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Liver abscess in the tropics: an experience from Jammu Shah Naveed, VB Gupta, Maria Kapoor, Hasina Quari, Asma Altaf and Maha Para Scott Med J published online 4 July 2014 DOI: 10.1177/0036933014543049 The online version of this article can be found at: http://scm.sagepub.com/content/early/2014/07/03/0036933014543049
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Scott Med J OnlineFirst, published on July 4, 2014 as doi:10.1177/0036933014543049
Original Article
Liver abscess in the tropics: an experience from Jammu
Scottish Medical Journal 0(0) 1–5 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0036933014543049 scm.sagepub.com
Shah Naveed1, VB Gupta2, Maria Kapoor3, Hasina Quari4, Asma Altaf5 and Maha Para6
Abstract Objective: To study the various types of liver abscesses. This prospective study was conducted over a period of one year, from November 2011 to October 2012, at the Department of General Surgery in Acharya Shri Chander College of Medical Sciences and Hospital Sidhra, Jammu. Materials and methods: The patients in this study were admitted from the emergency wing, and from indoor and outdoor departments of surgery and medicine over a period of one year (November 2011 to October 2012) to the Department of General Surgery in Acharya Shri Chander College of Medical Sciences and Hospital Sidhra, Jammu. Patients of all age groups and both genders who presented with clinical suspicion of liver abscess, or had already been diagnosed, were included in the study. A definitive diagnosis of liver abscess was made based on compatible clinical features, ultrasonography and aspiration or drainage of pus. Diagnostic criteria for the various types of abscesses were as follows: 1. 2. 3. 4. 5.
Amoebic abscess: demonstration of Entamoeba histolytica trophozoites in aspirated pus. Pyogenic abscess: positive cultures of blood or aspirated pus. If both of the above sets of criteria were satisfied, the abscess was considered to be of mixed aetiology. Tuberculous abscess was diagnosed by identifying acid-fast bacilli in aspirated material and polymerase chain reaction. The abscess was classified as indeterminate if none of the above criteria were satisfied.
Results : 1. The majority of patients in our study had amoebic liver abscesses (73.33%). 2. Escherichia coli and Klebsiella were the most common organisms cultured from the pyogenic abscesses. 3. The majority of patients with amoebic liver abscesses were treated with drug therapy alone, whereas all pyogenic liver abscesses required some form of drainage.
Keywords Abscess, tuberculosis, culture
Introduction Liver abscess remains an important clinical problem in both developing and developed countries, with a significant mortality rate even now.1 Jammu, a region in the state of Jammu and Kashmir (J&K), generally has lower socio-economic conditions. Amoebic liver abscesses are more common than pyogenic abscesses in this region. Percutaneous drainage is performed in most cases of pyogenic abscess. Since the advocacy of
1 Postgraduate Resident, Department of Surgery, Acharya Shri Chander College of Medical Sciences and Hospital, India 2 Professor, Department of Surgery, Acharya Shri Chander College of Medical Sciences and Hospital, India 3 Assistant Professor, Department of Surgery, Acharya Shri Chander College of Medical Sciences and Hospital, India 4 Medical Officer & Sonologist, Department of Health Services, India 5 Resident, Department of Dental Surgery, ITS Dental College & Hospital, India 6 Resident, Department of Dental Surgery, Goa Medical College & Hospital, India
Corresponding author: Shah Naveed, Department of Surgery, Acharya Shri Chander College of Medical Sciences and Hospital, Sidhra, Jammu & Kashmir 180017, India. Email:
[email protected]
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percutaneous drainage for the treatment of pyogenic abscesses, the technique has won increasing acceptance and has had a profound impact on the management of liver abscesses in our centre, dramatically reducing the need for open surgical drainage.2
Materials and methods Study design Ours was a hospital-based prospective study. Patients were admitted from the emergency wing, and from indoor and outdoor departments of surgery and medicine over a period of one year (November 2011 to October 2012) to the Department of General Surgery in Acharya Shri Chander College of Medical Sciences and Hospital Sidhra, Jammu.
Inclusion criteria Patients from all age groups and either gender who presented with clinical suspicion of liver abscess, or who had already been diagnosed, were included in the study.
