1) Amoebic liver abscess is caused by the parasite Entamoeba histolytica infecting the liver via the bloodstream from the intestines. 2) Ultrasound is the primary tool for diagnosis and guided aspiration is usually the first treatment, along with antibiotics like metronidazole. 3) Surgery may be needed if aspiration fails or the abscess ruptures, and homeopathic remedies like Belladonna, Hepar sulphur, Silicea, and Mercurius can help promote pus formation and healing.

1. AMOEBIC LIVER ABSCESS

2. • Amebic liver abscess is caused by Entamoeba
histolytica.
• This parasite causes amebiasis, an intestinal
infection that is also called amebic dysentery.
• After an infection has occurred, the parasite
may be carried by the bloodstream from the
intestines to the liver.

3. • It is also called Tropical abscess ( dysenteric
abscess).
• It is the commonest extra-intestinal
manifestation of amoebiasis.

4. Aetiopathogenesis
• This disease is caused by Entamoeba histolytica.
• It is almost always a complication of amoebic
dysentery.
• This can occur in the acute stage or in the chronic
carrier stage
Infection from the caecum (typhlitis) spreads
through the tributary of superior mesenteric
vein.
From sigmoid colon, through the tributary of
inferior mesenteric vein.

6. • The right branch of the portal vein is in direct
line with the portal vein.
• Hence, by streamline phenomenon organisms
reach the right lobe more often than the left
lobe.
• The right lobe is also much bigger than the left
lobe.

7. • In the right lobe, it is the posterosuperior
surface which gets involved because it is
extraperitoneal (bare area of liver).
• It has no peritoneal covering.

8. • After reaching the liver, the organism causes
destruction of hepatocytes by releasing
powerful cytolytic enzymes resulting in
liquefaction necrosis.
• It also causes aseptic thrombosis of blood
vessels resulting in necrosis of liver tissue.

9. • At the same time, some
RBCs are also broken
down.
• This causes anchovy
sauce pus, which is
chocolate brown in
colour, and is a mixture of
broken down RBCs,
hepatocytes, etc.

10. • Green pus is referred to pus mixed with bile,
which is seen in a few patients.
• In majority of the cases, pus is sterile.
Secondary infection occurs in about 20 to
30% of the cases.

11. • Amoebae are rarely present in the pus but are
present in the wall of the abscess cavity.
• The wall contains monocytes, plasma cells,
lymphocytes and fibroblasts.
• Abscesses are multiple which fuse to form a
single large abscess cavity in about 70% of the
cases.

12. • Due to perihepatitis, abscess gets fixed to the
diaphragm resulting in immobility of the
diaphragm.
• Liver abscess in the left lobe gets adhered to
anterior abdominal wall.

13. Amoebic infection of gall bladder and bile
does not occur because of deleterious effect
of bile on amoebae.

14. Clinical features
• Male alcoholics are commonly affected, in the age
group of 20-40 years.
• It is eight times more common in men.
• Seen in patients with low socioeconomic status.
• Severe pain in the right hypochondrium is due to the
enlarged liver. This stage is called stage of Amoebic
Hepatitis.
• If USG is done, it may not demonstrate any abscesses
but there may be many microabscesses.
• At this stage, there is low grade fever, weakness,
anorexia, etc.

15. Clinical features
• High grade fever with chills and rigors develop
if the stage proceeds to pyogenic liver abscess
due to secondary bacterial infection of
amoebic abscess.
• Thoracic symptoms such as nonproductive
cough, pleurisy and right shoulder pain are
common.

16. Signs
• Anaemia, emaciation, toxic look and an earthy
complexion is present.
• Jaundice may be present if abscesses are
multiple, due tocompression of biliary
radicles.
• However, it is rare ( 15% ).
• It is of cholestatic variety.
• Liver is enlarged in the right hypochondrium,
tender and soft (liver enlarges in upward
direction)

17. Signs
• Intercostal tenderness differentiates it from
acute cholecystitis.
• Intercostal oedema can also be present

18. Investigations
1. Total WBC count may be increased if there is
secondary infection.
2. Stool examination for ova and cysts of
Entamoeba histolytica may be positive in 25%
of cases.
3. Serologic testing:
The indirect haemagglutination test is
positive in 90-95% of patients with an
amoebic abscess.

