A clinical profile of patients with liver abscess at a rural tertiary care centre at the MGM medical college

 

 

Abstract              A liver abscess, also known as a hepatic abscess, is an accumulation of pus within the liver as a result of an infection. Overall liver abscesses are fairly rare and more frequently seen in developing nations. Most liver abscesses are caused by bacteria and amebic parasites (protozoa). However, other protozoa, fungi and helminths (parasitic worms) may also be responsible for hepatic abscesses. Methods: The present study was conducted in the indoor patients of medicine ward as well as on patients attending medicine OPD at M.G.M. Medical College and L.S.K. Hospital Kishanganj, Bihar. This study included 60 patients, out of 75 patients who were reported in Outdoor or admitted in Emergency Department remaining 15 patients were dropped out. The study period was Nov 2017 to September 2018 in M.G.M. Medical College and L.S.K. Hospital. The selection of the patients was based on clinical history, clinical examination and ultrasound findings. Those patients who were serologically positive for viral hepatitis, malaria (optimal test) and kalazar (rK 39) were excluded from this study. Results: There are 85 % male and 15 % female in this study. Age range varied from 12 to 70 years. The highest incidence was found in 31-40-year age group. Maximum number of cases were from rural areas 78.3% and remaining 21.7% from urban. The majority of cases 42/60 had leukocytosis (median -14,100) but 18 cases had white blood cells count within normal limit. Polymorphnuclear cells (median-81%) were predominantely present. Abnormally high alkaline phosphatase were seen in 82% of cases. There were six cases in which E. histolytica was detected in routine examination of stool. No single case was seropositive to HIV I and II serum creatinine level found to be within normal range in all cases. Conclusion: There was no mortality. Prognosis was better. It was due to early diagnosis of the diseases and early intervention.

Key Word: liver abscess.

 

INTRODUCTION

Liver abscess has been an important clinical problem which requires prompt diagnosis and early interventions. Two types of liver abscess are common –Amoebic or protozoal (ALA) and Pyogenic liver abscess (PLA). Worldwide about 40-50 million people are infected with amoebic abscesses with majority in developing countries.¹ Hepatic involvement is a frequent extra-intestinal complication which is encountered in 3 to 9% of the cases of amoebiasis² The prevalence of infection of amoebic abscess is higher than 5-10%³ and has been reported as high as to be 55% in some areas⁴ .India has 2nd highest incidence of liver abscess in the world ^5. PLA and ALA have many features in common and diagnosis is often delayed due to vague clinical symptoms resulting in adverse outcomes^6. Liver abscesses, both amoebic and pyogenic, continue to be an important cause of morbidity and mortality in tropical countries. However, recent advances in interventional radiology, intensive care, progress in antibiotic therapy, and liberal use of sonography and computerized tomography scanning of the abdomen have led to early diagnosis and treatment of patients with liver abscess, thus improving the patient outcome^7. PLA is still a serious illness and diagnostic challenge^8. So identification of risk factors and early diagnosis are the key issues for effective interventions. Information on LA is very limited from this part of the country .Keeping all these views in mind; the present study was conducted with the following objectives:

• To see the types of liver abscess prevalent in the area
• To study the different socio-demographic and clinical correlates
• To compare between the major types of liver abscesses.

Amebic liver abscess: Amebic liver abscess is the most frequent extraintestinal manifestation ofEntamoeba histolytica infection. This infection is caused by the protozoa E histolytica, which enters the portal venous system from the colon. Amebic liver abscess is an important cause of space-occupying lesions of the liver, mainly in developing countries. Prompt recognition and appropriate treatment of amebic liver abscess lead to improved morbidity and mortality.

