Discuss the management of amoebic liver abscess

AMOEBIC LIVER ABSCESS

1. DISCUSS THE MANAGEMENT OF
AMOEBIC LIVER ABSCESS
PRESENTER:
EZEAKU, CHIZOWA OKWUCHUKWU
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2. OUTLINE
•INTRODUCTION
•HISTORY
•PHYSICAL EXAMINATION
•DIFFERENTIALS
•INVESTIGATIONS
•TREATMENT
•FOLLOW UP
•COMPLICATIONS
•PROGNOSIS
•LOCAL EXPERIENCE/ FUTURE TREND
•PREVENTION
•CONCLUSION
•REFERENCE
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3. INTRODUCTION
•Amebic liver abscess is the most frequent extra
intestinal manifestation of E.histolytica infection.
•Results from portal dissemination of amoebic
typhilitis.
•It’s an important space-occupying lesion in the liver
in developing countries.
•It’s usually solitary, and the posterior inferior aspect
of the right lobe is usually involved.
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4. Epidemiology
•About 4% of people with amoebic colitis
develop it.
•Male : female = 9:1.
•Peak incidence : 3
rd
-5
th
decade.
•No racial predilection.
•Highest prevalence seen in the tropics e.g.
Mexico, India, Asia and Africa.
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5. Risk factors
•Immigrants from endemic areas
•Alcoholism
•Malnutrition
•Institutionalized persons
•Overcrowding and poor hygiene
•Immunosuppression-HIV, Chronic infections, steroid
abuse
•Male homosexuals-sexual acquired amebic colitis
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6. 6

7. Presentations
•Subacute
–Malaise and weightloss
•Acute
–High fever, chills and rigor, with tender, soft palpable liver
with intercostal tenderness
•Chronic
–Firm, hard nontenderpalpable liver without acute features
•Complications
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8. HISTORY
•BIODATA
–Male, 30 to 60 years,
•PRESENTING COMPLIANT
–Pain (90%)-RUQ or epigastric, dull, constant and aching,
radiates to right shoulder.
–Aggravated by coughing, deep breathing ,lying on right
side.
–Associated fever(89%), nausea, vomiting, weight loss,
yellowness of the eyes, malaise and chills.
–Previous history of cramping abdominal pain, watery or
bloody diarrhea and anorexia(60%).
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9. HISTORY
•History of risk factors:
•History of complications:
–CHEST: cough(+/-productive), chest pain, breathlessness
–ABDOMEN: generalisedabdominal pain, constipation and
progressive distension.
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10. PHYSICAL EXAMINATION
•GENERAL-painful distress, acute or chronically ill
looking, febrile, pale, jaundice, dehydrated.
•ABDOMEN
–Tenderness-epigastrium(28%), right hypochondrium(55-
75%)or generalised
–Associated subcutaneous pitting edema, guarding and
rigidity.
–Hepatomegaly(50%)-tender, point tenderness, soft or
hard, smooth
–+/_Ascites and absent bowel sound
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11. PHYSICAL EXAMINATION
•CHEST(20-45%):
–Tachypnea
–Chest wall tenderness
–Dullness
–Ralesand decreased air entry
–Pleural rub
–Pericardial rub
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12. DIFFERENTIAL DIAGNOSIS
•Pyogenic liver abscess
•Hepatoma
•Hydatidcyst of the liver
•Acute cholecystitis
•Metastatic liver deposit
•Viral hepatitis
•Hepatic hemangiomas
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13. INVESTIGATIONS
•Serologic testing is the most widely used method for
diagnosis.
•None of the imaging tests can definitively
differentiate a pyogenic liver abscess from an amebic
abscess.
•Clinical, epidemiologic, and serologic correlation is
needed for diagnosis.
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14. Investigation
•To confirm diagnosis(Serology):
–Enzyme immunoasay,EIA(Gold standard)
–Serum antigen detection(ELISA)
–Indirect hemagglutinationtesting
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15. Investigation
•Stool studies:
–Stool culture
–Stool antigen detection(EIA vsPCR)
–Stool examination(hemepositive, neutrophil
paucity, Charcot-Leyden crystal protein)
–Drawback, 60% with ameobicliver abscess , lacks
intestinal amebiasis.
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16. investigation
•Imaging studies(abdominal ultrasound)
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17. investigation
•CT scan
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18. Investigation
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19. Investigation
•FBC + Diff: anemia, leucocytosis
•ESR: usually raised
•LFT :elevated AST, alkaline phosphatase(70%)
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20. •The salient point of diagnosis
–Tender hepatomegaly.
–Demonstration of pus by aspiration with
supporting
–Haematological, biochemical and radiological
findings.
–Response to specific therapy.
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21. TREATMENT
•Most uncomplicated cases can be successfully with
amebicidaldrug therapy.
•Entails use of tissue and luminal amebicidal.
•Tissue amebicidalincludes Metronidazole(drug of
choice), tinidazole, chloroquine, emetine HCl,
dehydroemetine.
•Luminal amebicidalincludes diloxanidefuroate,
paromomycinand iodoquinol.
•Use of antibiotic in bacteria superinfection.
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22. Treatment
•Indications for Surgery
–Failure of medical therapy after 7days
–Left lobe liver abscess
–Cant differentiate from pyogenic liver abscess
–Ruptured abscess
–Multiloculatedthickedwalled abscess
–Abscess greater than 5cm
–Multiple abscesses
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23. Surgical options
•Needle aspiration-blindly or image guided
•Image guided catheter drainage
•Open surgery via laparotomy
•NB: Aspirate(Anchovy sauce) sent for C/S, cytology
and study of trophozoites
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24. 24

