurrence rate at 6 months post-treatment.

RESULTS

The PCD group had statistically significant rate of duration of antibiotics need, days for clinical improvement and time for 50% reduction in abscess cavity and treatment success rate with comparable long-term outcomes.

CONCLUSION

PCD is more efficient than PNA and can be used primarily in the treatment of both amoebic and pyogenic liver abscesses along with systemic antibiotics. However, PNA can serve as a safe alternative when PCD is not available.

Study of ultrasound-guided needle aspiration and catheter drainage in the management of liver abscesses

PURPOSE

To evaluate and compare the efficacy of intermittent needle aspiration and continuous catheter drainage in ultrasound-guided management of liver abscesses.

METHODS

This was a prospective, randomised study conducted on 100 patients (88 males and 12 females; age range 22-74 years) with liver abscess(es) and having abscess size more than 5 cm, divided into two groups: Percutaneous needle aspiration (PNA) (n = 50) and percutaneous catheter drainage (PCD) (n = 50). Criteria of exclusion were: rupture of abscess before intervention; prior intervention; uncorrectable coagulopathy; concomitant biliary tract malignancy. In the PNA group, pus was aspirated by an 18-gauge needle using freehand technique and the number of aspirations was limited to two. Failure of abscess size to decline below 50% of the original diameter or of clinical improvement after second aspiration was considered as failure of aspiration. In the PCD group, drainage was done by 12-French catheters using Seldinger technique. Drainage was considered as failure if abscess cavity did not resolve and laparotomy was needed to evacuate the pus cavity.

RESULT

The success rate in the PNA group was 88% and 92% in the PCD group; however, this difference was statistically not significant, suggesting that both are equally efficacious. The total duration of hospital stay (mean 6.8 days [PNA] vs 10.5 days [PCD]; p value: 0.011) and the average duration between intervention and discharge (5.9 days [PNA] vs 10.2 days [PCD]; p value:0.026) were significantly less in the PNA group. One major complication was seen in our study: peritonitis due to peri-catheter leak in PCD group.

CONCLUSION

Both procedures are equally efficacious in the management of liver abscesses; however in view of less duration of hospital stay, patient safety and comfort, procedure simplicity, and the reduced cost, needle aspiration should be used as the first-line procedure in the treatment of liver abscess (even in abscesses more than 5 cm). Catheter drainage should be reserved for cases that do not respond to a second attempt of aspiration.

Antiamoebic Activity of Adenophyllum aurantium (L.) Strother and Its Effect on the Actin Cytoskeleton of Entamoeba histolytica

In Mexico, the Adenophyllum aurantium (L.) Strother plant is consumed as an infusion to treat intestinal diseases such as amoebiasis, which is an endemic health problem in Mexico and other countries. However, the effect of A. aurantium on Entamoeba histolytica, the causative agent of amoebiasis, is unknown. An aerial part methanolic extract (AaMeA), a root methanolic extract (AaMeR) and a root ethyl acetate extract (AaEaR) were tested on E. histolytica trophozoites. AaMeA and AaMeR did not show antiproliferative activity; however, AaEaR exhibited an in vitro GI50 of 230 μg/ml, and it was able to inhibit the differentiation of Entamoeba invadens trophozoites into cysts. The intraperitoneal administration of AaEaR (2.5 or 5 mg) to hamsters that were infected with E. histolytica inhibited the development of amoebic liver abscesses in 48.5 or 89.0% of the animals, respectively. Adhesion to fibronectin and erythrophagocytosis were 28.7 and 37.5% inhibited by AaEaR, respectively. An ultrastructure analysis of AaEaR-treated trophozoites shows a decrease in the number of vacuoles but no apparent cell damage. Moreover, this extract affected the actin cytoskeleton structuration, and it prevented the formation of contractile rings by mechanism(s) that were independent of reactive oxygen species and RhoA activation pathways. (13)C NMR data showed that the major compounds in the AaEaR extract are thiophenes. Our results suggest that AaEaR may be effective in treatments against amoebiasis, nevertheless, detailed toxicity studies on thiophenes, contained in AaEaR, are required to avoid misuse of this vegetal species.