Pathophysiology: E histolytica exists in 2 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 contamination. Rare cases of transmission via oral and anal sex or direct colonic inoculation through colonic irrigation devices have occurred. Cysts are resistant to gastric acid, but the wall is broken down by trypsin in the small intestine. Trophozoites are released and colonize the cecum. To initiate symptomatic infection, E histolytica trophozoites present in the lumen must adhere to the underlying mucosa and penetrate the mucosal layer. Liver involvement occurs following invasion by E histolytica into mesenteric venules. Amebae then enter the portal circulation and travel to the liver where they typically form one or more abscesses. The E histolytica galactose/N-acetyl-D-galactosamine (Gal/GalNAc) lectin is an adhesion protein complex that sustains tissue invasion.⁹ The abscess contains acellular proteinaceous debris, which is thought to be a consequence of induced apoptosis¹⁰ and is surrounded by a rim of amebic trophozoites invading the tissue. The right lobe of the liver is more commonly affected than the left lobe. This has been attributed to the fact that the right lobe portal laminar blood flow is supplied predominantly by the superior mesenteric vein, whereas the left lobe portal blood flow is supplied by the splenic vein.

 

Epidemiology:

The following are the risk factors associated with amebic liver abscess:

• Immigrants from endemic areas
• Institutionalized persons, especially people with mental retardation
• Crowding and poor hygiene
• Men who have sex with men (secondary to sexually acquired amebic colitis)
• Presence of immunosuppression (eg, human immunodeficiency virus [HIV] infection, malnutrition with hypoalbuminemia, alcohol abuse, chronic infections, posttraumatic splenectomy, steroid use)
• Amebic liver abscess is rare and is currently seen almost exclusively in immigrants or travelers to the United States. In 1994, 2,983 cases of amebiasis were reported to the Centers for Disease Control and Prevention (CDC). The disease was removed from the National Notifiable Diseases Surveillance System in 1995. An estimated 4% of patients with amebic colitis develop an amebic liver abscess.
• An estimated 10% of the population is infected with Entamoeba dispar. Previously thought to be a nonpathogenic strain of E histolytica, this type of amoeba does not produce clinical symptoms even in the immunocompromised host.
• Race-, sex-, and age-related demographics
• All races can be affected by amebic liver abscess. Risk factors for infection include travel or residence in endemic areas.
• Amebic liver abscess is marked by a 7-12–fold higher incidence in males than in females despite an equal sex distribution of noninvasive colonic amebic disease among adults.¹¹ However, no sexual preponderance exists among children.
• Peak incidence of amebic liver abscess occurs in people in their third, fourth, and fifth decades of life, although it can occur in any age group.
• International data
• Worldwide, approximately 40-50 million people are infected annually, with the majority of infections occurring in developing countries. The prevalence of infection is higher than 5-10% in endemic areas ¹¹ and sometimes as high as 55%. ¹² The highest prevalence is found in developing countries in the tropics, particularly in Mexico, India, Central and South America, and tropical areas of Asia and Africa.

 

 

MATERIALS AND METHODS

Abscess are localized collections of purulent inflammatory tissue caused by suppurative buried in a tissue, an organ, or a confined space. Aliver abscess is a pus-filled mass inside the liver. This study included 60 patients, out of 75 patients who were reported in Outdoor or admitted in Emergency Department remaining 15 patients were dropped out. The selection of the patients was based on clinical history, clinical examination and ultrasound findings. Those patients who were serologically positive for viral hepatitis, malaria (optimal test) and kalazar (rK 39) were excluded from this study. Each patient was subjected for detailed clinical history and clinical examination. Patients’ name, age, gender, registration number and clinical symptoms with duration from onset and signs on thorough clinical examination were noted down.

Study Period: From November 2017 to September 2018 in M.G.M. Medical College and L.S.K. Hospital.

Inclusion Criteria: Patients of liver abscess,(both amoebic and pyogenic) diagnosed from history, physical examination, laboratory and radiological investigation.

The following parameters were included in clinical history and examinations:

• Presenting complaints (symptoms and duration); common symptoms were fever, pain abdomen, loss of appetite, nausea or vomiting, loose motion, cough, dyspnea, pain chest and other symptoms
• History of presenting illness.
• Past history of diabetes, tuberculosis, diarrhea or dysentery or any chronic illness.
• Personal history: about his/her habit, residence in rural or urban area, ever working outside Bihar.
• Thorough clinical examination common signs were:
• Temperature
• Enlarged palpable liver (consistency and tenderness)
• Inter costal tenderness
• Absence or presence of icterus, pallor
•  Dullness in abdomen and other signs.