19. Investigations
4. Screening chest: When the patient is asked to
take a deep breath, right side of the diaphragm
does not move due to inflammatory
(perihepatitis) adhesions between liver and
diaphragm.
This is called homolateral immobility of the
diaphragm.
A small pleural effusion may also be present.

20. Investigations
5. Sigmoidoscopy may demonstrate large, deep
amoebic ulcers-flask shaped.
6. Abdominal USG: It is the investigation of choice.
• To locate site of abscess and then to confirm
diagnosis.
• Ultrasound guided needle aspiration can also be
done and biopsy of abscess wall should be taken.
• Multiple abscesses can be made out.

21. Investigations
7. CT scan can demonstrate an abscess cavity as a
low density zone surrounded by peripheral
hypodense zone due to inflammatory reaction.

22. Treatment
• lt can be classified into:
I. Conservative
II. Ultrasound-guided aspiration and pigtail
drainage
III. Surgery-drainage

23. I. Conservative line of management
• It is indicated in amoebic hepatitis. Tab.
Metronidazole 400-800 mg, 3 times a day is
given for 14 days.
• The only recognisable side-effect is metallic
taste.
• If the condition does not improve, injection
Emeline 1 mg/kg body weight to a total of 60
mg/day deep IM for a maximum of 6 days is
given.

24. II. US-guided needle aspiration/pigtail
catheter drainage
• It is indicated in cases of amoebic liver
abscess.
• Before it is aspirated, bleeding profile (BT, CT,
PT) should be normal and injection vitamin K
10 mg, IM should be given for at least 3 days.
• US-guided aspiration is also the treatment of
choice where metronidazole is
contraindicated, e.g. 1st trimester of
pregnancy.

25. II. US-guided needle aspiration/pigtail
catheter drainage
• It can be easily done under local anaesthesia
• Can be repeated, if pus recollects.
• Typically it is anchovy sauce pus. Aspiration is
followed by insertion of pig tai I catheter.
• Before removal of the catheter do a repeat
ultrasound to check for residual pus.

26. Pigtail catheter drainage of amoebic
liver abscess-it is a nonoperative method of
treatment
Ultrasound is
done to check residual
abscess cavity

27. Ill. Surgery (open drainage) and
laparoscopic Indications
1. Failure of US-guided needle aspiration.
2. Ruptured amoebic liver abscess with amoebic
peritonitis.

28. Complications of amoebic liver
abscess
• Amoebic peritonitis, resulting in acute abdomen with
shock.
• It has to be treated like any peritonitis-laparotomy,
drainage of pus and drain the abscess cavity to outside
(possibility of amoebiasis cutis is still present but
rare).
• Rupture into pleural space causing pleural effusion.
• Rupture into the bronchus resulting in coughing out
anchovy sauce (may be a natural cure )-bronchopleural
fistula.
• Amoebic pericardia! effusion occurs due to rupture of
left liver lobe abscess into pericardia! space.

29. HOMOEOPATHIC TREATMENT

30. • Belladonna: This remedy is most often
indicated for the initiatory symptoms of
abscess. The parts swell rapidly, become
bright red, there is intense throbbing which is
painful,pus develops speedily the swelling
increases and the redness radiates.

31. • Hepar Sulphur : It is great homeopathic
remedy for suppurations where the pus is not
decomposed. It suits especially lymphatic,
phlegmatic individuals. Excessive sensitiveness
of the parts is a leading indication.

32. • Silicea: This remedy is indicated where the
suppuration continues and the wound refuses
to heal, no matter where the suppurative
process is located; the pus is apt to be thin,
watery and the process is sluggish and
indolent one. Under Silicea the suppurative
process takes on a healthy action, the pus
becomes benign, granulation appear.

33. • Mercurius: Differing from Belladonna, from
Hepar, and especially from Silicea is
Mercurius, which is one of our good remedies
in abscess. It comes in after Belladonna, when
pus has formed. It favors the formation of pus
especially in the lower potencies, and is
especially indicated in glandular abscesses;
the pus is greenish in tint, and quite thin and
fluid.