25. 25

26. 26
Anchovy sauce pus seen in amoebic liver abscess.

27. FOLLOW UP
•Follow up imaging studies is unnecessary after
resolution of symptoms.
•Follow up stool examination is recommended after
completion of therapy.
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28. COMPLICATIONS
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29. Prognosis
•Uncomplicated cases have favorable outcome.
•Rupture into the pericardium is associated with high
mortality(30%).
•Poor prognostic factors :
–Rupture, serum bilirubin >3.5 mg%, serum albumin < 2.0
g/dl, liver failure, cirrhosis, multiple abscesses ,volume of
abscess > 500 ml, encephalopathy, anemia, diabetes.
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30. LOCAL EXPERIENCE
•Judicious use of amebicidalshas resulted in a
downward trend in presentation.
•However there is reemergence due to the AIDS
pandemic.
•Paucity of serological laboratory continues to hamper
accurate diagnosis.
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31. FUTURE TREND
•Research ongoing towards the development of
vaccine using antigenic candidate:
•Serine rich E. histolyticaprotein (SREHP) expressed in
avirulentvaccine strains of salmonella spp.
•Gal-inhibitablelectinshows promise in animal
model.
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32. PREVENTION
•Direct patient and public education about sanitary
measures.
•Personal hygiene, hand washing and food hygiene.
•Avoiding fecal contaminated food and water
•Boiling of water for consumption
•Regular examination of food handlers and thorough
investigation of diarrheal episode.
•Safe sexual practices
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33. CONCLUSION
•Amoebic liver abscess is a common parasitic
infection of the liver.
•Seen in regions with poor sanitary measures.
•Prompt diagnosis ,aggressive medical treatment
supported by adjunctive surgical methods can keep
morbidity and mortality to a bare minimum.
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34. REFERENCES
•RavdinJI. Amebiasis. Clinical Infectious Disease. 1995Jun.
20, 20(6): 1453-64
•TanyukselM, etal. Laboratory diagnosis of amebiasis. Clin
microbiorev. 2003 Oct: 732-29
•Stanley SL Jr. Amoebiasis. Lancet.2003 Mar 22. 361(9362):
1025-34
•ArchampongE.Q., etal: Liver and biliary System. Baja’s
Principles and Practice of Surgery including Pathology of
the Tropics, 5
th
edition, 2015: pg779 –780
•SriramB.H: Infections of Liver. SRB manual of surgery, 4
th
edition, 2013: pg630-636
•emedicine.medscape.com/article/amoebic liver
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