DISCUSSION

A total of 60 adult cases of hepatic abscess were selected from amongst the patients reported or admitted in the department of Medicine at M.G.M. Medical College and L.S.K. Hospital, Kishanganj, Bihar. They were evaluated for detailed clinical history, thorough clinical examination, radiological and laboratory findings and clinical response after treatment. It shows that maximum cases were in 31-40 years age group (51.7%) and number of males was more than females. 13.3 % and 20 % of cases were in the age group of 21-30 years and 41-50 years respectively. Among the patients, male was 85% and female was 15 %. Ravdin JL et al (1995)¹³ had found that among 230 cases of amoebic liver abscess, most of them were in the age group of twenty to fifty years and male was more common than female. Maltz et al (1991)¹⁴ had observed that liver abscesses were 7 to 10 times more common in adult men. Mohsen AH et al (2002) had retrospectively reviewed the records of 270 adults with liver abscess in which 92% of cases were male and 8% of cases were female. The maximum number of patients were in the age group of 20-50 years. Lodhi S et al in (2004)¹⁵ had studied on 577 adults with liver abscess in which males were more common than female and most of them were younger age group. The observations in this study were with similar trends to other reported cases we found it from. It shows that out of total number of cases studied (n=60), the maximum number of patients (46.6%) were presenting their clinical features within one to two weeks of onset. 31.7 % of the cases had symptoms for two to three weeks. Salles JM et al (2003) had studied on patients with liver abscess. They had found that most of them presented as an acute illness (within two weeks). Khanna S et al (2005)¹⁶ had published their data in Eur J Clin Microbial Infect Dis. We shows that maximum number of cases belonged to rural areas (78.3%). The number of cases coming from urban areas was less (21.7 %). This data suggests that these diseases are more prevalent in those areas where sanitation is poor. Study shows that pain abdomen and fever were most common presentation seen in 96.7% and 95% of patients respectively. Loss of appetite (38.3%), nausea/vomiting (51.7%), cough (18.3%), dyspnea (13.3%) and diarrhea/dysentery (3.3%) were less common symptoms. Knobloch et al (1983) had analysed 216 cases in which they found that pain abdomen in upper quadrant (97.5%) and fever (92.2%) are the cardinal symptoms. Khanna S et al (2005) studied in patients with amoebic liver abscess in which pain abdomen was the earliest and most frequent complaint, present in almost 100% of the patients. The observations of this study were similar to Knobloch et al (1983) study. present study raised temperature (>98.6ºF) and local tenderness were most common physical signs seen in 95 % and 85 % of patients respectively where hepatomegaly (86.7 %) , icterus (20 %), rales (8.3 %), shifting dullness (3.3 %) were less common among them. According to Monson’ Tropical Disease (21^st ed, pg-1379), fever presents in most cases and localized tenderness at the lower right intercostals spaces, is frequent even in the absence of diffuse liver pain. According to Harrison’s internal medicine(17^th ed,pg-811), only 50 % of patients with liver abscesses, have hepatomegaly, right-upper-quadrant tenderness, or jaundice; thus, half of patients have no symptoms or sign to direct attention to the liver. Khanna et al (2007) in Gastroenterology tody reported the presence of jaundice in 5 to 30 % of patients, diarhhoea in 2% of cases. Sarda AK et al (1998)¹⁷ also reported the similar trends in their study. Our data shows that majority of cases 42/60 had leukocytosis (median -14,100) but 18 cases had white blood cells count within normal limit. Polymorphnuclear cells (median-81%) were predominantely present. Abnormally