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![AMEBIC LIVER ABSCESS
• Amebic liver abscess is the most common extraintestinal
manifestation of amebiasis caused by protozoa Entamoeba
histolytica.
• Is 7 to 10 times more common among adult men.
• seen in the fourth and fifth decades of life .
Risk factor includes
• Immigrants from endemic areas(India, Africa, Mexico, and parts of
Central and South America)
• Homeless person and those living in shelter homes
• People living in crowded places and poor hygiene
• Immunocompromised persons (eg, human immunodeficiency virus [HIV]
infection, malnutrition with hypoalbuminemia, chronic infections, post
traumatic splenectomy, steroid use)](https://image.slidesharecdn.com/finalcpcamoebicliverabscess-230716050103-9bd09642/85/Final-CPC-Amoebic-Liver-Abscess-pptx-25-320.jpg)
Final CPC Amoebic Liver Abscess.pptx
- 1. CLINICOPATHOLOGIC CONFERENCE • AMOEBICLIVER ABSCESS
- 2. Biodata of thePatient • Name: X.Y.Z. • Age: 45 years • Marital Status: Married • Resident of: Chak A.B.C. • Date of Admission: 9th February, 2022 (under treatment)
- 3. Case Study 45years oldmale presented with C/O 1.Fever -15days 2.Abdominal pain and vomiting- 15days 3.yellowish discoloration of skin and sclera -7days
- 4. History of PresentingIllness • He was in usual state of health 15days back. • Developed fever which was gradual in onset,low grade,intermitent not associated with chills ,relieved by taking antipyeritics. • Abdominal pain in right upper quadrant and epigastrium,sudden in onset, dull in character,mild-moderate intensity , continous, radiating to lower part of right chest ,aggravated by deep breathing and lying on right side ,not improved on leaning forward and relieved temporarily by medicine. • Associated with vomiting 3-4 episodes/day, nonprojectile, not preceeded by nausea ,foul smelling,mostly occuring after taking every meal containing food particles within it and is not blood stained. • After 7 days he developed yellowish discoloration of skin and sclera not associated with pruritis, high coloured urine and clay coloured stool.
- 5. CONT..... • History ofanorexia and some weight loss was there. • No history of receiving recent blood transfusion , tattooting • No history of alochol and drug abuse.
- 6. PAST HISTORY • Havinghistory of diarrhea 1 month back.( In which he has on and off semiformed small volume stools, 4-5 episodes/day sometimes containing blood and mucus within it and often associated with abdominal pain relieved by defecation lasting for 1 month,took some medicines from general physician but no record available) • Known hypertensive from 5 years on antihypertensive,well controlled • No past history of abdominal surgery.
- 7. Personal History andSocio-economic Status • Married for almost 12 years • 4 children • No history of similar illness in siblings • Middle class family • shopkeeper by occupation
- 8. Examination General Physical Examination; •Well cooperative, well oriented middle aged male of good built lying comfortably in bed • B.P : 110/70 mmHg • Pulses : 110/minute,normal volume;regular in rhythm • R/R : 18/min • Temp : 100F • Jaundice ++ • No clubbing, palmar erythema,dupuytrens contracture, parotid swelling or edema.
- 9. Systemic Examination • GASROINTESTINALSYSTEM; • Inspection • Shape of the abdomen was normal having a localized bulge over right hypochondrium. Abdomen was moving with respiration. Peristalsis were not visible. Umbilicus was central and of normal shape. No pulsations were visible. There was no scar, striae or prominent veins. • Abdomen soft tender over epigastrium and right hypochondrial region lower border of liver palpable 3 fingers below right costal margin tender having smooth surface, soft consistency and rounded edge , upper border in right 5th ICS , total liver span= 17 cm.(midclavicular line). • spleen not palpable • no fluid thrill or shifting dullness • bowel sounds audible • oral hygiene was satisfactory and external genital examination was unremarkable.
- 10. RESPIRATORY SYSTEM • InspectionRespiratory rate was 18/minute. Respiration was abdomino- thoracic. Elliptical chest. No deformity, scar, prominent veins or pulsations visible. Chest was moving equally on both sides with respiration. • Palpation Trachea was central. Movements of chest were equal on both sides. Expansion of the chest was 5 cm. Vocal fremitus was equal on both sides. • Percussion Percussion note was resonant and equal on both sides. • Auscultation Breath sounds were vesicular and of normal intensity. Vocal resonance equal on both sides. No added sounds.
