Ultrasonography in the diagnosis and management of 52 patients with amebic liver abscess in Cairo

Clinical characteristics of 52 patients with amebic liver abscess are reported. Forty-two percent had an acute illness, usually with high fever, vomiting, sweating, pain in the abdominal right upper quadrant, and leukocytosis. The other 58% had a more chronic illness, usually with a dull ache in the right upper abdomen, weight loss, fatigue, moderate or low-grade pyrexia, and anemia. Hepatomegaly and hepatic tenderness were present in all patients; fever occurred in 75%. The diagnosis was strongly suggested by amebic antibodies in high titer and hepatic abscesses demonstrated by sonography. Mean abscess diameter was 9.2 cm; 37% were larger than 10 cm. Most abscesses were solitary (81%), in the right lobe (73%), rounded or oval (78%), cystic (57%), and had a well-defined wall (53%). However, 43% were initially solid or heterogeneous. The latter lesions always developed a cystic pattern when ultrasonography was repeated. The diagnosis was confirmed by a good clinical response to metronidazole in 50 patients. Complications included right-sided pleural effusions or empyema (13%), ascites (13%), and jaundice (13%). Drainage of large abscesses was performed in four patients. All 52 patients survived and were cured.     

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.     

Features distinguishing amoebic from pyogenic liver abscess: a review of 577 adult cases

Distinguishing amoebic from pyogenic liver abscesses is crucial because their treatments and prognoses differ. We retrospectively reviewed the medical records of 577 adults with liver abscess in order to identify clinical, laboratory, and radiographic factors useful in differentiating these microbial aetiologies. Presumptive diagnoses of amoebic (n = 471; 82%) vs. pyogenic (n = 106; 18%) abscess were based upon amoebic serology, microbiological culture results, and response to therapy. Patients with amoebic abscess were more likely to be young males with a tender, solitary, right lobe abscess (P = 0.012). Univariate analysis found patients with pyogenic abscess more likely to be over 50 years old, with a history of diabetes and jaundice, with pulmonary findings, multiple abscesses, amoebic serology titres <1:256 IU, and lower levels of serum albumin (P < 0.04). Multivariate logistic regression analysis confirmed that age >50 years, pulmonary findings on examination, multiple abscesses, and amebic serology titres <1:256 IU were predictive of pyogenic infection. Several clinical and laboratory parameters can aid in the differentiation of amebic and pyogenic liver abscess. In our setting, amebic abscess is more prevalent and, in most circumstances, can be identified and managed without percutaneous aspiration.     

Causative agents of liver abscess in those with liver cirrhosis: a 10-year case review of hospitalized patients in Thailand

Although patients with cirrhosis of the liver show relative immunosuppression and therefore have increased susceptibility to most infections, they rarely develop liver abscesses. In a retrospective case review, the pathogens causing the liver abscesses observed, between January 1992 and December 2001 at the King Chulalongkorn Memorial Hospital, Bangkok, Thailand, in 44 hospitalized patients diagnosed as cases of liver cirrhosis were investigated. The most common clinical symptoms and signs of the abscesses--abdominal pain (80%), fever and chills (73%), and abdominal tenderness (73%)--were similar to those seen in non-cirrhotic patients with abscesses. The frequency of liver abscess among the cirrhotic patients was low (0.46%). Most (71%) of the abscesses were in the right lobe and most (71%) of those with abscesses only had a single abscess. Surprisingly, many of the abscesses (36%) were apparently caused by amoebae. Bacterial pathogens were identified in eight patients (18%) by blood culture and 15 (34%) patients by pus culture. Seven (16%) of the blood cultures and 13 (30%) of the pus contained Gram-negative aerobes, indicating that such pathogens, particularly Klebsiella pneumoniae (in six pus and six blood cultures) and Escherichia coli (in three pus cultures and one blood), were the most common causes of the bacterial abscesses. Pus culture appeared more successful than blood culture for bacterial abscesses, and amoebic abscesses could always be identified by direct microscopical examination of pus samples. Aspiration of liver abscesses, to obtain pus samples for culture and microscopy, is therefore recommended.     