Percutaneous needle aspiration versus catheter drainage in the management of liver abscess: a systematic review and meta-analysis

OBJECTIVE

The aim of this study was to compare the effectiveness of percutaneous needle aspiration (PNA) and percutaneous catheter drainage (PCD) in the management of liver abscess.

METHODS

Electronic searches (Cochrane Library, MEDLINE, EMBASE, SCIE) were conducted to identify randomized controlled trials (RCTs) comparing PNA and PCD. A meta-analysis was subsequently performed.

RESULTS

A total of five RCTs covering 306 patients were included. The meta-analysis showed that outcomes in patients treated with PCD were superior to those in patients treated with PNA in terms of success rate [relative risk (RR): 0.81, 95% confidence interval (CI) 0.66-0.99; P = 0.04], clinical improvement [standardized mean difference (SMD): -0.73, 95% CI 0.36-1.11; P = 0.0001] and days to achieve a 50% reduction in abscess cavity size (SMD: -1.08, 95% CI 0.64-1.53; P < 0.00001). No significant differences were found in duration of hospitalization (mean difference: -0.17, 95% CI -2.10 to 1.75; P = 0.86) or procedure-related complications (RR: 0.50, 95% CI 0.10-2.63; P = 0.41). Days to achieve the total or near total resolution of the abscess cavity and mortality were not calculated because data in the RCTs in the meta-analysis were insufficient.

CONCLUSIONS

Both PNA and PCD are safe methods of draining liver abscesses. However, PCD is more effective than PNA because it facilitates a higher success rate, reduces the time required to achieve clinical relief and supports a 50% reduction in abscess cavity size. However, among successfully treated patients, the outcomes of PNA are comparable with those of PCD.

Prognostic indications of the failure to treat amoebic liver abscesses

OBJECTIVES

To identify the variables that predict the failure to treat amoebic liver abscesses.

METHODS

We prospectively carried out a case-control study on a cohort of patients who had been diagnosed with amoebic liver abscesses using clinical, ultrasonic, and serologic methods. Patients with pyogenic abscesses, negative ELISA tests for amoebiasis, immunosuppression status, or previous abdominal surgery were excluded. All patients received metronidazole, and those who demonstrated 4 days of unfavorable clinical responses received percutaneous or surgical draining of the abscess. Demographic, laboratory, and ultrasonographic characteristics were assessed as prognostic indications of failure.

RESULTS

Of 40 patients with amoebic liver abscess, 24 (mean age: 36·7±11·2 years) responded to medical treatment and 16 (41·8±11·6 years) required drainage, including 14 patients who underwent percutaneous drainage and two patients who required surgery. The albumin level, abscess volume, abscess diameter, and alkaline phosphatase level were all statistically significant (P<0·05) on the bivariate analysis. The highest (>99%) sensitivity and negative predictive value were observed for an abscess volume >500 ml and diameter >10 cm, while the best specificity and positive predictive value were achieved with the combination of low serum albumin level, high alkaline phosphatase level, and large abscess volume or diameter.

CONCLUSIONS

The prognostic indications of the failure to treat amoebic liver abscesses include low albumin, high alkaline phosphatase, and large abscess volume or diameter. The combination of these variables is a useful and easy tool for determining appropriate therapy.

Amebic infection in humans

Clinical human infections with the protozoa Entamoeba histolytica is still estimated to occur in 50 million people worldwide, of which approximately 100,000 die annually. Although most clinical symptoms are due to involvement of the large intestine, 1 % present with involvement of the liver in the form of a liver abscess, a potentially fatal condition. Distinguishing an invasive form (E. histolytica) from a morphologically identical non-invasive one (E. dispar) requires molecular or enzymatic characterization. Further, the pattern of infection, interpretation of presence of antibodies in the host, manifestations of disease, approach to investigations and strategies for management remain complex. This article also provides a comprehensive review of the parasite and host factors that govern the complex relationship of the prozoa and humans, and tries to explain why some develop a particular form of the disease in endemic zones. Application of modern imaging and image guided therapy seems to be playing a major role in diagnosis and management of the potentially most serious form of the disease, amebic liver abscess. Despite lack of controlled studies there is a tendency to lower the threshold of their use in clinical practice, and indeed in-hospital mortality rate seems to be falling for amebic liver abscess. In a world getting increasingly swamped by non-infectious metabolic diseases, awareness of amebic infections, its bed-side diagnosis, the use of appropriate laboratory tests, and decision making in management are shrinking. This review tries to update the scientific developments in amebiasis.

