Frequency of Clinical Manifestations, in Cases of Liver Abscess in Hospital Based Study

1. Syed Khalid Shah 2. Abdul Kabir Kakar 3. Abdul Karim Zarkoon

1. Head of Dept. & Assoc. Prof. of Medicine, SPH/BMC, Quetta 2. PG Resident, Dept. of Medicine, SPH/BMC, Quetta 3. Prof. of Nephrology, Sandeman (P) Hospital/BMC, Quetta.

ABSTRACT

Objective: The study was designed to determine frequency of clinical manifestations, associated risk factors and early diagnosis to avoid complications in cases of liver abscess in hospital based study.

Study Design: Descriptive study

Place and Duration of Study: This study was conducted in the Medical Unit, Bolan Medical Complex Hospital, Quetta, Pakistan from August 2006 to Feb: 2008.

Materials and Methods:100 consecutive cases of liver abscess were reviewed. 99 cases (99%) were amoebic and 01 (1%) gynogenic. Majority of liver abscess were single and in right lobe (92%). Four (04%) in left lobe and four (04%) in both lobes.  

Results:Ultrasound guided aspiration with metronidizole was performed in 35% of our patients.  These patients had abscess that were usually larger then 5cm in diameter. The other cases were managed initially empirically with parentral antibiotics then with oral antibiotics. We found that percutaneous aspiration of liver abscess is helpful to confirm diagnosis provides the a better bacteriological culture yield, gives a good outcome and may uncover clinically unsuspected conditions like malignancy and tuberculomas which may mimic the presentation of liver abscess.

Conclusion:We recommend that ultrasound guided aspiration is a safe, economical easy way of management of liver abscess with low morbidity and negligible mortality.

Key Words: Liver abscess, Aspiration, Hospital based.


INTRODUCTION

Liver abscesses (Pus filled localized cavities in the Liver) have been recognized since the age of Hippocrates. In 1883, Koch described the amoebae as a cause of liver abscess. In 1938 Ochner and Debakey1 published the largest series of pyogenic and amebic liver abscesses in the literature. Over the past two decades, percutaneous drainage has become a useful therapeutic option.

In the early part of the twentieth century, liver abscess was described as a condition affecting predominantly young males in the setting of intra-abdominal infection1 However, in the antibiotic era, improvements in radiological diagnosis have led to the recognition of hepatobiliary pathology as the principal association2'3 More recent reports have suggested an increasing incidence of liver abscess, particularly among older people4. Treatment of liver abscess has changed over the last two decades of the twentieth century towards a non-surgical approach, largely because of improved interventional radiology technique and its wider availability5

Reports from South East Asia showed certain trends, amebic abscesses were more common then pyogenic abscesses.  In Pakistan most common organism are Klebsiella pneumoniae, Escherichia coll, Mycobaclerium tuberculosis  .Bacteroides species - Streptococcal species -Microaerophilic streptococci also involved in liver abscess. This organism can gain access to the liver by direct extension from contiguous organs or through the portal vein or hepatic artery. Hepatic clearance of bacteria via the portal system appears to be a normal phenomenon in healthy individuals; however, organism proliferation, tissue invasion, and abscess formation can occur with biliary obstruction, poor perfusion, or microembolization.

Main clinical presentation of the liver abscess include abdominal pain, fever, chills, anorexia, weight loss, cough, pleuritic chest pain, referred pain to the right shoulder7,8, jaundice, tender hepatomegaly etc.

An untreated hepatic abscess is nearly uniformly fatal with timely administration of antibiotics and drainage procedures mortality currently occurs in 5-30% of cases.  The most common causes of death includes sepsis, multi-organ failure, and hepatic failure.  

The right hepatic lobe is affected more often then the left hepatic lobe by a factor of 2:1.  Studies have suggested that a streaming effect in the portal circulation is causative. 

Pyiogeneic liver abces show no general difference.  Amoebic abcess is 10 times more common in men than women.

Residents of and travelers to developing or under developed areas where drinking water is contaminated by E-histolytica are advised for safe drinking water.

MATERIALS AND METHODS

This was observational study conducted in the Department of Medicine Bolan medical Complex Hospital Quetta, from August, 2006 to February, 2008,

Patients of all ages with fever of more than 101 Foreign Height with pain the right hypochondrium and ultrasound proven abscess were included in the study from OPD and Wards. 

Patients with past history of abdominal surgery carcinoma liver and carcinoma of gall bladder, haemangioma of liver, and hydatid cyst of liver were excluded from study.

RESULTS

Abscess Type: There were 100 patients with confirmed liver abscesses, 99 of whom (99%) had amoebic abscess, and one (1%) had pyogenic.