- 11. CARDIOVASCULAR EXAMINATION • Pulsewas 110/minute, regular, normal volume, normal character, no radio- femoral delay, vessel wall not palpable. BP 110/70 mmHg. • On examination of CVS, precordium was normal,non pulsatile with Apex beat palpable in 5th intercostal space medial to midclavicular line. Both heart sounds S1 and S2 were audible and of normal intensity. No added heart sounds NERVOUS SYSTEM EXAMINATION • No sensory or motor deficit was seen.
- 12. DIFFERENTIAL DIAGNOSIS • AcuteHepatitis • Liver Abcess ( pyogenic , amoebic, fungal) • Hydatid cyst • Primary (hepatoma) or Metastatic liver tumors • Billiary diseases (acute cholangitis , acute cholecystitis) Tumors can be excluded on the basis of short history of the patient. Also the liver was not firm or irregular on plapation.
- 13. PLAN • CBC,CRP. • DetailedLFTs,PT,APTT, Serum Albumin. • Hepatitis A, B, C,E Serology • Blood culture. • Ultrasound Abdomen(hepatobillary scan). • CT SCAN Abdomen • Stool antigen test for Entamoeba histolytica, stool culture, ELISA on blood should be done
- 14. • CBC showselevated ESR and CRP, leukocytosis which is neutrophil predominant. This indicates an infectious process. • LFTs shows elevated conjugated bilirubin and mildly deranged liver enzymes.This points towards a liver pathology.
- 15. LABS • HEPATITIS A,B ,C ,E serology negative.( this excludes viral hepatitis, in addition there were no risk factors present in history eg IV drug abuse or blood transfusion.) • BLOOD CULTURE = NEGATIVE .( so no sepsis from a pyogenic source) • We are left with liver abcess and biliary disease.
- 16. • Murphy signnot present so evidence against acute cholecystitis. • We can further perform ultrasound to comfirm. • No sonographic murphys sign • On ultra sound liver is enlarged. A large hetrogenous area is seen in the right lobe. Gall bladder is contracted , no gall stones seen, spleen not enlarged and pancreas normal. • No hydatid sand or daughter cysts seen. ( This excludes hydatid cyst)
- 17. • Points toliver abcess( pyogenic, amoebic ,fungal). • No immumodeficiency, organ transplant or haematologic malignancy so not fungal • No high grade fever or recent surgery-->So not pyogenic • Most probable diagnosis amoebic liver abcess.
- 18. CASE SUMMARY Young malehaving : • low grade fever with past history of diarrhea • tender hepatomegaly and • a single large abscess in right lobe of liver • all these points are in favor of AMEBIC LIVER ABCESS. • As the abscess is very large it is absolute indication of drainage . After following all necessary prerequisites (PT, APTT) Ultrasound guided needle aspiration done. • 1000 cc blood stained thick pus resembling anchovy paste aspirated. sample sent for C/S . Unfortunately , no growth identified on aerobic culture media.
- 19. CONT..... Patient was managedand discharge upon clinical resolution of symptoms. Patient was readmitted with complain of shortness of breath from 3-4 days that was gradually worsening not associated with cough , chest pain, orthopnea and PND. On examination • He was dyspneic ( spo2 88) , febrile ( 100F) RR=20/min • Chest shape was elliptical having reduce chest movements on right side ,with no scar marks and any localized bulge. • chest expansion was also reduced. • percussion note was stony dull below right mid scapular region and resonant percussion note over rest of chest. • on auscultation of chest, breath sounds were absent on right side up to mid scapular region with NVB and equal breath sounds in rest of chest. • He was re-investigated to look for possible complications:
- 20. ULTRASOUND GUIDED NEEDLEASPIRATION OF ABCESS: 1= 500cc blood stained thick pus drained 2= 500cc blood stained thick pus drained 3= 1200cc blood stained thick pus drained ULTRASOUND GUIDED NEEDLE ASPIRATION OF PLEURAL FLUID 1700cc serous pleural fluid drained CURRENT STATUS : • patient is undertreatment in the ward with IV MERONEM 1G TDS +IV FLAGYL TDS+ Tab ENTAMIZOLE DS 1 TDS . • His dyspnea and fever improved but abdominal pain is still there. • PLAN : • took radiologist opinion regarding USG guided percutaneous catheter placement for drainge of non resolving abcess.
