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Pyogenic versus amoebic liver abscesses. A comparative clinical study in a series of 58 patients. Cosme 1 , E. Ojeda 2 , I. Bujanda 1 , G. Garmendia 3 , M. Benavente 2. Donostia Hospital. University of the Basque Country. Departments of 2 Internal Medicine, 3 Radiology, and 4 Microbiology.
Objective: to compare the clinical and epidemiological characteristics of patients with pyogenic liver abscess PLA and with amebic liver abscess AHA in order to determine the potential factors that may help improve diagnosis and treatment for this disease.
Results: among the 45 patients with PLA 30 men and 15 women, with a mean age of 61 years and 11 months , more than a half were cholangitic 13 cases or were of unknown origin 15 cases. In 10 patients, diabetes was considered to be a predisposing condition. Twenty-five patients had single abscesses. Abscess and blood cultures were positive in A percutaneous drainage was performed on 22 patients. Mean hospital stay was 27 days, and overall mortality, including that related to concomitant conditions, was 7 of 45 cases.
Of the 13 cases of ALA 7 men and 6 women, with mean age of 42,9 years , 2 were locally acquired. There were single abscesses in 10 patients and all except one were located in the right lobe.
The serological test for E. A percutaneous drainage was carried out on 6 patients. Mean hospital stay was 18 days and two patients died. Conclusions: In our series, the clinical parameters suggesting pyogenic origin were: age 50 or older, male gender, diabetes, moderately elevated bilirubin and transaminases.
In amoebic cases the associated features were being aged 45 or younger, diarrhoea, and presence of a single abscess in the right lobe. Parasitism by E. Key words: Liver abscess.
Los abscesos fueron solitarios en 25 casos. The incidence of pyogenic liver abscess PLA ranges from 1. PLA occurs mainly in immunosuppressed and diabetic patients, and in individuals suffering from malignant neoplasia. Its prevalence has increased in recent years due to liver transplantation. Clinical characteristics depend on the pathogenic mechanism involved. Parasitism by Entamoeba histolytica in developed countries occurs in specific population subgroups: immigrants and travellers coming from endemic regions, psychiatric hospital patients, individuals with occasional contact with people coming from areas with amoebiasis, and those who have ingested contaminated food.
The prevalence of infection by E. The approximate incidence of amoebic liver abscess ALA in Guipuzcoa is of 0. In this study, liver abscess cases are reviewed retrospectively to establish the clinical differences between the pyogenic and amoebic aetiologies, thereby facilitating early treatment in these patients. Some of these cases have been the subject of prior reviews and communications 8,9. Pyogenic liver abscess was defined as the observation of one or more ultrasound and CT images with positive cultures, or by positivity in two or more blood cultures of germs consistent with the diagnosis.
Hepatic lesions diagnosed by imaging techniques, but without positive cultures of the pus, were included after ruling out other diseases according to the clinical history. An amoebic aetiology was demonstrated by serology antibody titre against E. The following variables were taken into account: age, sex, clinical features, blood and other diagnostic tests, type of abscess and location within the liver, treatment, evolution, and average hospital stay in both series.
In addition, predisposing diseases and the origin of abscesses for pyogenic abscesses 45 cases , and associated diseases, epidemiological history of travelling to areas with a high prevalence of amoebiasis, the origin of patients, and the time between having been to endemic areas and the occurrence of symptoms in amoebic cases 13 cases were analysed.
Differences between groups were considered to be significant when p value was less than 0. During the two decades studied, 45 patients were diagnosed with PLA caused by bacteria, and there were 13 cases of ALA. The clinical features and laboratory data of the two series are shown in table I. Predisposing conditions for pyogenic abscesses were: diabetes mellitus 10 cases ; tumours 4, out of which 2 had liver metastasis ; chronic pancreatitis 4 ; hydatid cysts; 3 infection by HIV 1 ; and liver cirrhosis 1.
The origin of the abscess was biliary in 13 cases, phlebitis of the portal vein in 5, spread of infection from previous liver lesions in 5, haematogenic in 4, by contiguity in 3, and 15 of unknown origin. The clinical history of patients with amoebic abscesses included: malaria, chronic liver disease due to hepatitis B and C viruses 1 case , and chronic obstructive pulmonary disease COPD 1 case. Eleven out of thirteen lived in Guipuzcoa, one lived in Uruguay was on holiday in Guipuzcoa , and another came from Japan but had been living in Guipuzcoa for the previous 6 months.
Two individuals did not have any history of exposure to endemic areas. Concomitant amoebic colitis was present in 5 patients. Microbiological diagnoses and findings from imaging techniques for the 58 patients studied are shown in tables II and III. The micro-organisms isolated from the pyogenic abscesses were: aerobic gram negative rods 23 cases , anaerobic bacteria 15 , aerobic gram positive cocci 14 , aerobic gram positive rods 1 and Brucella 1.
