以肝脓肿为首发表现的横结肠癌溃疡穿孔一例

临床上肝脓肿是一种常见的腹部急症,为细菌或阿米巴等寄生虫导致。结肠癌是临床常见的恶性肿瘤。但临床上,结肠癌穿孔致肝脓肿为首发表现则较为罕见,我们结合临床实践中遇到的一例以肝脓肿为首发症状的结肠癌,对此类病例进行讨论与复习,为其他医院的医生诊治提供参考。     

Hazards of cortisone therapy in hepatic amoebiasis

Twelve cases were presented as amoebic liver abscess. They were clinically diagnosed and confirmed by screening, selective hepatic angiography and aspiration of abscess cavity. History of cortisone therapy was obtained in 66 per cent of the cases within a period of 1--3 months. Corticosteroids being immunosuppressive drugs may turn dormant amoebic hepatitis into liver abscess.     

Immunogenicity of detergent membrane proteins of Entamoeba histolytica.

The lymphokine release and antibody production were assessed in the peripheral blood of 52 and 48 cases of amoebic liver abscess respectively, by employing detergent dissected membrane proteins (DDMP) of axenic Entamoeba histolytica (NIH:200). Lymphokine release by T lymphocytes in response to both DDMP and whole amoebic lysate (WAL) was performed by leukocyte migration inhibition test. A highly increased release of LMIF and 100 per cent positivity was observed with DDMP where as the same for whole amoebic extract, was only 73 per cent. The difference between the means of the above two values with regards to release of LMIF, was found to be highly significant (P less than 0.005). Antibodies production in response to both DDMP and whole amoebic lysate was performed by indirect haemagglutination assay on blood samples from amoebic liver abscess cases. A 53 folds increased titres of IHA and cent percent positivity was observed with DDMP compared to WAL. The difference between mean titres of the above two with regards to detection of antibodies, was found to be highly significant (P less than 0.001). This shows that the patients, had high degree of leukocyte sensitization and production of antibodies which will not be assessed simply with WAL. These findings suggest that the shed material might have important role as a potent antigen in elicitation cell mediated and humoral immune response in amoebic liver abscess cases.     

Drug and immuno-diagnostic resistant amoebic liver abscess in Ibadan: an elucidation of a possible mechanism.

A thick fibrous walling of amoebic abscess of the liver is very rare. Using as a basis the case of drug and immunodiagnostic resistant amoebic liver abscess in an adult Nigerian, an account is given of the possible mechanisms for such therapeutic and diagnostic failure. A theory of blood-abscess cavity barrier is postulated and suggested as a mechanism for the constant failure to detect antibodies to E. histolytica in the small percentage of cases of amoebic liver abscess (Morris, Powell and Elsdon-Dew, 1970). A study of the rate of diffusion of amoebic excretion/secretion through a thick fibrous tissue or artificial membrane of comparable properties is strongly advocated.     

Amoebic liver abscess rupturing into the chest: ultrasonographic appearance

Two cases of amoebic liver abscess perforating into chest are reported. Both patients were males in their twenties. They presented with right upper quadrant pain in abdomen in one case and right lower chest pain in second case. Ultrasonography demonstrated hypoechoic liver abscess in superior subdiaphragmatic part of the right lobe of liver, with communication through a hole in the diaphragm into the thoracic cavity in both the cases. Both these cases were diagnosed as cases of amoebic liver abscess perforated into chest on the basis of ultrasonographic findings and both of them showed good response to specific antiamoebic therapy.     

Immunodiagnosis of amoebiasis

Serological studies were done on 127 cases using three different techniques namely indirect haemagglutination (IHA), indirect fluorescent antibody test (IFT) and counter immunoelectrophoresis (CIEP) to detect antiamoebic antibodies. All amoebic liver abscess cases showed significant titre of antibodies by all the three tests used. In the group of patients suffering from amoebic pathology of liver, 90.47 per cent were positive by IHA, 100 per cent by IFT and 85.71 per cent by CIEP respectively. Among amoebic dysentry and amoebic colitis cases 81.81 per cent and 80.64 per cent respectively were positive by IHA. The corresponding figures for IFT were 100 per cent and 74.19 per cent and for CIEP 90.90 per cent and 64.51 per cent respectively. Follow up study showed no significant fall in antibody titre in nine cases studied upto 10 weeks after treatment. Amoebic antigen could be detected in pus from all the nine cases with amoebic liver abscess by CIEP test.     