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- 22. NON RESOLVING AMEBIC LIVERABSCESS COMPLICATED BY SEPTICEMIA AND RIGHT SIDED PARAPNEUMONIC EFFUSION
- 23. TREATMENT GIVEN MEDICAL Tissue amebicidalagents (METRONIDAZOLE 750mg TDS for 7-10 days )plus Luminal amebicidal agents ( DILOXANIDE FUROATE 500mg TDS for 10 days ) IV broad spectrum antibiotic ( IV MERONEM 1G TDS) SURGICAL Imaging guided Needle aspiration of total 2200cc blood stained thick pus. + 1700 cc of serous pleural fluid .
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- 25. AMEBIC LIVER ABSCESS •Amebic liver abscess is the most common extraintestinal manifestation of amebiasis caused by protozoa Entamoeba histolytica. • Is 7 to 10 times more common among adult men. • seen in the fourth and fifth decades of life . Risk factor includes • Immigrants from endemic areas(India, Africa, Mexico, and parts of Central and South America) • Homeless person and those living in shelter homes • People living in crowded places and poor hygiene • Immunocompromised persons (eg, human immunodeficiency virus [HIV] infection, malnutrition with hypoalbuminemia, chronic infections, post traumatic splenectomy, steroid use)
- 26. • Route ofTransmission • Amoebiasis is transmitted by: • ingestion of faecally contaminated food or water containing amoebic cysts. • indirect hand contamination from contaminated surfaces through vector like flies, rodents. • oral–anal sexual contact with a chronically ill or asymptomatic carrier.
- 27. Pathophysiology • E histolyticaexists in two forms. The cyst stage is the infective form, and the trophozoite stage causes invasive disease. • People who chronically carry E histolytica shed cysts in their feces; these cysts are transmitted primarily by food and water • Cysts are resistant to gastric acid, but the wall is broken down by trypsin in the ileum small intestine. Trophozoites are released and colonize the large intestine • To initiate symptomatic infection, E histolytica trophozoites present in the lumen must adhere to and penetrate the underlying mucosal layer by amebic cysteine protenase and pore forming molecules. • E.histolytica enters into mesenteric venules then in portal circulation and travel to the liver to form one or more abscesses.
- 29. • The Ehistolytica has special adhesion protein complex called galactose/N-acetyl-D-galactosamine (Gal/GalNAc) lectin through which it mediates liver invasion and forms absceses there. • Right lobe is more commonly involved than left lobe.
- 30. Clinical Presentation • Thesign and symptoms of amebic liver abscess are often nonspecific, resembling those of pyogenic liver abscess or other febrile diseases. Fever and abdominal pain;Fever is present in 87-100% of cases. Abdominal pain is most common.usually constant, dull, and aching, frequently in the right upper quadrant , may radiate to the right shoulder or scapular area. pain increases with coughing, walking, and deep breathing, as well as when patients rest on their right side. Associated with anorexia,nausea,vomiting, weight loss, malaise and diarrhea contaning blood or mucus Tender hepatomegaly is also present In amoebic liver abscess. Pulmonary symptoms; present in 18-26% . Most frequent symptoms are cough and chest pain, which may represent a sign of secondary pulmonary involvement by abscess rupture in the pleural cavity.
- 31. WORKUP • CBC (leucocytosis) •Liver Biochemistry (Hyperbilirubinemia in small no of pts , raised AST in acute condition, mildly raised ALP) • Clonoscopy with brushing may reveal typical flask-shaped ulcers, which should be scraped and examined immediately for E. Histolytica • Aspiration of Fluid Liver abscess aspirate is usually an odorless thick yellow-brown liquid classically referred to as “anchovy paste.” • Stool Studies • Examination of the stool for hematophagous trophozoites of E histolytica must be made on at least three fresh specimens because the trophozoites are very sensitive and may be excreted intermittently. • The PCR stool test shows high sensitivity for detecting E histolytica and for distinguishing nonpathogenic amoebas. However, this test is expensive. • Stool antigen detection facilitates early diagnosis before an antibody response occurs (< 7 d). • Stool culture for amoeba is sensitive but has limited availability • Serologic testing Serum antigen detection of E histolytica galactose lectin antigen is detected by ELISA in at least 75 % of Patient samples.