high alkaline phosphatase were seen in 82 % of cases. Katzenstein et al suggested that the value of alkaline phosphatase is correlated with duration of disease. The SGPT level [median-127] were mildly elevated.. Routine examinations of stool for E. histolytica were positive in 4 cases. All cases were HIV-negative. Serum creatinin levels were within normal range in all cases. Fang et al (1999)²⁵ have reported in a study that invasive amoebiasis is an emerging parasitic disease in patients infected with HIV in an area endemic for amoebic infection. Fortunately no single case was HIV +ve in the present study. Qin et al (2000)¹⁹ in clinical analysis of 36 patients with amebic liver abscess retrospectively had seen leukocytosis in 61.1% of patients and increased of ESR in 88.5% (23/28). The observations in this study were near to other studies. It shows that among the 60 cases under study, 86.7 % of patients had positive serological tests for Entamoeba histolytica. Qin SL et al (2000) studied in 36 cases with amebic liver abscess and noted that 92.6% of cases had positive serologies against Entamoeba histolytica. Shyam Mathur et al (2002)²⁰in prospective study they performed serological test in 82 patients, out of which 79 (96%) were detected positive. Stanley SL Jr et al (1998)²¹ observed in longitudinal study of the antibody response to recombinant Entamoeba histolytica antigens in patients with amebic liver abscess. Their results showed the similar trends. shows that the study, all patients (100%) were toddy abusers. 11 cases of them were also alcoholic. There is no documented evidence which may show an association of toddy with amebic liver abscess. The growth of E. histolytica requires in cultures the presence of starch or rice floor and some metabolic associates, such as enteric bacteria, organisms (non pathogenic bacterium) or the parasitic flagellate T.cruzi, living or dead. [K.D.Chaterjee’s parasitology, 12^th ed,. It supposed that toddy might be the good culture media for Entamoeba histolytica. revealed that about 88.3 % of patients had upto 10 cm size diameter of abscess while 11.7% of patients had larger size (>10 cm) abscess measured by ultrasonogram. We showed that the most common site involved was the right lobe of the liver (78.3%). 15 % of cases presented involvement of both right and left lobe. 6.7% patients had isolated left lobe abscess.73.3 % of patients had single abscess where 26.7% had multiple lesions Sharma MP et al (1993)^[22] in Trop Gastroenterol have reported multiple abscess in 0 to 16% of cases. Khanna et al (2007) in Gastroenterol Today reported the presence of multiple liver abscess in 40/144 (27.7%) of patients, which was higher than previously reported. Maneschy et al (1974) observed that left lobe abscess is usually seen along with a right lobe abscess. Isolated left lobe abscess can be present in 16% of patients with amebic liver abscess. The same trends were also seen in this study. We have found showed that among 36 patients in which USG guided percutaneous needle aspiration were done for diagnostic and therapeutic purpose, 15 cases were culture-positive. Escherichia coli in 3 cases, Staphylococcus aureus in 7 cases, Bacteroides spp. in 2 cases, Peptostreptococcus spp in 1 case, Proteus spp. in 1 case, Enterobacter spp. in 1 case and Clostridium spp. in 1 case were present. Culture of remaining cases was sterile but recovery was fast after drainage. In a study by Rani R et al (2006)²³, they demonstrated the presence of two anaerobic genera, viz. Bacteroides and Peptostreptococcus, in ALA pus sample, and this observation was unprecedented and the clinical significance was not known. Hanna et al²⁴ (2000) reported in his study of drug resistant ALA that when percutaneous drainage is combined with antiamebic therapy, it expedites the recovery and it is also curative in such cases.