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 in Crohn's Disease

Liver abscess is a rare but serious complication of Crohn's disease. Intra-abdominai abscesses, fistulous disease, and metronidazole or steroid therapy have all been reported to be important predisposing factors in the pathogenesis of the disease, and the mortality has been reported to he high. We report six patients who developed a liver abscess as a complication of Crohn's disease. Three patients presented with a liver abscess as the first manifestation of Crohn's disease and two others bad quiescent disease at presentation. Ibe diagnosis was delayed by 1–8 wk after the onset of fever because of the paucity of signs indicating a bepatic infection. None of the patients had intra-abdominal abscesses, active fistulas, or metronidazole therapy before the onset of symptoms. The only predisposing conditions identified were two minor skin infections in patients developing staphylococcal liver abscesses. Nonoperative catheter drainage was successful in four of the six patients. One patient required surgical placement of drains, and the patient with the longest delay before diagnosis required hepatic lobectomy because of extensive necrosis. Shaking chills, fever with leukocytosis, and an elevated alkaline phosphatase are suggestive of a liver abscess and should prompt an ultrasound examination. Catheter drainage with antibiotic therapy is effective if the liver abscess is diagnosed before extensive necrosis has occurred. Minor skin infections may predispose to stapbylococcal liver abscess in some cases.     

Treatment of amoebic liver abscess with metronidazole alone or in combination with ultrasound-guided needle aspiration: a comparative, prospective and randomized study

Thirty-nine patients with amoebic liver abscess (ALA), admitted to the Central Hospital of Hué (Vietnam), were evaluated in a comparative, prospective and randomized study for the treatment of ALA. Adult patients with an abscess located in the right liver lobe and an abscess diameter of 6 to 10 cm were included. Bacterial abscesses were excluded by microbiological examination of abscess fluid in all patients. Nineteen patients were treated with metronidazole for 10 days alone and 20 patients were punctured under ultrasound guidance with aspiration of abscess fluid in addition to drug administration. The clinical symptoms fever, pain in right upper abdomen and liver tenderness, and the laboratory parameters erythrocyte sedimentation rate, white blood cells, haemoglobin and C-reactive protein and the abscess size were determined on the day of admission and followed during an observation period of 38 days. Improvement of liver tenderness was significantly faster in the aspiration group during the first 3 days (P < 0.001), whereas all the other parameters showed no differences between the two groups. This minor benefit is obviously not sufficient to justify routine needle aspiration and advocates drug treatment alone for uncomplicated amoebic liver abscesses with a diameter up to 10 cm located in the right liver lobe.     

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.     

Obstructive jaundice: an unusual presentation of amoebic liver abscess

A case of amoebic liver abscess with obstructive jaundice is described. Treatment with metronidazole resulted in improved general condition while the jaundice continued to increase. The abscess was twice aspirated and a total of 500 ml fluid was obtained with no improvement in the jaundice. A percutaneous catheter was introduced and drained 300-400 ml bile a day, decreasing and stopping over a week. The jaundice progressively improved.     

Hepatobiliary disorders presenting as fever of unknown origin in Cairo, Egypt: the role of diagnostic ultrasonography

Among 130 patients with fever of unknown origin (FUO) studied from 1981 to 1985, 34 were diagnosed as having hepatobiliary disorders: amoebic liver abscess (11), pyogenic liver abscess (4), hepatic hydatid cysts (2), hepatic fascioliasis (2), tuberculous hepatic granulomas (1), chronic calcular cholecystitis with recurrent cholangitis (2), chronic active hepatitis (2), hepatocellular carcinoma (3), lymphoma involving the liver (4) and hepatic metastasis in (3) cases. Hepatobiliary disorders were the cause in 27% of FUO seen during 4 years.     