Pathophysiology of jaundice in amoebic liver abscess

Jaundice in patients with amoebic liver abscess is a frequent occurrence. However, the pathophysiology of jaundice in these patients is not fully understood. Hepatic necrosis leads to damage to bile ducts as well as various vascular structures, which in turn leads to biliovascular fistula and jaundice. We studied the mechanism of jaundice in patients with amoebic liver abscess. We prospectively evaluated 12 patients with amoebic liver abscess and jaundice from February 2002 to August 2007. All patients underwent various investigations, including imaging studies. There were 11 males and 1 female patient with a mean age of 41.3 years. Mean duration of illness before presentation was 13.8 days. All patients had fever and jaundice. We detected damaged hepatic veins and bile ducts in all patients with amoebic liver abscess causing biliovascular fistula and hyperbilirubinemia, which reverted to normal after biliary diversion with nasobiliary drainage. Jaundice in patients with amoebic liver abscess is caused by biliovascular fistula resulting from hepatic necrosis leading to damage to bile ducts and hepatic veins.     

Ultrasound patterns and frequency of focal liver lesions after successful treatment of amoebic liver abscess

OBJECTIVE: To evaluate the frequency and morphology of residual liver lesions in patients successfully treated for amoebic liver abscess. METHODS: Retrospective ultrasound-based study of 240 adult males from an amoebiasis-endemic area in Vietnam with a documented clinical history of amoebic liver abscess. Subjects were re-examined by hepatic ultrasound 1-13 years after abscess treatment. RESULTS: In 17 subjects (7.1%) focal hypo- or isoechoic areas were identified within the liver with a diameter of 8-48 mm surrounded by a hyperechoic wall. These lesions were associated with positive amoeba serology, were located at the site of the previous abscess and their sonographic appearances corresponded to post-amoebic liver abscess residues. Residues were found in all groups of patients irrespectively of the time-span since the abscess was treated. However, lesions older than 7 years showed some degree of calcification. Otherwise, lesions were apparently inactive, as patients had no clinical symptoms or signs of inflammation and follow-up after one year revealed no changes in size or pattern. CONCLUSION: The vast majority of amoebic liver abscesses resolve to a sonographically normal parenchymal pattern. However, in a small proportion of cases characteristic residues remain. These residues do not require further treatment or diagnostic intervention and should be considered in the differential diagnosis of space-occupying liver lesions, in particular in patients from amoebiasis-endemic areas.     

Antibodies to the serine rich Entamoeba histolytica protein (SREHP) prevent amoebic liver abscess in severe combined immunodeficient (SCID) mice

Amoebic liver abscess caused by Entamoeba histolytica is a major cause of morbidity and mortality worldwide. We used mice with severe combined immunodeficiency (SCID mice) to study the role of antibody in protection from amoebic liver abscess, and to identify protective antigens of E. histolytica. Antisera to recombinant versions of two major surface antigens of E. histolytica, the serine rich E. histolytica protein (SREHP) and the 170 kDa adhesin were used in this study. We found that 100% of SCID mice passively immunized with antiserum to the recombinant SREHP molecule were protected from developing amoebic liver abscess after intrahepatic challenge with virulent E. histolytica trophozoites. In contrast, preimmune serum, antiserum to a portion of the 170 kDa adhesin, and antiserum to the trpE fusion partner of SREHP did not protect SCID mice from amoebic liver abscess. Our study demonstrates that antibodies to a recombinant version of the amoebic SREHP molecule can protect against amoebic liver abscess, and suggest the recombinant SREHP molecule should be considered as a possible vaccine candidate to prevent amoebic liver abscess.     

Detection of Entamoeba histolytica trophozoites in liver pus by the indirect fluorescent antibody test for the aetiological diagnosis of amoebic liver abscess

The indirect fluorescent antibody test was used to detect trophozoites of Entamoeba histolytica in liver pus aspirated from patients with amoebic liver abscess. The test can be carried out in no more than two hours. Trophozoites with fluorescence were observed in 17 of the 18 patients with amoebic liver abscesses who were studied. Cells with fluorescence were not found in any negative control specimens from patients with bacterial liver abscess, primary liver cancer, cirrhosis or tuberculous peritonitis. These results indicate that this sensitive, specific and rapid test is very useful in aetiological diagnosis of amoebic liver abscess.     

Cholestasis in amoebic liver abscess.