A total of Amoebic abscesses were larger than 10 cm in diameter in 5 cases 4 single and 1 multiple , and larger than 5 cm in a further 7 cases 5 single and 2 multiple. The treatment of patients with PHA consisted of antibiotherapy, drainage and surgery. The most commonly used antibiotic combination were third generation cephalosporins with metronidazole, alone or with aminoglycosides 17 cases , imipenem or piperacillin-tazobactam 16 , and aminoglycosides with metronidazole 5.
Antibiotic therapy without drainage was carried out in 10 patients one recurred and needed surgery due to biliary stenosis. CT-guided percutaneous drainage in association with adequate antibiotic coverage was used in 22 patients Table IV. This procedure was successful in 18 full recovery In 13 patients, where the drainage was not successful, surgery was undertaken. Overall mortality was related to the diseases that needed surgical treatment acute cholecystitis, obstructive icterus, infected hydatid cyst in the liver, peritonitis, postoperative biliary stenosis, and carcinoma of the gallbladder.
The average hospital stay of those patients who were treated with percutaneous drainage was shorter than that of those treated with surgery 21 versus 40 days. Patients suffering with ALA were treated with metronidazole and paramomycin as a first choice. CT-guided percutaneous drainage was carried out in 6 cases 5 of them with abscess sizes exceeding 10 cm , and surgery in 4 cases.
Mortality rates and mean hospital stay are shown in table IV. Two people died; one due to peritonitis secondary to multiple perforations in the colon due to amoebic ulcerative colitis Fig.
In Spain, during the last decade, there has been an increase in the number of autochthonous cases. Some series of patients suffering from ALA have indicated a predilection for middle-aged men, and that it is less common at extreme ages PHA has a variable occurrence in the population according to concomitant diseases.
The risk of developing a pyogenic abscess in diabetic people and in those suffering from malignant tumours is tenfold higher than that of the general population; in patients who have undergone liver transplantation it is times higher 2. PHA often occurs in individuals over 50 years old with a slight predominance in men 14, Abscesses secondary to ascending cholangitis and of unknown origin are the most common.
ALA is caused by the colonization of the liver by trophozoites of pathogenic strains of E. It causes foci of necrosis in the liver parenchyma, most of the time leading into a single cavity. Sometimes, the abscess only causes fever. The classical symptomatology of PLA fever, shivering, and pain in the lower right abdomen with or without hepatomegaly, of subacute presentation , occurs in a small percentage of patients.
Icterus is often associated with biliary pathology. Blood tests for both types of abscesses are similar: increased ESR, leukocytosis with left shift, and slight changes in liver function tests.
In cases secondary to biliary tract infection, bilirubin levels are often increased. In blood tests in amoebic infections there is often a moderate increase of alkaline phosphatase; icterus is rare and, when present, moderate.
Abdominal contrast CT is the technique of choice for the diagnosis of liver abscesses. However, both CT scans and echography may lead to false negatives in abscesses smaller than 1 cm in diameter, in those located near the diaphragmatic dome, and in those in early stages of development.
In amoebic abscesses several methods were used: detection of specific antigens adhesine Gal-GalNac and serum antibodies against E. PCR is considered the gold standard for immigrants coming from endemic areas and frequent travellers who carry antibodies against E. Currently, a very specific technique which can be used for the diagnosis of ALA as long as the subject has not been treated with amoebacides is the presence of adhesin Gal-GalNac in the serum The absolute contraindications for guided drainage are when there is an indication for surgery because of an associated disease or significant coagulopathy.
Relative contraindications are ascites, very viscous purulent material, multiple small abscesses, and the risk of damaging vital structures, especially those in the left lobe. Surgery is performed when percutaneous treatment fails, or there are absolute or relative contraindications for guided drainage, associated diseases secondary to surgical treatment, or abscesses with rupture or haemorrhage.
Antibiotic treatment without drainage is controversial. It should be applied only in patients with small abscesses and always considering each individual case 9, In our series, such diverse treatments are explained by the fact that patients were seen at different points over a long period 20 years. The treatment for ALA consists of the intraluminal and systemic administration of amoebacides as soon as possible.
There is no current evidence whether guided percutaneous drainage provides extra benefits compared to treatment with metronidazole alone in uncomplicated ALA cases Surgical treatment is performed if percutaneous drainage fails or complications arise. The limitations of this study are its retrospective, observational nature, and that it includes a relatively small number of cases compared to other Central and South American Asian studies.
However, it represents one of the few series in our country 12 in which the clinical pictures of these two types of liver abscesses are compared. On the other hand, subjects with ALA had an epidemiological history of travel or immigration.
Diarrhoea was one of the initial symptoms of the disease, and they had a single abscess predominantly in the right lobe. Pyogenic hepatic abscess: a ten year population-based retrospective study.