- 32. Imaging Studies Ultrasonography Ultrasonography isthe preferable initial diagnostic test. It can distinguish an abscess from a tumor or other solid focal lesion. • CT scanning CT scanning is sensitive but the findings are not specific. The abscess typically appears low density with smooth margins and a contrast-enhancing peripheral rim.
- 33. HISTOLOGICAL FINDINGS • Theliver involvement in amebiasis consists of necrotic abscesses and periportal inflammation. The abscess contains acellular proteinaceous debris and is surrounded by a rim of amebic trophozoites invading tissue. The abscess contains a chocolate-colored fluid that resembles anchovypaste and consists predominantly of necrotic hepatocytes. Triangular areas of hepatic necrosis, possibly due to ischemia from amebic obstruction of the portal vessels, have been observed.
- 34. TREATMENT 1-MEDICAL TREATMENT o METRONIDAZOLE(Tissueamebicidal agents) 750mg TDS for 7- 10 days OR o TINIDAZOLE 2G (Oral) OD for 5 days PLUS o DILOXANIDE FUROATE (Luminal amebicidal agents) 500mg TDS for 10 days to eliminate intraluminal cysts OR o PAROMOMYCIN 25-30mg/kg /day for 7 days) .
- 35. 2-SURGICAL TREATMENT o Imaging-guidedneedle aspiration o Catheter drainage o Open surgical drainage
- 36. INDICATIONS of IMAGINGGUIDED NEEDLE ASPIRATION 1) Abscess Size greater than 5cm (Right lobe). 2) Left lobe liver abscess. 3) Failure to observe a clinical response to drug therapy within 5-7 days. 4) Cannot be differentiated from a pyogenic liver abscess . 5) Age older than 55 years.
- 37. Characteristics of liverabscess Findings suggestive of AMEBIC liver abscess Findings suggestive of PYOGENIC liver abscess Age Younger adults Older adults Gender distribution Usually males Both Males and Females Left shift on white blood cell count Usually absent Often present Serum bilirubin concentration Usually normal Often elevated History Exposure to resource-limited settings, travel to endemic areas Prior history of gallstones, abdominal surgery; Appendectomy
- 38. Characteristics of liverabscess Findings suggestive of AMEBIC liver abscess Findings suggestive of PYOGENIC liver abscess Number of cavities usually single often multiple Location usually right lobe near the diaphragm either lobe of liver Diagnosis ultrasound / CT and serology ultrasound/ CT with or without aspiration Treatment medical medical with or without surgery
- 39. COMPLICATIONS • Pleuropulmonary infection(Bronchopneumonia ,empyema, hepatobronchial fistula, pleuropulmonary amebiasis ) • Peritonitis (Intra-peritoneal rupture occurs in 2-7% of patients) • Cardiac involvement( Pericarditis) • Sepsis • Cerebral Amebiasis • Fulminant Necrotizing Amoebic Colitis • Rectovaginal Fistula • Right sided pleural effusion • Atelactasis
- 40. PROGNOSIS • Mostly, Rapidclinical improvement <1 week drug therapy alone. • Resolution of clinical symptoms early on. • Radiological resolution lags behind. • Radiological resolution is approximately 12 months, with a range of 3 months to more than 10 years.
- 41. PROGNOSIS • Independent riskfactors for increased mortality includes:- i. Bilirubin level >3.5 mg/dL ii. Serum albumin <2.0 g/dL iii. Large volume of the abscess cavity iv. Multiple abscesses v. Encephalopathy.
- 42. PROGNOSIS • Death occursin approximately 5% of patients having extra-intestinal infection, including :- i. Liver abscess. ii. Rupture into the peritoneal cavity iii. Rupture into the Pericardium.
- 43. PREVENTION • Sanitation • Thoroughlywash fruits and vegetables • Use bottled water and soft drinks from sealed containers. • Boil Tap water at least 1 minute • Chlorination • Iodine tablets to the filtered water • Avoid ice cubes or fountain drinks • Avoid unpasteurized dairy products • Avoid food from street vendors.
- 44.