31.5.14 The Outcomes of Liver Abscess, in A Tertiary Care Unit

Original Article

 

Liver Abscess

The Outcomes of Liver Abscess, in A Tertiary Care Unit

Sajid Hussain1, Junaid Cheema2 and Fatima Zulfiqar2

ABSTRACT

Objective: To study aims at the early clinical presentation, diagnosis, management and to establish guidelines in view of conservative or either intervention.

Study Design: Longitudinal study

Place and Duration of Study: This study was conducted at the Surgical Department of Allama Iqbal Memorial Teaching Hospital Sialkot from Jan 2017 to Jan 2020.

Materials and Methods: A total of 200 patients visited the OPD; only 40 were willing to be hospitalized from Jan 2017 to Jan 2020. Patients more than 20 years. Suspicion of liver abscess on the basis of clinical and diagnostic confirmation.

Results: A total of 40   cases were studied, with the mean age of 44years; all patients male and female studied
for their presentations(pain.fever,vomiting,chills,jaundice,diarrhea,tenderness,enlarged liver, management conservatively or surgically, The collected  data was analyzed through SPSS 20.

Conclusion: Males affected more than female, ultrasound is the best imaging technique and aspiration found to be best in interventional technique.

Key Words: Enlargedliver,conservative,aspiration,pig tail,mortality.

Citation of article: Hussain S, Cheema J, Zulfiqar F. The Outcomes of Liver Abscess, in A Tertiary Care Unit. Med Forum 2020;31(5):62-65.

 

 

INTRODUCTION

Liver abscess had a long history since 3000 B.C1, for which patients present with upper abdominal pain which is more marked in right hypochondrium. If these patients are not managed earlier they will have higher morbidity and mortality2.The most of the abscesses were amoebic than pyogenic.3

The pyogenic variety is more marked in the western countries as compared to developing countries4, which are failed to be documented due to lack of insufficient resources.

The main reasons of pyogenic abscess are ascending biliary infection through portal venous system and septicemia as result of infections caused by E.Coli, klebsiella, streptococcal followed by staph and proteus5.

The investigations which are carried out are ultrasonography, by aspirating reddish brown paste like material.

 

 

1. Department of Surgery, Allama Iqbal Memorial Teaching Hospital Sialkot.

2. Department of Surgery Unit-III, Khawaja Safdar Medical College, Sialkot.

 

 

Correspondence: Dr. Fatima Zulfiqar, Registrar, Department of Surgery Unit-III, Khawaja Safdar Medical College, Sialkot.

Contact No: 03354299111

Email: dr.fatimazulfiqar9632@gmail.com

 

 

Received:    February, 2020

Accepted:    March, 2020

Printed:        May, 2020

 

 

The diagnosis of amoebic liver abscess is made by the clinical picture, examination findings, ultrasound findings and management plans6.

There were enough literature present internationally to talk about the involvement of the lobes right, left or both, liver enlargement ,raised LFTs, type of liver abscess amoebic pyogenic, single or multiple and different management plans. Globally, which reveals that smaller abscesses may be treated conservatively while  larger needs some modalities ranging from aspirations to pig tail catheter insertion but there is no definite consensus for the management of the symptomatic liver abscess but there was a very scarce literature available to be studied in order to bridge a existing gaps and comparing our data with established data in order to predict about the clinical picture, examination findings and diagnostic tools which are available and different treatment modalities in order to decrease morbidity and mortality of the patients. The idea of the minimal invasive procedures are still of the significant importance in the treatment modalities of liver abscess7, in combination with modern antibiotics. Best treatment option is the percutaneous techniques8.

Keeping all above mentioned facts in mind a study was carried out in 40 patients in our local context of a tertiary care unit   draining more than four million populations.

The present study is to finding out some link between the clinical   presentations, examination findings and treatment modalities and comparing their efficacy with already researched before.

 

 

MATERIALS AND METHODS

A total of 200 patients visited the OPD; only 40 were willing to be hospitalized from Jan 2017 to Jan 2020.

Inclusion criteria: Patients more than 20 years

Suspicion of liver abscess on the basis of clinical and diagnostic confirmation.

Exclusion criteria: Age less than 20 years and cases associated with malignancy, immune compromised, and ascetic with other effusions.

A thorough hospital based longitudinal  study age,gender,pain,fever,chills,vomiting,jaundice,diarrhea,enlarged liver, tenderness, raised liver function tests, lobes involved, single or multiple, amoebic/pyogenic, conservative or intervention like aspiration, pigtail, both or any surgical intervention, morbidity /mortality.