Two hundred and thirty six patients with amoebic liver abscess were investigated for cholestasis, its mechanism and the natural course of the disease. Cholestasis was seen in 29% of cases and it presented with some unusual features: it was frequently seen in young men (mean age 38.6 +/- 6.3 years) (87%) with acute onset (69%) and was associated with signs of peritonism, or peritonitis (28%), splenomegaly (12%) and hepatic encephalopathy (coma 13%). Raised diaphragm was seen only in 37% of cases. Alcoholism may have contributed to the cholestasis in 37% of cases. Multiple (43%) and single (32%) large liver abscesses, especially on the inferior surface of the liver (25%), were common in jaundiced patients with amoebic liver abscess, while size and number of abscesses were directly related to the raised serum bilirubin concentrations. Bromsulphalein excretion (BSP) was found to be significantly reduced (p less than 0.01) in patients with jaundice (60%). Retrograde injection of contrast media into the common bile duct during six necropsies showed compression by amoebic liver abscess on the hepatic ducts. The mortality (43%) and the complications were significantly higher (p less than 0.001) in patients with jaundice. The aspiration/surgical drainage of amoebic liver abscess together with a combination of metronidazole and di-iodohydroxyquinoline was more effective than either metronidazole alone, or dehydroemetine with chloroquine.     

Increased frequency of HLA-DR3 and complotype SCO1 in Mexican mestizo children with amoebic abscess of the liver

The increase of HLA-DR3 and complotype SCO1 previously found in Mexican mestizo adults with E. histolytica amoebic abscess of the liver, was also found in Mexican mestizo children of either sex with the same disease, when compared to the healthy control population (adults and/or children) of the same ethnic and socioeconomic background. This HLA and complotype pattern was not found in Mexican Mestizo patients with amoebic rectocolitis. No linkage disequilibrium was found between these and the other MHC determinants tested in this survey. Thus, HLA-DR3 and SCO1 may constitute primary, independent risk factors, not for any kind of amoebic tissue invasion (i.e. amoebic rectocolitis), but specifically for amoebic liver abscess, irrespective of age or sex. The possibility of linkage disequilibrium with other factors (i.e. the TNF family) within or close to the MHC that were not tested in this study, is discussed. Children with amoebic liver abscess revealed a significant increase in HLA-DR5, and the absence of HLA-DR6 when compared to adults with amoebic liver abscess, suggesting that at least in this ethnic group these class II HLA traits may contribute to some of the peculiarities of pediatric amoebic liver abscess as opposed to the adult version of this disease. HLA-DR3, SCO1, but also HLA-DR5 and HLA-DR6 have all been associated with certain forms of immune-dysfunction, and may thus contribute to some of the clinical and immunological features of this parasitic disease.     

Causative agents of liver abscess in HIV-seropositive patients: a 10-year case series in Thai hospitalized patients

Liver abscess is an important tropical gastrointestinal disorder. HIV seropositive patients show relative immunosuppression and are more susceptible to infection, including liver abscess. This retrospective case review was made on 23 patients who were diagnosed as HIV seropositive with liver abscess in Bangkok, Thailand. We demonstrated the high rate of amoebic liver abscess in our series (17.4%) from fresh smear with five cases of tuberculosis and one case of Nocardosis. The rates of positive bacterial culture were 17.4% from blood and 47.8% from pus. Gram-negative aerobes were the major abscess pathogens in our series. Among Gram-negative aerobes, Klebsiella was the most significant microorganism, followed by Escherichia coli and Pseudomonas aeruginosa.     

Amoebic abscess in the cirrhotic liver.

Though amoebic liver abscess and liver cirrhosis occur very commonly in hospital practice in the tropics, they have not to the knowledge of the present authors hitherto been reported to occur simultaneously in the same patient. The patient described here, who had clear-cut clinical and histological features of chronic liver cirrhosis with portal hypertension and ascites, presented somewhat acutely with liver pain and an amoebic liver abscess that contained 'chocolate sauce' on needle aspiration. The amoebic abscess, although, no doubt, superimposed on chronic irreversible cirrhosis, rapidly regressed on metronidazole therapy. The infrequency with which liver abscess and liver cirrhosis coexist cannot be satisfactorily explained. It is probable, however, that extensive scarring in the liver may prevent entamoeba histolytica from thriving.     

Ponction échoguidée plus métronidazole versus métronidazole seul dans la prise en charge des abcès amibiens collectés de l’enfant

Preamble

Metronidazole is usually sufficient for the treatment of amoebic liver abscess. But in some cases, it is necessary to add drainage.

Objective

To demonstrate the importance of the association of metronidazole with ultrasound-guided draining in the outpatient treatment of amoebic liver abscess in children.

Patients and methods

This is a retrospective case-control study of 5 years. It involved 60 children with a liver filled with abscess. They were managed as outpatients by the paediatrician and the radiologist with metronidazole and ultrasound-guided draining. The duration of hospital stay, time for disappearance of clinical signs and time to dry abscesses were compared with a population of 26 children, hospitalized for the same pathology, in the same period, whose treatment involved only metronidazole.

