The document discusses a rare case of simultaneous amoebic colonic perforation and ruptured liver abscess in a 70-year-old male presenting with severe abdominal pain and fever. Key features include the use of imaging techniques for diagnosis and surgical intervention, which involved right hemicolectomy and drainage of the liver abscess. The discussion highlights the prevalence and risks associated with invasive amoebiasis, surgical management options, and the importance of early detection to reduce mortality rates.

1. SIMULTANEOUS AMOEBIC
COLONIC PERFORATION WITH
RUPTURED LIVER ABSCESS –
A RARE PRESENTATION
Dr.B.GOPIKRISHNA
PG.in General surgery

2. INTRODUCTION
 amoebiasis caused by Entamoeba histolytica manifest as
acute intestinal infectious diarrhoea clinically,
pathologically as ulcerative and inflammatory lesion(
bottle-neck ulceration )in the caecum and the entire
colon.
 Trophozoites of Entamoeba histolytica usually invade
interglandular tissue of the crypts of Lieberkuhn and
burrow through the mucous membrane to lodge in the
submucosal plane for multiplication.

3.  The organism during the invasive stage, gain access
to the liver via the portal vein where marked tissue
destruction occur resulting in a liver abscess.
 Liver abscess and colon perforation are the clinical
syndromes associated with amoebiasis.
 Management of a complicated severe form of
invasive amoebiasis is challengeable.

4. o As many as 55% of those in endemic regions are
infected, although less than 50% are
symptomatic.
 severe amoebic infection is known as invasive or
fulminant amoebiasis.
o Still rarer is the occurrence of simultaneous
amoebic colonic perforation and ruptured
amoebic liver abscess presenting as an acute
abdomen

5.  One such presentation of synchronous ruptured liver
abscess with large bowel perforation in a 70 years old
male is reported.

6. CASE REPORT
 A 70-year-old male, a chronic alcoholic (35years) non-
hypertensive, non-diabetic coolie presented with high
fever and pain in right upper and lower abdominal pain
for one weak.
 Physical examination revealed tenderness and guarding
in the whole abdomen, simulating peritonitis.
 Routine investigations revealed leucocytosis, raised
blood urea and serum creatinine. Mild elevation of liver
enzymes, elevated PT-INR levels and hypoprotenemia.

7.  X-ray of the abdomen showed elevated right diaphragm
and pleural effusion.
 Ultrasonography of the abdomen revealed free fluid in
the peritoneal cavity with ruptured liver abscess .
 CT abdomen showed ruptured liver abscess and minimal
right –sided pleural effusion .

8.  A provisional diagnosis of peritonitis due to ruptured
liver abscess with sepsis was made and the patient was
taken up for emergency laparotomy.
 Laparotomy revealed, ruptured liver abscess in the right
lobe of liver and large bowel perforation in the caecum
and ascending and transverse colon, with patchy colonic
wall necrosis and massive peritoneal faecal and pus
contamination.

9.  Right hemicolectomy with covering ileostomy and
peritoneal wash with tube drainage of the liver abscess
cavity was performed , postoperative period uneventful.
 Drains were removed on 9th postoperative day and
patient was discharged on 15th postoperative day.

10. COMPUTED TOMOGRAPHY: RUPTURED LIVER
ABSCESS CAVITY FIG-1

11. PERFORATED COLON FIG-2

12. RIGHT HEMICOLECTOMY SPECIMEN
FIG-3

13. HISTOPATHOLOGICAL EXAMINATION OF THE SPECIMEN
SHOWED AMOEBIC ULCERS OF THE CAECUM
FIG-4

14. DISCUSSION
 Amoebic liver abscess is the most common manifestation
of extra intestinal amoebiasis. The causative agent is a
protozoan, Entameba histolytica.
 10% of the world population harbours
E.histolytica in their colon, 10% of them may develop
invasive amoebiasis and 1-10% of these patients develop
amoebic liver abscess.
 Amoebic liver abscess is common in tropical countries
and prevalent in low socioeconomic class living in
unhygienic conditions
 Trophozoites of Entameba histolytica usually invade
mucosa and submucosa of colon [4].

15.  Invasion may reach up to musclar layer and serosa causing
silent perforation often involving caecum [1,2].
 Bowel perforation occurs between 1%-6% of the patients
with amoebiasis [5].
 The surgical approach is most efficient to treat a large liver
amoebic abscess(>5cm) and intraperitoneal collection and
colonic perforation [1,3,4].
 Fecal peritonitis with concomitant ruptured liver abscess
usually leads to severe septicemia. If not detected at an early
stage ,mortality ranges from 6% to as high as 50% [4,5].

16.  The presentation of amoebic caecal perforation may vary
from well contained abscess to faecal peritonitis with or
without concomitant hepatic abscess or fulminant colitis.
 Traditionally, the treatment option was faecal diversion.

17.  FC Eggleston et al. documented a study of 26 patients with
amoebic colonic perforation with 71% mortality in the
resection group and 43% mortality in the faecal diversion
group.
 Hasan et al. showed that in patients with well contained disease
or minimal faecal peritonitis, resection of caecum with primary
ileo-colic anastomosis could offer comparable results.

18. CONCLUSION
 Uncomplicated liver abscess 90% curative rate with
metronidazole and luminal agents.
 Ruptured liver abscess may treated successfully with
percutaneous drainage.
 Ruptured liver abscess with concomitant colonic
perforation – resection and primary anastomosis
or faecal diversion is mainstay of treatment.

19. REFERENCES
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amoebic caecal perforation with ruptured liver abscess - a rare
presentation. The Internet Journal of Surgery; 2009, Vol. 19,
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colonic perforations and ruptured liver abscess - a case report.
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Essential surgical practice, 3rd edition, Cuschieri A, Giles GR,
Moossa AR (Eds.), Butterworth Heinemann Ltd. Oxford; 1995;
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