RESULTS

The liver abscess was more common in male30 (75%) female 10 (25%), pain was marked in 32 patients(80%),fever in 27 patients(67.5%) chills in 30 (75%) vomiting 20 patients(50%)jaundice in 20 (50%), complaint of diarrhea in 21 patients (52.5%),enlarged liver in 21 (52.5%) tenderness in 17 patients (42.5%), LFTs raised in 18 patients(45%),involved right, left or both lobes as shown in table 1 which when further analyzed found to be significant (p value 0.01749)

Table No.1: Lobes involvement

Lobe

Single

Multiple

Total

Right

 9

  10

 19(47.5%)

Left

  14

   1

 15(37.5%)

Both

   4

    2

  6(15%)

 

There was a single abscess in 23 cases (57.5%) while multiple in 17 (42.5%) cases, most of the liver abscess was amoebic 22 (60%) pyogenic in 18cases (40%). (Table 2)

Table No.2: Types of abscess

Abscess

Amoebic

pyogenic

Total

Single

18

5

23

Multiple

4

13

17

Total

22

18

40

The single and multiple when further analyzed in respect to their type (amoebic)/pyogenic their relation found to be significant (P value 0.0002)

As regard treatment modalities are concerned 15 (37.5%) managed conservatively, aspiration was done in 12(30%) pig tail in 10 cases(25%), surgery in only 3 cases.

The statistical analysis of involvement of lobes in respect to the treatment modalities also found to be significant as shown in table 3 and table 4.

 

 

Table No.3: Statistics analysis of lobes in respect to treatment

Lobe involved

Treatment

Total

Conservative

Aspiration

Pig Tail

Surgery

Right Lobe

Count

3

9

6

1

19

% within Lobe_involved

15.8%

47.4%

31.6%

5.3%

100.0%

Left Lobe

Count

11

1

3

0

15

% within Lobe_involved

73.3%

6.7%

20.0%

0.0%

100.0%

Both

Count

1

2

1

2

6

% within Lobe_involved

16.7%

33.3%

16.7%

33.3%

100.0%

Total

Count

15

12

10

3

40

% within Lobe_involved

37.5%

30.0%

25.0%

7.5%

100.0%

 

 

 

 Table No.4: statistics analysis

Chi-Square Tests

 

Value

df

Asymp.

Sig. (2-sided)

Pearson Chi-Square

20.110a

6

.003

Likelihood Ratio

19.490

6

.003

Linear-by-Linear Association

.061

1

.804

N of Valid Cases

40

 

 

DISCUSSION

Our study included 40 patients show mean age group of presentation was 44.35 the minimum age was 22 years while maximum age was 65 years, there is a male preponderance in our case with a ratio of 3:1 as compared to other literature ratio ranging from 10:1 to 11.7:19, in another study carried out by the kapoor et al it was 5.66:110.

Incidence of pain was in 80% of cases which was consistent with the recent study where it was 88 %(11),which is quite high as compared to 75% in India ,the incidence of jaundice was also 50%while it was 31.5 % in the study of see to and Rockey11.

Most of the liver abscess was amoebic 60% while it was 67% Rajakn CLstudy12 while the incidence of amoebic liver abscess was more or less same 61.81% in a study carried

Out by sudhirjayakar13 while studies carried out in western countries the incidences of pyogenic abscesses were more than amoebic abscesses carried out by the Kaplan14. Liver enlargement is not necessarily associated with liver abscess as it was present only in 21 cases (52.5%) which is consistent with the studies carried out in 56 patients studied in san Francisco hospital between 1979 to 199415. Similarly LFTs are raised in 18% of the cases(45%) while 22 patients did not had any elevations in the LFTs (55%) which was consistent with the studies carried out in 352 cases in univariate  and multivariate analysis16.

Right lobe involved in 47.5% while left lobe involved in 42.5% while in case of study by Rose it was 55% involving right lobe,27.7% in left lobe and 16% in both lobes.23,25 while in a prospective study in 45 patients 80% right lobe left lobe 18% while 2%15, similarly liver abscess involved 57.5% as a single while 42.5 as multiple abscesses which was consistent with the study of Mathieu et al and other studies .our study was
also consistent with the studies carried out by Greenstein et al16.

Most of our patients responded to the conservative treatment with good control of antibiotics 37.5% patient improved after a conservative treatment, which was consistent and coherent with the studies carried out  by Akgun et al6 where metronidazole were given to single solitary liver abscess while PCD was carried out in 12 cases (30%)  which is  more successful in terms of recurrence of abscess, relief of symptoms and  decrease in the size of cavity and took a short duration as compared to other modalities, Pig tail catheter was used in 10 cases (25%) while surgery was carried out in only three case where all modalities failed as a last resort. The management of the liver abscess is quite debatable and it varies center to center ,lot of comparative studies have been carried out in the past where pig tail was preferred over percutaneous aspirations17 but in 306 patients success rate and clinical improvement was more in percutaneous aspiration  as there is lot of reduction in size of the cavity. while a study on the 45 patients a comparative studies of needle and catheterization showed the superiority of catheterization on pig tail,  similarly few other studies showed the same results and inconsistent to our studies. Total 45 patients in which 22 patients were aspirated while 23 got pig tail catheterization18 while in an another study in 98patients 13 were managed conservatively, 79 were managed through PCD while in 6 patients, laparotomy was carried out19.