Results

Ultrasound-guided draining was well tolerated by all patients. There were no complications or death The duration of hospital stay was 1.35 days against 6.65 days for patients treated with metronidazole alone (significant difference, p = 0.001). The disappearance of clinical symptoms was obtained in 4.77 days against 6.65 days for the group of patients treated with metronidazole alone (significant difference, p < 0.001). The drying up of abscesses was obtained in an average of 21.2 days and ranged from 7 to 56 days, in contrast to the control group, which required an average of 90 days, with the range of 77–140 days (significant difference, p < 0.001).

Conclusion

The combination of metronidazole and ultrasound-guided draining of amoebic liver abscess in children appears beneficial in terms of duration of hospital stay and time for disappearance of clinical signs and drying up of abscesses.     

Liver abscess: a rare but an important complication that must be considered in Crohn's disease

Liver abscess is a quite rare complication in Crohn's disease. Early diagnosis and differentiation of pyogenic abscess from amoebic abscess are as important as the choosing of proper treatment in the management of liver abscess. Herein, 28-year-old man with Crohn's disease developing liver abscess is presented. He was treated with surgical drainage.     

Hepatic trauma and amoebic liver abscess

A patient with a history of severe trauma over the hepatic area followed 2 weeks later by a large amoebic liver abscess of the right lobe is described. The possible role of hepatic trauma in the genesis of liver abscess is discussed. A history of hepatic trauma should not distract the clinician from diagnosing an amoebic liver abscess when suggestive symptoms and signs occur.     

Ultrasonographic features of amoebic abscess: Study in 59 patients

Sonographic examination was carried out in 59 patients with a clinical diagnosis of amoebic liver abscess during the previous 4 years (January 1982 to December 1985). The amoebic liver abscess was located in the right lobe in 45 patients, in the left lobe in eight patients, and in both lobes in six patients. The ultrasonic diagnosis was confirmed in the majority of patients by the indirect haemaglutination test (titres 1:512 or greater) coupled with excellent response to metronidazole, or by ultrasonic-guided percutaneous aspiration producing anchovy sauce pus.
The sonographic patterns of the abscess were evaluated. All patients had well-defined hypoechoic lesions near the surface, which demonstrated fine homogeneous low-level echoes throughout at a normal and a high-gain setting, without a peripheral echo-free halo. The configuration of the abscess was round, oval or lobulated. The walls were irregular in 53 patients, and showed a slight distal sonic enhancement. This ultrasonic feature is suggestive of amoebic liver abscess. The specific ultrasonographic features of amoebic liver abscess, combined with a feature of pleural effusion, pericardial effusion, or an abdominal abscess, were suggestive of the complications of liver abscess found in 19 patients.
It is concluded that ultrasonography is a valuable aid in the diagnosis of amoebic liver abscess. It is of value not only for detection, but also for determination of the site, depth, size, and location of the complicating rupture of the abscess.     

Fundamental studies on serological diagnosis of amoebiasis. 2. Application of antigen of Entamoeba histolytica for complement fixation test to counterimmunoelectrophoresis; and clinical relevance of serological tests

Antigen of Entamoeba histolytica for complement fixation (CF) test was applied to counterimmunoelectrophoresis (CIE), and the result was compared with that of CF test and enzyme-linked immunosorbent assay (ELISA) in regard to sensitivity and specificity. Besides, we studied antibody titers to E. histolytica in sera from acute and convalescent patients, and from patients with amoebic colitis and amoebic liver abscess. Sera used were from patients with amoebic colitis, amoebic liver abscess and uninfected control subjects. The CIE was less sensitive than the CF test and ELISA. Most CIE-negative samples had low CF and ELISA titers, but a few samples had higher CF and ELISA titers. On the other hand, all uninfected controls were negative by CIE and ELISA, and 98% were negative by the CF test. The level of antibodies tended to decrease with time after clinical recovery, but CF test and ELISA results remained positive in all patients 6 months after clinical cure. CIE converted negative in only one patient after 6 months. The level of antibodies of CF test and ELISA was significantly higher in amoebic liver abscess than amoebic colitis. These results suggested that all these three methods were so specific, and antibody titers by the CF test and ELISA were well correlated to clinical manifestations. The CIE with CF-antigen was less sensitive as compared with CF test or ELISA.     

Fistulisation cutanée d’une amibiase hépatique : une complication rare

In most cases, the clinical course of amoebic liver abscesses involves a gradual increase in the area of necrosis as well as the risk of the rupture of neighbouring organs, especially the peritoneum, pleura, bronchi, pericardium, or another hollow viscus. Cutaneous fistulas are rare. We report a case of untreated amoebic liver abscess, complicated by a cutaneous fistula.