Catheter drainage versus needle aspiration in management of large (>10 cm diameter) amoebic liver abscesses

OBJECTIVES

To compare the effectiveness of percutaneous catheter drainage (PCD) and percutaneous needle aspiration (PNA) in the management of large (>10 cm diameter) amoebic liver abscesses.

METHODS

Eighty-two patients with amoebic liver abscess were randomly allocated to PCD (n = 42) or PNA (n = 40). Intervention was done under ultrasonography (US) [mainly] or computed tomography guidance within 24 h of admission. PNA was repeated every 3rd day if the cavity size had not reduced to 50% of the original size, for up to three times. Persistence of cavity or of clinical symptoms was considered failure of treatment. Duration to attain clinical relief, duration of hospital stay, complications, treatment failure and deaths were recorded.

RESULTS

PNA was successful in 32 (80%) patients (one aspiration in 4, two in 18 and three in 10 patients), while PCD was successful in 38 (90.5%) patients. Durations to attain clinical relief and parentral antibiotics required were significantly lesser in the PCD group. Hospital stay, although did not differ significantly, was lesser for PCD group. The only procedure-related complication due to PCD was rupture of abscess in two cases, leading to sepsis and death of one patient. Complications of PNA included pleural injury in one patient, and haemorrhage leading to subcapsular hematoma in another.

CONCLUSION

PCD is a better treatment option than PNA for the management of large (>10 cm diameter) amoebic liver abscess, in terms of duration to attain clinical relief and duration for which parentral antibiotics were needed.

Identification of high-risk group and therapeutic options in children with liver abscess

The outcome of children with liver abscess (LA) depends upon prompt diagnosis and intervention. We evaluated the etiology, clinical profile, various interventional modalities of management and outcome of children with LA. A total of 39 hospitalized children (mean age 7.2 ± 3.9 years) with radiologically proven LA were analyzed. Parenteral antibiotics, percutaneous drainage (PD) or open surgical drainage (OSD) was done as required. Cases with ruptured or impending rupture of LA, upper gastrointestinal bleed, jaundice, pleural effusion or consolidation were labeled as "high risk" cases. Triad of fever, pain and hepatomegaly was the most common presentation. Single abscess was present in 66.7% and right lobe was involved in 69.2% of cases. Majority of LA were pyogenic (PLA, 25/39). Amebic liver abscess (ALA) and PLA had similar clinical and laboratory profile except that multiloculated abscess on ultrasonography was a feature of PLA (12/25 vs. 0/11; p = 0.006). Cases with ALA settled significantly more often with antibiotics alone (5/11 vs. 3/25; p = 0.04) than PLA and none required surgery (0/11 vs. 7/25; p = 0.03). Subjects with "high-risk" LA (n - 26) had significantly larger abscesses, more polymorphonuclear leucocytosis (74 ± 15% vs. 61 ± 13%; p = 0.01) in peripheral blood and need of drainage (24/26 vs. 7/13; p = 0.03) than patients with average-risk LA. Based on the results, 38/39 children recovered, with complete abscess resolution in 28, over 48 ± 63.8 days. In conclusion, ALA, although similar in presentation, are uniloculated, and patients with ALA recover more often without drainage than patients with PLA. Patients with "high risk" LA are more common and have a good outcome with drainage. PD, being safe, efficacious and less invasive than OSD, should be the preferred drainage procedure.

Complications of percutaneous fluid drainage

Percutaneous abscess drainage is one of the most common and rewarding procedures performed by interventional radiologists. Technical success is immediately apparent by aspiration of purulent contents and is nearly always achieved, with rates exceeding 90% in most literature studies. Clinical success is typical even for many abscesses colonized with multidrug-resistant organisms. In patients presenting with sepsis, this procedure offers an immediate and minimally invasive solution to a life-threatening condition, often resulting in defervescence and restoration of hemodynamic stability within 1 to 2 days. Although complications of abscess drainage are uncommon, radiologists should be able to recognize and treat all adverse sequelae discussed in this article.

