JOURNAL OF EVIDENCE BASED MEDICINE AND HEALTHCARE

Table of Contents

2018 Month : August Volume : 5 Issue : 32 Page : 2389-2393

CLINICAL ANALYSIS OF AMOEBIC LIVER ABSCESS

Aravind Ramachandra Mirajkar1, Kalavathi G. P2

1. Associate Professor, Department of General Medicine, Karwar Institute of Medical Sciences, Karwar, Karnataka.
2. Assistant Professor, Department of General Medicine, Karwar Institute of Medical Sciences, Karwar, Karnataka.

Dr. Kalavathi G. P,
Assistant Professor,
Department of General Medicine,
Karwar Institute of Medical Sciences,
Karwar- 581301, Karnataka.
E-mail: kalavathigp@gmail.com
DOI: 10.18410/jebmh/2018/493

ABSTRACT
BACKGROUND
Hepatic Amoebiasis is the infection of the hepatic tissue by the trophozoite form of Entamoeba histolytica from the intestine. Hepatic amoebiasis or liver abscess is commonest complication of amoebiasis.
The aim of the study is to know the clinical profile of amoebic liver abscess using a non-invasive diagnostic procedure like screening chest X-ray with special reference to abdominal ultrasound to confirm amoebic liver abscess. Clinical course of disease admitted to hospital and response to both medical and surgical line of treatment were studied.

MATERIALS AND METHODS
Thirty-five patients referred to general medicine department of Karwar Institute of Medical Sciences were screened and selected for this study. Inclusion criteria for study are patients having right hypochondriac pain and palpable tender liver with intercostal tenderness &/or patients having fever, chills, rigor with palpable tender liver &/or patients having cough, breathlessness, right sided chest pain and palpable tender liver &/or patients having loose motion, pain abdomen and palpable tender liver. All the patients who fulfilled inclusion criteria were subjected to blood test, X-ray and abdominal ultrasonography.

RESULTS
Fourteen patients gave history of loose motion associated with blood and mucus, blood or mucus. Pain abdomen, fever and right sided chest pain were the most common symptoms in these patients. Fever and anaemia were the most general physical examination findings. On systemic examination, intercoastal tenderness and tender hepatomegaly were seen in nearly all the patients. Anaemia was seen in 71.4%, polymorphonuclear leucocytosis in 65.70% and raised ESR in 77.01% of patients. All the patients had elevated diaphragm, which had restricted movement on X-ray. On abdominal ultrasonography, abscess was observed in right lobe of liver in majority of cases. In the present study, two patients expired before any medical intervention could be given.

CONCLUSION
Pain abdomen and right sided chest pain associated with fever is the presenting complaint. Intercostal tenderness with tender hepatomegaly is seen in almost all cases. Clubbing, jaundice, pedal edema and tachycardia are some findings in general examination. Anaemia, polymorphonuclear leukocytosis and raised ESR are seen in 2/3 of the patients. Solitary right lobe abscess was seen in 91.4% of cases. Raised diaphragm with restriction of movement seen in all patients.

KEYWORDS
Amoebic Liver Abscess, Clinical Analysis, Abdominal Ultrasonography, X-Ray.

How to cite this article

Mirajkar AR, Kalavathi GP. Clinical analysis of amoebic liver abscess. J. Evid. Based Med. Healthc. 2018; 5(32), 2389-2393. DOI: 10.18410/jebmh/2018/493

BACKGROUND

Hepatic Amoebiasis is the infection of the hepatic tissue by the trophozoite form of Entamoeba histolytica from the intestine. Hepatic amoebiasis or liver abscess is commonest complication of amoebiasis. Other tissue and organs may be involved and amoebiasis of the lung, amoebic pericarditis by direct extension, amoebic abscess of the brain and other organs, spleen, psoas muscle, buttocks and thigh by systemic spread.1

Incidence was 0.57% - 0.7%,2,3 4.86 Debakay and Ochsner found an average incidence of hepatic involvement associated with intestinal disease to be 13.2% upto 40%.4 In under developed countries amoebiasis is common, more so amongst in low social-economic status group, living in congested area with poor sanitation.5,6

It is more frequently encountered in adult life with highest incidence occurring in the 3rd, 4th & 5th decades.7 Hepatic amoebiasis characteristically occurs in adults and only rarely appears in children.8 More common in males than in females. About 85-95% of the total cases seem to occur in males.

Amoebic liver abscess is more prevalent in tropical areas, where invasive amoebiasis is common.9 India has maximum case reports of amoebic liver abscess. 