Amoebic hepatic abscesses in an HIV-positive patient

Herein we report the case of hepatic amoebic abscesses in an HIV-positive Italian seaman with a history of promiscuous heterosexual intercourse. In October 2004, the patient was hospitalized because of fever and recurring abdominal pain. Abdominal ultrasonography revealed six hepatic hypoechoid oval lesions with hyperechoid margins. Stool samples were negative for parasites and bacteria, and serology for Entamoeba histolytica was also negative. Therapy with meropenem plus levofloxacin was initiated. After a partial resolution of clinical symptoms and reduction of three hepatic lesions, the patient was again hospitalized in December 2004, because of recurring intense pain at the right hypochondrium and fever. At this time, one hepatic lesion at the sixth segment was enlarged, two lesions were unchanged, and the remaining three smaller abscesses were resolved. Serum antibodies for E. histolytica and amoebic antigens on the largest abscess drainage were positive; moreover, E. histolytica was also identified on drainage fluid with polymerase chain reaction (PCR). Therapy with metronidazole followed by paromomycin improved both symptoms and radiographic images. This case report suggests that in HIV-infected patients, invasive amoebiasis should be considered and atypical aspects, such as multiple hepatic lesions, delayed positivity of serology for E. histolytica, and possible bacterial superinfection should be evaluated.     

Hepatic abscess: sensitivity of imaging tests and clinical findings

The imaging studies of 63 patients with hepatic abscess were evaluated to determine the sensitivity of specific imaging tests and define causes of false-negative test results. Computed tomography (CT) detected 57 of 59 (97%) separate episodes of hepatic abscess. The two false-negative CT examinations were in patients with a diffuse low-density pattern throughout the liver. The radionuclide (RN) examination detected 16 of 20 (80%) cases, missing abscesses less than 2 cm in diameter. Ultrasound detected 33 of 42 (79%) cases, missing abscesses in the dome of the liver, small abscesses, and 2 large early abscesses. For all three imaging modalities, a specific diagnosis of abscess was possible only in those patients in whom CT scans demonstrated abscess gas (15%). The results of the imaging studies were correlated with the patients' clinical condition and laboratory findings. Thirty-one percent of patients were afebrile while 23% had normal white blood cell counts. Thirteen percent had totally normal liver function tests. We conclude that the clinical absence of fever, leukocytosis, or elevated liver function tests does not permit exclusion of the diagnosis of hepatic abscess. A CT scan is highly specific in excluding the diagnosis of hepatic abscess in the absence of diffuse liver disease. In this retrospective study CT was the most sensitive imaging modality available for the detection of hepatic abscess.     

Amebic liver abscess: a therapeutic approach

The clinical presentation of 48 patients with amebic liver abscess was no different than that reported in earlier studies. However, most patients were from countries endemic for parasitic disease. Failure to consider this diagnosis resulted in potentially avoidable surgery for six patients. Although metronidazole was successful primary therapy in 85% of 41 patients so treated, four of seven ruptured abscesses occurred in cases where metronidazole treatment failed. For assessment of factors that might predict metronidazole treatment failures, multiple parameters were analyzed. Of the factors evaluated, only timing of clinical response correlated with successful therapy. Ninety-four percent of metronidazole responders showed dramatic clinical improvement within 72 hours of initiation of therapy, whereas only 33% nonresponders had improved modestly during this time (P = .0014). Therefore, early diagnosis of amebic liver abscess in patients from endemic areas and treatment with metronidazole will result in successful therapy in 85% of cases. Surgical intervention or alternative medical therapy is indicated for those patients who do not respond after 72 hours of metronidazole therapy.     

The pathogenesis of raised serum alpha-fetoprotein levels in amoebic and pyogenic hepatic abscesses.

Serum alpha-fetoprotein (AFP) concentrations may be slightly raised in patients with amoebic hepatic abscesses. In an attempt to learn more about the pathogenesis of the raised levels, we studied 74 patients with amoebic and six with pyogenic hepatic abscesses. Serum (AFP) levels were slightly elevated (24-72 ng/ml) on admission in four patients and markedly raised (2000 ng/ml) in one, who had hepatocellular carcinoma in addition to a pyogenic hepatic abscess. The pattern of the early rise in AFP levels could not be determined because these four patients were lost to follow-up. However, serial serum AFP estimations were obtained in 29 patients with a normal value on admission and in none of these did the concentration rise during recovery. Our findings do not support the prevailing hypothesis that regenerating hepatocytes are responsible for the raised serum AFP levels in non-neoplastic hepatic disorders, including hepatic abscesses.     

Comparison of metronidazole and chloroquine for the treatment of amoebic liver abscess. A controlled trial.