Surgical interventions were carried out in just 3 cases which presented with peritonitis. No previous attempt of percutaneous, pig tail catheterization was attempted, a lot of variation also exist in this aspect, where treatment of pyogenic abscess was compared with the percutaneous drainage in a study carried out by
Bertel et al15, another study the 48 patients study with pyogenic liver abscess out of which 35 patients needed surgical intervention with 91.5 % improved results with mortality rate of 8.5%20.

Mortality and morbidity rates were also compared, the morbidity was decreased with early diagnosis and the earliest interventions which were carried out, in our study, mortality rate was quite low as because of early diagnosis and management, the morbidity was found in 11 cases while mortality rate was 3/40 (7.5%).Hospital stay was 13.6+_8.1 days and with antibiotic therapy 34.7+ 40.6 days which was carried out in a 67 patients study with 61 male and 6 female patients21.

CONCLUSION

The study revealed most common affected age group was between third and fifth decade. Males are affected more than female, incidence of amoebic liver abscess was more as compared to pyogenic liver abscess, and few responded to medical treatment, majority required aspirations found to be better followed by pig tail catheterization, surgery as interventions in liver abscess management with less morbidity and quite rare mortality.

Author’s Contribution:

Concept & Design of Study:

Sajid Hussain

Drafting:

Fatima Zulfiqar

Data Analysis:

Junaid Cheema

Revisiting Critically:

Fatima Zulfiqar

Final Approval of version:

Sajid Hussain

Conflict of Interest: The study has no conflict of interest to declare by any author.

REFERENCES

1.      Barkate MS, Stephen MS, Celik Y. Pyogenic and amoebic liver abscess, a review of 10 years, experiences in management. Aust NZ surg 1999; 69:205-9.

2.      Hepatobiliary system: liver. In: Strandring S, editor. Grey’s Anatomy: The anatomical basis of clinical practice. 39th ed. Section 7.chapter 85.London: Elsevier Churchil Livingstone; 2005.p.1213-1226.

3.      Anatomy and function. In: Sherlock S, Dooly J. Disease of the liver and heaptobiliarysystem. 11th ed. Italy: Balckwell Publishing;2002.p.1-16.

4.      Sutherland F, Harris j. Claude Couinaud:a passion for the liver. Arch Surg 2002:137(11):1305-10.

5.      The Digestive System In. Scanlon VC, Sanders T, eds. Essential of anatomy and physiology. 5th ed. Chapter 16.philadelphia: F A Davis Company; 2007.p.367-389.

6.      Akgatin Y, Tacylutiz IH, Celik Y. Liver abscess. Changing trends over 20 years. World J Surg 1999; 23:102-6.

7.      Napier LE. The principles and practice of Tropical Medicine. The principle and practice of Tropical Medicine 1946:444.

8.      Martinez Beez, M Proc. Intert Conf on Amoebiasis 1975; 53:277-8.

9.      Mathur S, Gehlot RS, Motha A, Bhargava N. clinical profile of amoebic liver abscess, J Ind Acad Clinc Med 2002;3:367-73.

10.  Alobaidi M, Shirkhoda A. Benign focal liver lesions: Discrimination from malignant mimickers. Curr Probl Diagn Radiol 2004; 33:239-53.

11.  Seeto RK, Rocky DC. Liver abscess: epidemiology, clinical features and outcome of treatment. West J Med 1999; 170: 104-9.

12.  Rajack CL, Gupta S, Chawala Y. Percutaneous drainage of liver abscess. Am J Roentgenol 1998; 170(4);1035-9.

13.  Sudhir R, Jayakar Prabhat B. Liver abscess management series and outcomes Int Surg J 2018; 5(9);3093-3101.

14.  Kaplan GG, Gregson DB, Laipkind KB. Population-based study of the epidemiology of and the risk factor for pyogenic liver abscess. Clin Gastroenterol. Hepatol 2004;2(11):1032-8.

15.  Bertel CK, van iteerden JA, sheedy PF. Treatment of pyogenic hepatic abscess: Surgical I/S percutaneous drainage. Arch Surg 1986;121:
554-558.

16.  Greenstein AJ, et al. Am J Gastroenterol 1985.

17.  Caiyl, xiong x2, Luj, cheng y, yangc, linx4, zhang J, Cheng NS. Percutaneous needle aspiration versus catheterdrainage in the management of liver abscess, a systemic review and meta-analysis HPB (oxfords) 2015;17(3):195-201.

18.  Amitesh Kumar JHA, et al. Management of large amoebic liver abscess. A comparative study of needle aspirator& catheter drainage. J Ind Med Assoc 2012.

19.  Barakate MS, Stephen MS, Waugh RC, et al. Pyogenic liver abscess, a review of 10 years  experience  and management Aust NZ J Surg 1999;69:205-209.

20.  Herman P, Pugliese V, montagnini AL.et al. pyogenic liver abscess: the role of surgical treatment, Int Surg 1997;82:98-101.

21.  Abbas MT, Khan FY, Mohsin SA, Al-Dehwe B, et al.  Epidemiology, clinical features and outcome of liver abscess: A single Reference center experience in Qatar, Oman Med J 2014; 29 (4): 260-3.