Patient Characteristics: Out of 100 patients of liver abscess included in this study, 88 were male and 12 were female. The ratio of male to female was 7:1.

Age of the patient ranged from 18 years up to 60 years (mean 2.00 years and standard deviation 0.83 ).

Subjects participated in my study were 20 (20%) Afghan Pathan, 43 (43%) were local Pathans, 26 (26 %)  Baloch, and 9 (9%) Hazara.

Clinical Presentation: The clinical features at presentation in all hundred (100) patient. The duration of the symptom range from 5 to 90 days. Sixty-four patients (64%) had tender hepatomegaly, forty six patients (46%) jaundice and two patients (2%) had toxic appearance. Two patients (2%) had a dyspnoea and cough during routine activity with positive sign of pleural effusion and basal crepitation corresponding to the side of the abscess. One patient (1%) had a weight loss.

Laboratory Finding: Laboratory abnormalities at presentation were leukocytosis, seventy nine patients (79%), seventeen patients (17%) had anemia, two patients (2%) had low platelet count, three patients (3%) had prolong prothrombin time. Eighty nine patients (89%) had a high alkaline phosphatase level, Twenty three patients (23%) had a high level of alanine aminotransferase (ALT), thirty seven patients (37%) had a hyper bilirubinemia, thirteen patients (13%) had high Gama Glutamyl transferase (G-GT) and two patients (2%) had low albumin. One patient (1%) had a high urea and creatinine.

Ten patients (10%) had a positive stool report for ova and cyst. One patient (1%) had a positive pus culture for Klebsiella pneumonia.

Radiological Characteristics: Ultrasound performed in all the hundred patients, was the first line most accurate tool detected liver abscess in 96 patients (96%). Ninety two (92%) had a single abscess only in the right lobe of liver; four patients (4%) had multiple abscess involving both lobes of the liver, while four patients (4%) had a single abscess in the left lobe of the liver.

The size of the abscess in the whole series ranged from four centimeter to eleven centimeter. Seven patients (7%) had a raised hemidiaphram on chest x ray and two patient (2%) had a right sided  pleural effusion.

Table No.1: Symptoms of liver abscess (n=100)

Sr.#

Symptoms

No. of Patients

%age

1

Pain right hypochondrial

62

62%

2

Pain whole abdomen

3

3%

3

Pain lower chest

1

1%

4

Pain left hypochondrium

1

1%

5

Pain to tip of shoulder

1

1%

6

Fever>101oF

47

47%

7

Nausea and vomiting

38

38%

8

Diarrhea 

17

17%

9

Dyspnea/cough 

2

2%

10

Weight loss  

1

1%

11

Hiccup     

0

0%

Table No.2: Signs of liver abscess (n=100)

Sr.#

Signs

No. of Patients

%age

1

Tender & enlarge liver

64

64%

2

Temperature>101 0F

47

47%

3

Jaundice

46

46%

4

Toxic appearance

15

15%

5

Pl effusion & rub

2

2%

Table No.3: Laboratory findings of liver abscess (n=100)

Sr.#

Laboratory feature

No. of Patients

%age

1

White blood cell count>1 1000/dl

79

79%

2

Haemoglobin<11g/dl

17

17%

3

Platelet count<1 50 000/dl

2

2%

4

Prolonged protrombin time

3

3%

5

Urea<7.6mmol/l

1

1%

6

Creatinine>140 iu/l

1

1%

7

Bilirubin >34 iu/l

37

37%

8

Alkaline phosphatase>150 iu/l

89

89%

9

Gamma glutamyl transferase>40 iu/l

13

13%

10

Alanine aminotransferase>33 iu/l

23

23%

11

Albumin<35g/dl

2

2%

Management: Sixty four patients (64%) having abscess less than five centimeter responded to metronidazole only. And one patient responded to third generation Cephalosporine plus Metronidazole. In thirty five patients (35%) with abscess larger than five centimeter ultrasound guided aspiration was combined as part of our routine.>

Table No.4: Radiological findings of liver abscess (n=100)

Sr.#

Ultrasound findings

No. of Patients

%age

1

Right lobe single abscess

92

92%

2

Left lobe single abscess

4

4%

3

Both lobe multiple abscess

4

4%

4

Total

100

100%

Risk Factors: All the hundred patients were evaluated for risk factors. Seven patients (7%) of chronic liver disease had found liver abscess of unknown cause, two Patients (2%) of diabetes mellitus had liver abscess and one patient (1%) had an  ascending  cholangitis  from cholelithiasis.  There were no  risk  factors detected in the remaining patients.

There was no mortality in our series of patients studied; all patients after discharge were reviewed as out patients to ensure both clinical and radiological resolution of the liver abscess.