Chloroquine and metronidazole were compared in a randomized trial for the treatment of amoebic liver abscess in 36 patients. An additional 30 patients were treated without randomization. Chloroquine was given according to the standard protocol at Los tangeles County-University of Southern California Medical Center, which is 500 mg daily for 10 weeks, whereas metronidazole was given in a dose of 750 mg three times daily for 10 days. Criteria for the diagnosis of amoebic abscess included (a) a suitable clinical picture, (b) filling defect on hepatic scan, (c) high titer of antibody to Entamoeba histolytica by indirect hemagglutination, and (d) eventual complete recovery with treatment or appropriate findings on autopsy examination. Treatment failure, defined as illness that persisted beyond 10 days or recurred after that time, occurred in 1 of 28 patients treated with chloroquine and in 2 of 36 treated with metronidazole. In 2 patients who died it was difficult to assess the result of drug therapy. We conclude that both drugs are highly effective. Metronidazole has the advantage of effectiveness against intestinal amoebiasis and the probability of cure with a shorter course of treatment. Speed of response was slightly greater with metronidazole and was somewhat related to abscess size.     

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.     

An Unrecognized Etiology for Pyogenic Hepatic Abscesses in Normal Hosts: Dental Disease

Cryptogenic pyogenic hepatic abscesses are a diagnosis of exclusion. We have identified two patients with severe dental disease at the time of the diagnosis of their liver abscess. In both cases, oral flora was cultured from the abscess. Unlike a previous report, both patients were immunocompetent. When compared with a group of patients with liver abscesses and diverticulitis, two differences were found. In contrast to the single abscesses seen in 10 of 10 patients with diverticulitis, the patients with dental disease had multiple abscesses (p < 0.02). In addition, Fusobacterium nucleatum was cultured from both dental disease associated abscesses but only one of the diverticulitis associated liver abscesses (p < 0.05). If a liver abscess is thought to be cryptogenic, a thorough dental exam is recommended.     

Some unusual presentations of hepatic amoebiasis in Enugu, Nigeria

Eighty-two cases of hepatic amoebiasis were diagnosed and treated at the University of Nigeria Teaching Hospital during a 4-year period. Typical or classical features were observed in 75 (91.4%) of the cases while the remaining seven presented atypically or unusually. These were obstructive jaundice (three cases), coma (two cases) and pyrexia of unknown origin (two cases). All the cases had positive gel diffusion precipitation test for amoebic antibodies, and in all but one there was demonstration of an abscess cavity. In the three cases of obstructive jaundice, the abscess cavities were located close to the hilum and compressed the main bile duct. There was no mortality recorded especially in the jaundiced cases despite the grave prognosis associated with jaundice in hepatic amoebiasis. This study demonstrates the need to consider hepatic amoebiasis in an area when patients present with either obstructive jaundice, coma or pyrexia of unknown origin and to do ultrasonography as an initial investigation in such patients.     

The prognostic factors of severe amebic liver abscess: a retrospective study of 125 cases.

One hundred twenty-five cases of amebic liver abscess were diagnosed at Chang Gung Memorial Hospital in Taiwan from January 1981 to December 1989. An analysis of possible prognostic factors for severe amebic liver abscess was done retrospectively. The majority of the patients came from the southern part of Taiwan. Severe amebic liver abscess was defined as the rupture of an abscess that was resistant to 72 hr of medical treatment, or complicated by secondary bacterial infection. The results showed significant differences between patients with severe liver abscess and those with more moderate forms of amebic liver abscess in indices such as jaundice, hemoglobin and serum bilirubin levels, and dyspnea, as well as in pulmonary changes (right diaphragm elevation, right pleural effusion) seen on chest radiographs. Those patients with diabetes mellitus also had greater evidence of severe liver abscess. Moderate cases that were treated with amebicides showed excellent responses (no mortality). Severe cases required, in addition to amebicide therapy, either percutaneous or surgical drainage of pus, especially in those patients with ruptured abscesses. Those patients with abscesses that ruptured into the thoracic cavity were treated by either thoracostomy or needle aspiration, and all were cured. Three patients died of abscess rupture into the abdominal cavity, associated with secondary bacterial infection. The overall mortality rate was 2.4%. These symptoms and signs of severe liver abscess are indicators of the need for intensive treatment such as aspiration or surgical drainage.     

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.