Comparative study of catheter drainage and needle aspiration in management of large liver abscesses

OBJECTIVE

To compare the effectiveness of percutaneous catheter drainage (PCD) and percutaneous needle aspiration (PNA) in the management of large (>10 cm diameter) liver abscesses.

METHODS

Seventy-two patients with liver abscess (amebic 48, pyogenic 24) were randomly allocated to PCD or PNA (36 each), which were done within 24 hours of admission. Both groups received parenteral antibiotics for at least 10 days. 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. Duration to attain clinical relief, duration of hospital stay, complications, treatment failure, and deaths were recorded.

RESULTS

PNA was successful in 31 of 36 (86%) patients (one aspiration in 10, two in 18, and three in 3 patients), whereas PCD was successful in 35 (97%) patients (p=ns). Duration to attain clinical relief (10.2 [2.0] vs. 8.1 [2.7] days; p=0.02) and parenteral antibiotics needed (15.5 [1.1] vs. 10.9 [2.7] days; p=0.04) were significantly lower in PCD group. Duration of hospital stay was similar in the two groups. One patient with PNA had a subcapsular hematoma and one with PCD had continuous bile leakage which stopped spontaneously. One patient in PCD group died.

CONCLUSION

PCD is a better treatment option than PNA for the management of large liver abscesses of size >10 cm, in terms of duration to attain clinical relief and duration for which parenteral antibiotics are needed.

[Analysis of factors associated to failure of medical treatment of amoebic liver abscess]

INTRODUCTION

To identify the laboratory and ultrasound factors that could predict the response to medical treatment of amoebic liver abscess.

MATERIAL AND METHOD

Retrospective study of patients diagnosis with amoebic liver abscess in Hospital Central in San Luis Potosí, Mexico. We included patients greater than 15 years of both sexes. We excluded those with probable pyogenic abscess, immunosupression, history of abdominal or biliary surgery, abdominal neoplasm abdominal or sepsis. We identified patients with good response to medical treatment and patients who needed the abscess drained. We studied the ultrasound findings, plasma levels of albumin, alkaline phosphatase and bilirubin.

RESULTS

We analysed 45 patients, 31 had a good response (controls) and 14 needed drainage (cases). The medians of the variables with statistical significance in bivariate analysis were: albumin 2.65 g/dl and 1.7 g/dl (p < 0.001); alkaline phosphatase 133 U and 259 U (p = 0.02) and diameter of absences 5.9 cm and 9.95 cm (p < 0.001), controls and cases respectively. By logistic regression the diameter of the abscess showed a determination coefficient of 0.447 (p < 0.05) and OR = 14.85 (95% CI, 2.11-104.9) for drain if it was > or = 8 cm.

CONCLUSIONS

A diameter bigger than 8 cm in hepatic amoebic abscess is associated with failure of medical treatment. Low albumin could be related to malnutrition and increased alkaline phosphatase with extrinsic compression of extrahepatic conducts due to big abscesses.

What affects mortality after the operative management of hepatic abscess?

BACKGROUND

Historically, the operative mortality associated with hepatic abscess was >50%. More recently, patients have been treated with percutaneous drainage; however, those failing conservative management are treated operatively. Our aim was to evaluate the outcome of operation for hepatic abscess in those failing conservative treatment or in those presenting as a surgical emergency.

PATIENTS AND METHODS

This was a retrospective review of patients undergoing operation for hepatic abscess at the Mayo Clinic, Rochester, Minnesota from 1990 to 2003.

RESULTS

Of 288 patients diagnosed with hepatic abscesses, 32 required operation. Percutaneous drainage was the initial treatment in 15 (47%). The remaining 17 were initially managed with operation. Operative indication was septic shock (41%), failed nonoperative management (31%), and failure to make a diagnosis (28%). Operation was drainage (62%) or resection (38%). The morbidity and mortality rates were 41% and 15.6%, respectively. Factors associated with increased operative mortality were shock (p=0.04), INR > 1.5 (p=0.03), WBC >15 000 (p=0.04), AST > 150 U/L (p=0.01), alkaline phosphatase >500 U/L (p=0.03), positive blood cultures (p=0.03), total bilirubin >2.0 mg/dl (p<0.01), multiple abscesses (p=0.01), and second operation (p<0.001). Factors not associated were extent of resection (p>0.10), peritonitis (p>0.10), intensive care admission (p>0.10), polymicrobial infection (p>0.10), and blood transfusion (p>0.10).