Exclusion criteria All patients who refused to give consent were excluded from the study. The total sample size was 30 patients. The research was approved by the ASCOMS ethical committee. A definitive diagnosis of liver abscess was made based on compatible clinical features, ultrasonography and aspiration or drainage of pus. Diagnostic criteria for the various types of abscesses were as follows: 1. Amoebic abscess: demonstration of Entamoeba histolytica trophozoites in aspirated pus. 2. Pyogenic abscess: positive cultures of blood or aspirated pus. 3. If both of the above sets of criteria were satisfied, the abscess was considered to be of mixed aetiology. 4. Tuberculous abscess was diagnosed by identifying acid-fast bacilli in aspirated material and polymerase chain reaction (PCR). 5. The abscess was classified as indeterminate if none of the above criteria were satisfied. Once the diagnosis of a single or multiple liver abscess was made, broad spectrum parenteral antibiotics were started. Routine haematological tests, liver function tests and amoebic serology to rule out amoebic abscess were carried out, and blood cultures
(before onset of antibiotic therapy was ever possible) were obtained. A trail of antibiotics alone was given to patients with multiple small abscesses, at a low risk of rupture and with a lack of toxaemia (i.e. no haemodynamic instability, patient not feeling acutely ill). On getting the report of amoebic serology, if it was negative we continued with parenteral antibiotics. After culture results and sensitivity profiles had been obtained, antibiotic therapy directed at the specific organism(s) was administered intravenously for at least two weeks and then orally for up to six weeks. Lack of improvement after a reasonable course (48–72 h) indicated failure of the treatment. Worsening of fever, leucocytosis and symptoms at any time also indicated failure of the treatment and immediately qualified the patient for a more aggressive treatment regimen in the form of percutaneous aspiration. As complete as possible a drainage of the abscess cavity was done on first aspiration. The aspirated pus was sent for culture and sensitivity. Response was measured by decrease in fever and leucocytosis, and symptomatic improvement. Further aspiration would be done as and when required. Indications to proceed to percutaneous catheter drainage were persistence of sepsis, worsening of clinical features, failure to improve after a reasonable time period, failure of initial aspiration or thick abscess contents. Contraindications to percutaneous catheter drainage included coagulopathy, the lack of a safe or appropriate access route (transpleural drainage), multiple macroscopic abscesses and ascites. Operative drainage of pyogenic hepatic abscess was indicated for the following patients: patients who required laparotomy for an underlying problem; those in whom percutaneous catheter drainage had failed; patients with contraindications to percutaneous drainage (in left lobe of liver); and patients whose liver abscesses ruptured into the peritoneum and thoracic cavity. If serology was positive for amoeba, then metronidazole remained the drug of choice as it is highly effective, inexpensive and has the advantage of being effective for intestinal as well as extraintestinal amoebiasis. The dose regimen is 750 mg three times daily for 10 days. Percutaneous aspiration of amoebic abscesses is unnecessary unless bacterial suprainfection is suspected, a pyogenic liver abscess is suspected, the abscess is large (>5 cm in diameter) and left sided (segments 2 and 3) resulting in a concern of impending rupture, symptoms persist beyond 48–72 h or clinical deterioration is seen despite medical management. Laparotomy is indicated for ruptured amoebic abscesses.
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Discussion Our sample had markedly increased numbers of amoebic (73.33%) over pyogenic abscesses (Table 1). This matches with previous regional studies, but contrasts with a study from Singapore where pyogenic abscesses were more common.2 This changing trend is probably due to improved socio-economic conditions in Singapore. We found Escherichia coli to be the most common pathogen in pyogenic abscesses (Tables 2, 3 and 4), as did some western reports,3,4 although in recent years Klebsiella pneumoniae has been cited in some Western reports as the most common pyogenic organism.5,6 This is in accordance with the studies conducted by Rahimian et al.7 and Johannsen et al.8 who also reported E. coli and Klebsiella to be the most common organisms cultured. There was also a paucity of anaerobic organisms in our culture results. This may have been due to failure to use anaerobic culture bottles and/or because a significant number of our patients had received prior antibiotic treatment. Essop et al.9 reported that the prevalence of tubercular liver abscess was just 0.34% in patients with hepatic tuberculosis. In our study, we had a single patient
Table 1. Distribution of different types of liver abscess (n ¼ 30). Types of liver abscess
No. of patients
% age
Amoebic liver abscess Pyogenic liver abscess Tubercular liver abscess
22 7 1
73.33 23.33 3.33
Table 2. Organisms cultured from pus of pyogenic liver abscess. Organism grown
No. of patients (n ¼ 7)
Percentage
E. coli Klebsiella
4 2
66.66 28.57
Table 3. Results of blood culture of patients in our study (n ¼ 30).