In recent years, an increased incidence of amoebiasis has been noted in urban male homosexual population.10 Homosexual mode of transmission is probably oro-anal or genitoanal with oro-genital contact.5

 

Aims and Objectives

This study is done to know the clinical profile of amoebic liver abscess, using a non-invasive diagnostic procedure like screening X-ray chest with special reference to abdominal ultrasound to confirm amoebic liver abscess. Clinical course of disease admitted to hospital and response to both medical and surgical line of treatment were studied.

 

MATERIALS AND METHODS

Thirty-five patients referred to general medicine department of Karwar Institute of Medical Sciences were screened and selected for this study. This study was conducted over a period of a year in 2016-17.

Inclusion criteria for study were patients having right hypochondriac pain and palpable tender liver with intercostal tenderness &/or patients having fever, chills, rigor with palpable tender liver &/or patients having cough, breathlessness, right sided chest pain and palpable tender liver &/or patients having loose motion, pain abdomen and palpable tender liver.

All the patients who fulfilled inclusion criteria were subjected to stool examination for finding trophozoites of amoebae and cysts. In all cases, cysts were confirmed by Iodine staining. As majority of these patients were alcoholic, hepatic function tests were done. Bleeding time, clotting time, estimation of blood glucose, HIV and HbsAg test were done in all the cases. Abdominal ultrasound was done to confirm the presence of the abscess in the liver, and the situation and extent of the abscess. These patients were further investigated for radiological evidences of restriction of diaphragmatic movement, elevated dome of diaphragm, involvement of lung and pleura. All the cases were investigated further for the evidence of systemic complications of amoebic liver abscess.

All the patients were treated with tablet metronidazole 400 mg t.i.d. x 10 days and in acute cases intravenous (IV) metronidazole 500 mg t.i.d. x 5 days followed by oral metronidazole. Tablet Chloroquine 150 mg base 2 BD x 2 days followed by 1 BD x 19 days. In some cases, oral or IV course of antibiotic was given and prognosis was noted in all the cases.

 

RESULTS

A total of thirty-five amoebic liver abscess cases were screened and enrolled into study by general medicine department of Karwar Institute of Medical Sciences during period 2016-17. The following clinical observation were made in the study.

 

 

 

 

 

History

No. of Patients

% of Patients

No. of patients with present and past history of loose motion

14

40.00

No. of present/past history of loose motion

21

60.00

Total

35

100.00

Table 1. History of Loose Stools

 

Symptoms

No. of Patients

% of Patients

Pain Abdomen

31

88.60

Fever

28

80.00

Right side chest pain

23

65.70

Cough

11

31.40

Breathlessness

05

14.30

Bowel disturbance

04

11.40

Jaundice

02

05.70

Table 2. Symptoms of Amoebic

Liver Abscess

 

Signs

No. of Patients

% of Patients

Fever

28

80.00

Anaemia

25

71.40

Toxic

04

11.40

Jaundice

03

08.60

Clubbing

03

08.60

Pedal Oedema

02

05.70

Table 3. General Physical Examination Findings

 

Sign

No. of Patients

% of Patients

Intercostal tenderness

35

100.00

Tender hepatomegaly

33

94.3%

Rt. basal crepitation’s

15

42.90

Pleural effusion

08

22.60

Tachycardia

10

28.60

Table 4. Systemic Examination Findings

 

Blood Test Findings

No. of Patients

% of Patients

Anaemia

25

71.40

Polymorphonuclear leukocytosis

23

65.70

Raised erythrocyte sedimentation rate (ESR)

27

77.10

Table 5. Findings of Haematological Investigations

 

Radiological Tests/ Findings

No. of Patients

% of Patients

Screening chest: Decreased movement of diaphragm

35

100.00

X-Ray Chest: Raised dome of Diaphragm

35

100.00

Right Basal pneumonitis

15

42.90

Pleural Effusion

08

22.90

Table 6. Radiological Findings

 

Figure 1. Chest X-ray Showing Elevated Right Dome of the Diaphragm with Minimal Effusion Right Side

Hepatic Site of Amoebic Liver Abscess

No. of Patients

% of Patients

Right lobe

32

91.40

Left lobe

02

05.70

Multiple

01

02.90

Total

35

100.00

Table 7. Abdominal Ultrasound Findings

Figure 2. Abdominal Ultrasound showing a Hypoechoic Lesion in Posterior Aspect of Right Lobe

 

Figure 3. Treatment and Prognosis of Amoebic Liver Abscess Patients

DISCUSSION

Few of the important studies are considered for comparison purpose and the comparative study is discussed below.