CONCLUSION

Operative intervention is avoided in 89% of patients with hepatic abscess. Septic shock is the most common reason for operation. Patients with septic shock, INR>1.5, WBC>15 000, AST>150 U/L, total bilirubin >2.0 mg/dl, positive blood cultures, or alkaline phosphatase >500 U/L have increased mortality when undergoing operation for hepatic abscess.

Experience with aspiration in cases of amebic liver abscess in an endemic area

The study presented here was performed to evaluate the need for aspiration in patients with amebic liver abscess (ALA). Patients older than 12 years with a diagnosis of ALA based on clinical features, ultrasound results, and positive amebic serology were included in the study (n=144). Serological testing was performed to detect the presence of immunoglobin G antibody against Entamoeba histolytica, and a value of more than 0.4 optical density units was considered positive. All patients were given intravenous metronidazole (500 mg every 8 h) and their clinical progress and need for abscess aspiration was documented. Fever, pain in the upper abdomen, and tender hepatomegaly was seen in 133 (92.3%), 128 (88.8%), and 144 (100%) patients, respectively. Multiple abscesses were seen in 40 (27.7%) patients. Six (4.1%) patients died. Seventy-one (49.3%) patients responded to metronidazole alone. A total of 73 (50.69%) patients required aspiration of the abscess. This study shows that almost 50% of the patients with amebic liver abscess failed to respond to metronidazole and required aspiration.

Amebic liver abscess

Amebic liver abscess is the most common extraintestinal manifestation of infection with Entamoeba histolytica, and it is associated with significant morbidity and mortality. In this article the most recent available information is reviewed relating to epidemiology, pathogenesis, presentation, diagnosis, and treatment. We reviewed thousands of cases of amebic liver abscess in the medical literature and present that information as it pertains to mortality, gender, anatomic location of abscesses, and clinical signs and symptoms.

Drainage of deep-seated amoebic liver abscess by Supra cath

Supra cath is an effective alternative to trocar for drainage of deep-seated liver abscess especially in obese or muscular patients with a thick parietal wall.

[Amoebic liver abscess. Study of 20 cases with literature review]

PURPOSE

The management of amoebic liver abscess includes antiamoebic drugs combined or not with percutaneous puncture or surgical drainage. This study was to suggest a decision tree for the therapeutic approach of such feature.

METHODS

We report a retrospective analysis of 20 imported cases with amoebic liver abscesses admitted at the Department of Tropical Diseases during 1995-1999 at the Bordeaux University Hospital Centre, France, and a review of the literature.

RESULTS

The twenty patients were 14 males and 6 females, mainly 20 to 40 years old. The clinical presentation was mainly accounting a painful liver enlargement with hyperthermia. The echographic picture was mostly represented by a unique liver element located at the liver right lobe. They were numerous in an HIV infected patient. Thirteen patients have been treated using a medical therapeutic approach. A percutaneous puncture has been necessary for 4 cases. A percutaneous drainage has been realised for two patients as regard to the persistence of the hepatalgia occurrence. A surgical drainage has been experienced by two patients after a lack of efficacy of a percutaneous drainage, after rupture of an abscess treated medically, respectively. A review of the literature and the analysis of the 20 cases history have been used to determine a therapeutic algorithm.

CONCLUSION

The occurrence of immediate complications at onset must indicate a first line surgical drainage procedure. Beside this situation, risk factors for rupture must be assessed (high size abscess, pejorative localization), as well as poor prognosis feature (liver failure, bacteraemia). If no pejorative condition occurs, a first-line exclusive medical approach can be undertaken with a clinical efficacy evaluation at H72. Otherwise, the indication of the percutaneous drainage must be discussed.

Amebic liver abscesses masquerading as pyemic abscesses

We describe a 50-year-old man who presented with multiple liver abscesses that suggested biliary sepsis or portal pyemia. A wet preparation of a sample of aspirate showed the presence of amebic trophozoites, and subsequent serological testing for amebae was strongly reactive.