Culture Positive culture
Amoebic liver abscess (n ¼ 22) No. (% age)
Pyogenic liver abscess (n ¼ 7) No. (% age)
Tubercular liver abscess (n ¼ 1) No. (% age)
0 (0)
3 (42.85)
0 (0%)
(3.33%) with a tubercular liver abscess who was a female of 60 years. She presented to us with fever, abdominal pain and significant weight loss. On ultrasound examination, a single abscess was found in the right lobe of the liver. 100 ml of pus was aspirated under ultrasound guidance and was sent for microbiological investigations. Gram stain, stains for acid-fast bacillus and fungus were negative. In our study, diagnosis of tubercular liver abscess was made only by PCR detected in the abscess aspirated under ultrasound guidance. Four first-line systemic anti-tubercular drugs (isoniazid, rifampicin, pyrazinamide and ethambutol) were started. Percutaneous aspiration of pus was undertaken three times. A routine bacteriological culture was sterile. Despite all these measures, she died due to resistance to anti-tubercular drug therapy. A study conducted by Diaz et al.10 showed that at least 57% of tuberculous hepatic granulomas gave positive PCR results compared to other conventional diagnostic techniques for tuberculosis. It should certainly be considered a possible cause in this part of the world when an abscess fails to respond to standard treatment. We found ultrasonography to be reliable in the diagnosis and follow-up of abscesses. It is less costly, but the results are operator-dependent. Halvorsen et al.11 reported computed tomography (CT) to be the most sensitive imaging modality for detecting hepatic abscesses. Unfortunately, the facilities for CT scan were not possible for all patients at our centre due to financial condition of the patients, and this is true for all developing Nineteen cases (86.36%) of 22 amoebic liver abscess patients were managed with antibiotics alone, with three (13.63%) patients requiring percutaneous drainage when they failed to respond to antibiotics for 72 h (Table 5). These results match with those of McGarr et al.,12 a prospective study where 150 of 178 patients were managed successfully with drug therapy alone, with those demonstrating clinical deterioration or no improvement after 48 to 72 h then receiving percutaneous ultrasound-guided aspiration. Thus, we concluded that conservative medical management of uncomplicated amoebic liver abscesses was safe, and patients who fail to respond medical therapy should be considered for ultrasound-guided percutaneous aspiration. Table 4. Organisms cultured from blood of pyogenic liver abscess. Organism grown
No. of patients (n ¼ 7)
Percentage
E. coli Klebsiella
2 1
66.66 33.33
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Table 5. Various modalities of management used in patients of our study (n ¼ 30).
Treatment modality
Amoebic liver abscess (n ¼ 22) No. (% age)
Pyogenic liver abscess (n ¼ 7) No. (% age)
Tubercular liver abscess (n ¼ 1) No. (% age)
I.V. Drug therapy only Percutaneous aspiration Catheter drainage Open surgical drainage
19 3 0 0
0 5 0 2
0 1 0 0
(86.36) (13.63) (0) (0)
(0) (71.42) (0) (28.57)
(0) (100) (0) (0)
3. The majority of patients with amoebic liver abscesses were treated with drug therapy alone, whereas all pyogenic liver abscesses required some form of drainage. Acknowledgements The authors would like to pay their regards and express sincere gratitude to all their teachers, viz., Dr SR Anand, Dr RK Chrungoo and others for their teaching, guidance and encouragement. The authors are highly grateful for their constant help and advice whenever sought for.
Declaration of conflicting interests None declared.