 

History

Kapoor 19797

Present Study

Present & Past of history of altered bowel Habit

60%

40%

 

Symptoms

Turril et al 19668

Kapoor 19797

Present study

Pain Abdomen

66%

75%

88.6%

Fever

67%

63%

80%

Right side chest pain

44%

62%

65.7%

Cough

36%

21%

31.4%

Jaundice

11%

2.5%

5.7%

 

 

Turill et al 1966 and Kapoor 1979 series, has lesser incidence of pain abdomen compared to the present study may be due to lesser enlargement in their group. The present study compared favourably with Turril et al 1966 and Kapoor 1979 series. Pain in the right side of the chest seen due to diaphragmatic and pleural involvement present study compares favourably with Kapoor 1979 series. The present study results of cough and breathlessness are comparable with other studies. The incidence of jaundice compared favourably with other studies.

 


 

Sign

Ramachandran et al 197211

Samsi et al 197412

Kapoor 19797

Present Study

Tender Hepatomegaly

90%

91.2%

88%

94.3%

Table 10. Comparison of Systemic Examination Findings from Different Studies

 

Most of the other studies also show a similar incidence of tender hepatomegaly.

 

 

Sign

Subramaniam and Krishnan et al 197713

Present study

Jaundice

7.8%

8.6%

Table 11. Comparison of Jaundice from Different Studies

 

The present study favourably compared with Subramaniam and Krishnan et al 1977, where the jaundice is less common clinical feature.

 

Sign

Turril et al 19668

Kapoor 19797

Ramachandran

 et al 197211

R N Garrison et al 19943

P. Nigam et al 198514

Present Study

Lung Signs

18%

35.5%

3.6%

54%

16%

42.9%

Table 12. Comparison of Lung Signs from Different Studies

 

The present study correlates well with Kapoor 1979 and R N Garrison et al 1994 series, where the incidence of involvement of lung was more as the patient starts the medical advice late during the disease.

 

 

R.N. Garrison et al 19943

Kevin M Decock et al 19935

P. Nigam et al 198514

Present study

Anaemia

47%

50%

57%

71.4%

Table 13. Comparison of Frequency of Anaemia from Different Studies

 

In the present study, anaemia was higher compared to other studies probably because of poor social-economic status of the patients in the present study leading to anaemia.

 

 

Subramaniam and Krishnan et al 197713

Ramachandran et al 197211

Present Study

Polymorphonuclear leukocytosis

24%

60%

65.7%

Raised ESR

37%

74.6%

71.1%

 

The present study result of polymorphonuclear leucocytosis is comparable with Ramachandran et al 1972 study. In the other series, the incidence was less. ESR is raised in all the series except Krishnan et al 1977 Series.

 

Hepatic Site of Amoebic Liver Abscess

Burton L. Reid et al 199215

H. Kean et al

195616

Present Study

Right lobe

80%

51%

91.4%

Left lobe

10%

24%

5.7%

Multiple

10%

25%

2.9%

 

Right lobe of liver is involved in majority of the cases as the right lobe is bigger in size. The present study compares favourably with other series. Left lobe involvement is less common in amoebic liver abscess, which is seen in other series also. Multiple abscess seen in only one case in our study. Whereas in other series, the incident is slightly more compared to the present study, probably due to less immune compromised stage in the other series.

 

 

Subramaniam and Krishnan et al 197713

Kapoor 19797

Present study

Mortality

7.5%

6.6%

5.7%

Table 16. Comparison of Mortality from Different Studies

 

With the availability of anti-amoebic drugs, the mortality in cases of amoebic liver abscess considerably improved. With surgical intervention of large abscess has further reduced the incidence of mortality in amoebic liver abscess. The present study compares well with mortality seen in the above studies.

 

 

CONCLUSION

Pain abdomen and right sided chest pain associated with fever is the presenting complaint. Intercostal tenderness with tender hepatomegaly seen in almost all cases. Clubbing, jaundice, pedal edema and tachycardia are some findings in general examination. Anaemia, Polymorphonuclear leukocytosis and raised ESR are seen in 2/3 of the patients. Solitary right lobe abscess was seen in 91.4% of cases. Raised diaphragm with restriction of movement seen in all patients. Morality was seen in two patients i.e., 5.7% of cases.

 

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