 

CONCLUSION

All the patients were toddy abusers. It suggests an association with amoebic liver abscess. 11 of them were alcoholic too. Involvement of right lobe of liver and single abscess were most common ultrasonographic findings. There was also increasing incidence of multiple liver abscess. Isolated left lobe abscess were seen in 4 cases. Out of 60 patient, 36 patient were undergone USG guided percutaneous needle aspiration. Recovery was fast in non-responder. In liver abscess, E.coli, Bacteroides, Peptostreptococcus, Proteus etc, were common pathogens isolated from drained pus. Budd-chiari syndrome was complication seen in 4 cases. It subsided after drainage of pus. Pleuropulmonary rupture in one case and peritoneal rupture in one case were also seen. There was no mortality. Prognosis was better. It was due to early diagnosis of the diseases and early intervention.

 

REFERENCES

1. Bhatti A, Ali F, Satti S, Satti T. Clinical and pathological comparison of Pyogenic and Amoebic liver abscess .Advances in Infectious Diseases 2014;4:77-123.
2. Perez JY Jr. Amoebic liver abscess: Revisited. Philip J Gastroenterol 2006;2:11-3
3.  Stanley Jr. S.L. Amoebiasis. The Lancet. 2003; 361:1025-34.
4. Haque R, Duggal P, Ali IM, Hossain MB, Mondal D, Sack RB et al. Innate and acquired resistance to Amebiasis in Bangladeshi children. J Infect Dis.2002;186:547-52
5. Channanna C, Rehman FU, Choudhuri B, Patil A. A clinical study, diagnosis and management of Liver Abscess at VIMS, Bellary. .Journal of Evidence Based Medicine and Health Care 2014; 1:668-85.
6. Dutta A, Bandyopadhyay S.Management of Liver abscess. Medicine Update 2012; 22:469-75.
7. Singh S,Chaudhary P, Saxena N, Khandelwal S,Poddar DD,Biswal UC.Treatment of liver abscess: prospective randomized comparison of catheter drainage and needle aspiration. Ann Gastroenterol. 2013; 26: 332–39.
8. Malik AA,Bari SU,Rouf KA,Wani KA.Pyogenic liver abscess: Changing patterns in approach .World J Gastrointest Surg. 2010 ; 2: 395–401
9. Acuna-Soto R, Maguire JH, Wirth DF. Gender distribution in asymptomatic and invasive amebiasis. Am J Gastroenterol. 2000 May. 95(5):1277-83. 
10. Blessmann J, Ali IK, Nu PA, et al. Longitudinal study of intestinal Entamoeba histolytica infections in asymptomatic adult carriers. J Clin Microbiol. 2003 Oct. 41(10):4745-50.
11. Haque R, Duggal P, Ali IM, et al. Innate and acquired resistance to amebiasis in bangladeshi children. J Infect Dis. 2002 Aug 15. 186(4):547-52. 
12. Ralston KS, Petri WA Jr. Tissue destruction and invasion by Entamoeba histolytica. Trends Parasitol. 2011 Jun. 27(6):254-63. 
13. Ravdin, JI. Amebiasis. Clin Infect Dis 1995;20:1453
14. Maltz, G, knauer, CM. Amebic liver abscess: A 15- year experience Am J Gastroenterol 1991; 86:704.
15. Lodhi S; Sarwari AR; Muzammi M; Salam A; Smego RA: features distinguishing amebic from pyogenic liver abscess: a review of 577 adult cases. Trop Med Int Health 2004 Jun;9(6):718-23.
16. Khanna, S, Chaudhary, D, Kumar, A, Vij, JC. Experience with aspiration in cases of amebic liver abscess in an endemic area. Eur J Clin Microbiol Infect Dis 2005;24:428.
17. Rubin, RH, Swartz, MN, Malt, R. Hepatic abscess: Changes in clinical bacteriological and therapeutic aspects. Am J Med 1974; 57:601.
18. Qin SL, Wang AX, Sheng RY, Liu ZY; clinical analysis of 36 cases with amebic liver abscess.2000; 18(6): 356-8.
19. Shyam Mathur, R S Gehlot, A Mohta, N Bhargava,: clinical profile of amoebic liver abscess. JIACM 2002; 3(4): 367-73.
20. Stanely SL Jr, Jackson TF, Foster L, Singh S. Longitudinal study of the antibody response to recombinant E. histolytica antigens in patients with ALA. Am J Trop Med and Hyg 1998; 58(4): 414-6
21. Sharma MP, Dasarathy, S, Amoebic liver abscess. Trop Gastroenterol 1993; 14:3.
22. Rani R, Murthy RS, Bhattacharya S, Ahuja V, Rizvi MA, Paul J; changes in bacterial profile during amebiasis; demonstration of anaerobic bacteria in ALA pus sample. Am J Trop Med Hyg 2006;75:880-85.
23. Hanna RM, Danhiya MH, Badr SS, EI Betagy A. Percutaneous catheter drainage in drug-resistant amebic liver absess. Tropical Medicine and Internal Health 2000; 5(8): 578-81.
24. Menz XY, Wu JX. Perforated amebic liver abscess: clinical analysis of 110
25. cases. South Med J 1994; 87: 985-90.
26. Kale S, Nanavati AJ, Borle N, Nagral S. Outcomes of a conservative approach to management in amoebic liver abscess. J Postgrad Med. 2017 Jan-Mar. 63(1):16-20.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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