Surgery still plays a vital role in the comprehensive treatment of hepatic abscesses. This is illustrated in a series from Bertel et al.13 in which 61% of patients with hepatic abscesses required an additional procedure at time of operation to treat the causative condition. In our study, two patients of pyogenic liver abscess who required surgical drainage had underlying hepatic hydatid cyst which had become secondarily infected. The diagnoses of hydatid cyst was hinted in the CT scan of the patient and confirmed intraoperatively and on histopathological report. As the contents of the abscess cavity appeared to be thick on the CT scan and as there was a strong possibility of hydatid cyst getting infected, we proceeded to open surgical drainage in both of these patients. The super-infection probably occurs from sites next to the hydatid cyst (e.g. biliary) or as a complication of bacteraemia of any cause. Chen et al.14 stated that bacterial and fungal infections have been described in hydatid cyst in case reports or in small series with a limited number of patients. In conclusion, amoebic liver abscesses are still more common in India than in Western countries, where pyogenic are more frequent. Amoebic liver abscesses are especially common in rural areas such as our location. The most common organism isolated from pyogenic abscesses was E. coli. Percutaneous aspiration of liver abscess is helpful to confirm the diagnosis, provides a better bacteriological culture yield, gives a good outcome and may uncover clinically unsuspected conditions like tuberculosis. We recommend routine examination of aspirated materials by cytology, as well as stains and culture for acid-fast bacilli.
Results 1. The majority of the patients in our study had amoebic liver abscess (73.33%). 2. E. coli and Klebsiella were the most common organisms cultured from the pyogenic abscesses.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Ethical approval This study was approved by the Ethical Review Committee of ASCOMS Hospital and Medical College Jammu. References 1. Goh KL, Wong NW, Paramsothy M, et al. Liver abscess in the tropics: experience in the University Hospital, Kuala Lumpur. Postgrad Med J 1987; 63: 551–554. 2. Yeoh KG, Yap I, Wong ST, et al. Tropical liver abscess. Postgrad Med J 1997; 73: 89–92. 3. Karatassas A and Williams JA. Review of pyogenic liver abscess at the Royal Adelaide Hospital 1980–1987. Aust NZ J Surg 1990; 60: 893–897. 4. Donovan AJ, Yellin AE and Ralls PW. Hepatic abscess. World J Surg 1991; 15: 162–169. 5. Hansen N and Vargish T. Pyogenic hepatic abscess: a case for open drainage. Am Surg 1993; 59: 219–222. 6. Yinnon AM, Hades-Halparn I, Shapiro M, et al. The changing clinical spectrum of liver abscess: the Jerusalem experience. Postgrad Med J 1994; 70: 436–439. 7. Rahimian J, Wilson T, Oram V, et al. Pyogenic liver abscess: recent trends in etiology and mortality. Clin Infect Dis 2004; 39: 1654–1659. 8. Johannsen EC, Sifri CD and Madoff LC. Pyogenic liver abscesses. Infect Dis Clin North Am 2000; 14: 547–563. 9. Essop AR, Segal I, Posen J, et al. Tuberculous abscess of the liver. S Afr Med J 1983; 63: 825–826. 10. Diaz ML, Herrera T, Lopez-Vidal Y, et al. Polymerase chain reaction for the detection of Mycobacterium tuberculosis DNA in tissue and assessment of its utility in the diagnosis of hepatic granulomas. J Lab Clin Med 1996; 127: 359–363. 11. Halvorsen RA Jr, Foster WL, Wilkinson RH Jr, et al. Hepatic abscess: sensitivity of imaging tests and clinical findings. Gastrointest Radiol 1988; 13: 135–141.
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12. McGarr PL, Madiba TE, Thomson SR, et al. Amoebic liver abscess: results of a conservative management policy. S Afr Med J 2003; 93: 132–136. 13. Bertel CK, van Heerden JA and Sheedy PF II. Treatment of pyogenic hepatic abscesses: surgical versus percutaneous drainage. Arch Surg 1986; 121: 554–558.
14. Chen YC, Yeh TS, Tseng J, et al. Hepatic hydatid cysts with super-infection in a non-endemic area in Taiwan. Am J Trop Med Hyg 2002; 67: 524–527.
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