An elderly male farmer with no known chronic illness presented to our facility with fever, severe right upper quadrant pain and yellowish eyes of a week duration.
The right upper abdominal pain was gradual in onset. Pain radiated to the right shoulder tip. He couldn’t breath deeply because this worsened the pain. He had lost appetite and weight within the period. Patient is a habitual drinker of locally prepared alcohol. He has not been transfused with blood. He is not a recreational drug user. Patient had been on several course of oral metronidazole for about a month prior to presentation.
Examination: patient was ill looking, jaundiced, wasted, in respiratory distress and febrile.
Chest: fullness of the intercostal spaces on the right. Air entry was adequate on the left lung fields but was slightly reduced on the right. Abdomen was full, moved with respiration. The right upper quadrant was obviously tender. There was tender hepatomegaly.
An initial diagnosis of hepatitis was made and abdominal ultrasound ordered. The right lobe of the liver was enlarged. A large collection of fluid was seen in the right lobe of the liver . Fluid had internal echoes. The gallbladder, pancreas and spleen all looked normal. There was no ascites .
Diagnosis : Amoebic Liver abscess
Condition explained to patient. Decision taken to perform percutaneous ultrasound guided drainage. Signed consent form obtained
Patient was put in intravenous ciprofluoxacin and metronidazole for 24hours in preparation for percutaneous ultrasound guided drainage of the abscess.
Percutaneous Ultrasound Guided Aspiration of Abscess
The following was assembled for the procedure: sterile gauze, xylocaine 1%, size 14G needle, methylated spirit, sterile gloves
The skin and intercostal space over the right upper quadrant was anaesthesised with 10mls of 1% xylocaine . The abscess cavity was located with the ultrasound . The size 14g needle was guided into the abscess cavity to perform the aspiration. Size 20F drain was inserted into the abscess cavity percutaneously to drain the rest of the abscess . Tube was left in situ for 4 days . A total of 2000mls was drained . Tube was removed . Chest physiotherapy was encouraged by making patient blow balloons.
Patient experienced dry cough hours after the procedure due to re expansion of the lower zones of the right lung. Three days into treatment ,patient developed sympathetic right pleural effusion with associated respiratory distress. Effusion was drained with a chest tube . Lung re expansion was satisfactory. Patient spent a total of 10 days on admission and was discharged home on a further course of oral metronidazole
The abdominal pain resolved. The tinge of jaundice resolved. His appetite improved prior to disharge
- Amoebic liver abscess (ALA) is the collection of pus within the liver. Abscess are usually large, single and located in the right hepatic lobe. In advanced cases multiple abscesses can occur.
- ALA are caused by a protozoan known as Entamoeba histolytica which is transmitted between its cysts. It accounts for a couple of death mainly in the tropics and occasionally in other regions.
- The cyst of E. histolytica are ingested in water or uncooked food contaminated by human feces. Infection can also be acquired through anal/oral sexual practices. In the colon, vegetative trophozoites form emerges from the cysts. The parasites invade the mucous membrane of the large bowel, producing lesions that are maximal in the caecum but as far down as the anal canal. These are flasked-shaped ulcers, varying greatly in size and surrounded by healthy mucosa.
- Amoebic trophozoites can emerge from the vegetative cyst from the bowel and can be carried to the liver in a portal venule. They can multiply rapidly and destroy the liver parenchyma causing an abscess.
- Early features of ALA are malaise, swinging temperature and sweating, abdominal pain (right upper quadrant), pain in the right shoulder, cough and weight loss. However, symptoms may remain vague and sometimes minimal. In extreme cases, large abscess may penetrate the diaphragm and rapture into the lungs from where it contents may be coughed up.
- Diagnosis can be aided with imaging studies such as ultrasonic scanning of the liver which detects fluid accumulations within the liver parenchyma. On a CXR, you will notice a raised hemidiaphragm. An aspiration of the liver will produce a characteristics anchovy sauce or chocolate brown appearance. With FBC, there is often leukocytosis/neutrophilia.
- Most uncomplicated ALA can be treated successfully with conservative management such as with amoebicidal drugs (metronidazole, Tinadazole) therapy alone. Metronidazole is considered to be the drug of choice with about 90% cure rate. After the use of tissue amoebicide, it’s needful to use luminal amobicides for eradication of the asymptomatic colonization. This helps to avoid relapse (which occurs in 10% cases without it).
- Therapeutic aspiration of amoebic liver abscess should be considered in cases where there are high risk of abscess rapture, left lobe liver abscess as well as failure to observe clinical medical response within 5-7 days. Most people present late in endemic areas hence may require aspiration. Image –guided needle aspiration and catheter drainage are procedure of choice.
- Complications of amoebic liver abscess includes pleuropulmonary infection (which is most common) following sympathetic serous effusion, rapture of the liver abscess into the chest wall. Bacterial superinfection can occur as well as cardiac involvement following rupture of the abscess.
Dr Richard Ametih
St Benito Menni Hospital