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 : 3rd -5th 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 nontender palpable 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: generalised abdominal 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
– Rales and decreased air entry
– Pleural rub
– Pericardial rub
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12. DIFFERENTIAL DIAGNOSIS
• Pyogenic liver abscess
• Hepatoma
• Hydatid cyst 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 hemagglutination testing
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15. Investigation
• Stool studies:
– Stool culture
– Stool antigen detection(EIA vs PCR)
– Stool examination(heme positive, neutrophil
paucity, Charcot-Leyden crystal protein)
– Drawback, 60% with ameobic liver 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
amebicidal drug therapy.
• Entails use of tissue and luminal amebicidal.
• Tissue amebicidal includes Metronidazole(drug of
choice), tinidazole, chloroquine, emetine HCl,
dehydroemetine.
• Luminal amebicidal includes diloxanide furoate,
paromomycin and 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
– Multiloculated thicked walled 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 amebicidals has 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. histolytica protein (SREHP) expressed in
avirulent vaccine strains of salmonella spp.
• Gal-inhibitable lectin shows 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
• Ravdin JI. Amebiasis. Clinical Infectious Disease. 1995Jun.
20, 20(6): 1453-64
• Tanyuksel M, etal. Laboratory diagnosis of amebiasis. Clin
microbio rev. 2003 Oct: 732-29
• Stanley SL Jr. Amoebiasis. Lancet.2003 Mar 22. 361(9362):
1025-34
• Archampong E.Q., etal: Liver and biliary System. Baja’s
Principles and Practice of Surgery including Pathology of
the Tropics, 5th edition, 2015: pg 779 – 780
• Sriram B.H: Infections of Liver. SRB manual of surgery, 4th
edition, 2013: pg 630-636
• emedicine.medscape.com/article/amoebic liver
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