Analysis of 69 patients with amebic liver abscess

All 69 patients with amebic liver abscess that we treated in 1981-1992 were studied retrospectively. Men predominated by a 10:1 ratio. Of our 227 patients with amebiasis, some 30% yearly had liver involvement. The incidence peaked in 1988, decreasing later but increasing again in 1992. Most patients were 30-50 years old, the overall mean age being 45 years (range, 22-79), and decreasing with time. Patients with the related factors of travel abroad, positive results of a test for Treponema pallidum hemagglutination, and homosexuality have increased in number in recent years. Fever, abdominal pain, and hepatomegaly were the most frequent findings, and 39 patients had neither bloody stools nor diarrhea. Only 8 patients had had amebiasis previously. A solitary abscess in the right lobe of the liver was found in 40 patients. Entamoeba histolytica was found in the stool of 31 patients and in the pus of 39 patients. Sixty-one patients had positive results for an amebic serological test(s). The abscesses ruptured into the peritoneal cavity in 4 patients. All patients received metronidazole. Percutaneous or surgical drainage (or both) was done in 62 patients. The outcome was good, with 1 exception, and only 2 patients had recurrences.

Percutaneous catheter drainage of amebic liver abscesses with and without intrahepatic biliary communication: a comparative study

Influence of communication with the intrahepatic biliary system on the clinical picture of amebic liver abscesses in 33 consecutive patients resistant to medical therapy, and their response to percutaneous catheter drainage was evaluated. Abscess-biliary communication was found in 27% of the sample. Patients with abscesses communicating with the biliary tree presented more frequently with jaundice (67% vs. 0%, P < 0.005), with a longer duration of illness (median 20 vs. 12 days, P < 0.001), had larger lesions (median 600 vs. 320 ml, P < 0.001) and required catheter drainage for longer periods (median 17 vs. 6.5 days, P < 0.000001). However the presence of a biliary communication did not materially affect the cure rate with catheter drainage (89% vs 100%, P > or = 0.05). In conclusion, an abscess-biliary communication is not uncommon in refractory amebic liver abscesses, and can be clinically detected by the presence of jaundice. Though a prolonged period of drainage may be necessary in the presence of this complication, catheter drainage can be expected to result in cure.

Complex ruptured amebic liver abscesses: the role of percutaneous catheter drainage

The failure of medical therapy for amebic liver abscess may be followed by its perforation, a complication associated with high mortality. We assessed the role of percutaneous catheter drainage in management of the sequelae of ruptured amebic abscesses in 13 critically ill patients; 22 intrahepatic lesions, three of which were multiloculated, were drained. Catheters were also placed in 17 extrahepatic collections: pleural space (n = 5), subphrenic (n = 7), perihepatic/subhepatic (n = 3), greater sac of peritoneum (n = 2). No attempt at percutaneous drainage failed. Prompt resolution of clinical features following drainage was a uniform feature. Successful resolution of the abscesses occurred within 20 days in 11 patients. In the remaining two, catheters needed to be retained in situ for 35 and 50 days. The mean hospital stay was 15 days (range 10-20 days). 100% patient survival was achieved, without a single morbid episode. Our results suggest that patients with ruptured amebic abscesses can be effectively and safely managed by percutaneous catheter drainage irrespective of the extent of extrahepatic contamination.

Computed tomography and ultrasound in the diagnosis and treatment of liver abscesses

Liver abscess remains a serious and even life-threatening condition, despite advances in imaging and treatment. The diagnosis of liver abscess depends heavily on radiologic imaging, particularly ultrasound (US) and computed tomography (CT) scanning. The appearance of liver abscesses on these modalities depends mainly on the chronicity of the abscess. The US and CT features of 33 patients with liver abscesses are presented. Percutaneous drainage of pyogenic abscesses under imaging control is the treatment of choice. Eleven of 24 patients with pyogenic abscesses had percutaneous drainage with good results.

Amoebiasis: a rare cause of cardiac tamponade

Cardiac tamponade secondary to perforation of a hepatic amoebic abscess developed six years after the patient had visited an area where Entamoeba histolytica is endemic. He was treated with metronidazole and imipenem, emergency percutaneous catheter drainage, and open surgical drainage.