Table No.5: Treatment of liver abscess (n=100)

Treatment

Abscess size

No. of Patients

%age

Metronidazole only

Less than 5cm

64

64%

Third generation Cephalsporin plus metronidazole

Less than 5cm

01

01%

Ultrasound guided aspiration plus metronidazole

More than 5cm

35

35%

Total

 

100

100%

Table No.6: Risk factor of liver abscess (n=100)

Sr.#

Risk Factors

Abscess +ve

Percentage

1

Chronic Liver Disease

07

7%

2

Diabetes Mellitus

02

02%

3

Ascending cholangitis

01

01%

4

Inflammatory bowel diase

00

00%

5

Pyelonephritis

00

00%

6

Endocarditis

00

00%

7

Leukemia

00

00%

8

Total

10

10%

DISCUSSION

Although the incidence of the liver abscess is higher in our region but still cases are diagnosed very late. Most of the cases in our series were treated as that of acid-peptic disease, cholecystitis or malaria, initially before being referred to us by general practitioners. Delay in diagnosis causes increase in severity of the disease which is further complicated.

The median age of the 100 patients included in our study was 20. It has been reported that the age of presentation has been progressively rising.

In our study, the clinical presentation of the patients with liver abscess was non specific. In early clinical diagnosis requires a high index of suspicion and is often based on a constellation of non specific clinical features.10

Therefore in an endemic area a patient with lower chest and upper abdominal symptoms with space occupying lesion should raise the suspicion of Liver abscess11

Our patients presenting symptom did not differ from that reported literature, with right hypochondrial pain and fever being the two most commonly documented symptoms12 these finding in young man from a low socioeconomic status should raise the suspicious of Amoebic liver abscess.11.

In our case series study 17 patients (17%) had presented with diarrhoea. While this symptom has been reported in 12-33% of the patients13,14   .  Male and right hepatic lobe predominance have been noted in several studies like our one and the later has been attributed to relative sizes of lobe 13.

Jaundice has been attributed to sever illness, large abscess compressing the porta hepatis, sepsis, peritoneal rapture, cholestasis15'16 , 46% of the patients were with jaundice in our region which is comparatively higher than the literature, 6-33% 17.

Non specific biochemical features such as anemia and leukocytosis were common. A raised alkalaine phospatse with a rise in bilirubin, was also found in two third of our patients18.           

Ultrasound is safe, economical and easily available and its sensitivity is  nearly 92-97% 10, in our study ultrasonography has detected liver abscess in 96 % of the patients. It would seem that ultrasonography by an experience radiologist should be the first line imaging modality in patients with suspected liver abscesses. Computerized Tomography (CT) scanning may confirm the ultrasonographic diagnosis. The role of more sophisticated imaging techniques remains undefined although recent literature suggests that magnetic resonance imaging and serial gadolinium-enhanced gradients-echo images can help differentiate hepatic abscesses from other focal hepatic lesions.19

However ultrasound feature of the amoebic liver abscess and other space occupying leision of the liver e.g., hepatoma, pyogenic liver abscess etc. may over lap. The combination of ultrasound with clinical features and aspirate analysis increases its sensitivity20 .

Ultrasound guided aspiration with metronidazole in liver abscess was performed in 35% of our patients these patients had abscesses that were usually larger than 5 cm in diameter and in locations approachable to per cutaneous drainage. However needle aspiration is reportedly less invasive, less costly and less laboured-intensive as it obviates the need for meticulous catheter care. In addition multiple cavities can be drained in the same session. However one study showed a decreased success rate if needle aspiration was limited to two attempts21

A range of medical conditions, particularly diabetes mellitus has been reported to increase the risk of liver abcess22,23, in our study there were only two patients with diabetes mellitus.

Only one percent of our patient had features of ascending cholangitis. However a study by Lee et al shows 4% occurrence of ascending cholangitis. Most cases of pyogenic liver abscess are in fact cryptogenic24'

CONCLUSION

Liver abscess should be diagnosed early to decrease morbidity and mortality. Early diagnosis offers the best chance of cure. This study was helpful in finding out the factor helpful in early diagnosis and effective management of liver abscess and analysed the effects on the management by delay in presentation and diagnosis. Ultrasound guided aspiration is a safe, economical, easy way of management of liver abscess with low morbidity and negligible mortality.

Acknowledgment: We are indebted to Mr. Hamdullah for his assistance in drafting and typing the final manuscript.

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Address for Corresponding Author:

Dr. Syed Khalid Shah,

Head of Dept. & Assoc. Prof. of Medicine, SPH/BMC,

H.No 24-B, chaman Housing Scheme,

Airport Road, Quetta.

Email: This email address is being protected from spambots. You need JavaScript enabled to view it.