Classifieds for every web site!
| View Our Guestbook | Sign Our Guestbook | Search Our Web Site |
| Chat Room | Discussion Forums | Free Classified Ads |
SURGERYSurgery Text Book by Dr Taj Uddin SURGICAL WEBSITES BREAST DISEASE LIVER ABSCESS Anatomy of liver SURGICAL WEBSITES KIDNEY SURGERY POSTGRADUATE SURGERY LINKS
BREAST DISEASE Breast cancer Breast lump Breast awareness Breast calcifications Breast cysts Breast pain Duct ectasia Fat necrosis Fibroadenoma Hyperplasia Intraductal papilloma Phyllodes tumour Sclerosing adenosis
LIVER ABSCESS Anatomy of liver Physiology of liver Method of examination of liver Haematology of liver disease. Amoebic liver abscess .Pyogenic liver abscess. Percutaneous needle aspiration of liver abscess. Case study. Result Result continued Discussion
CHOLECYSTECTOMY Introduction Historical Review Anatomy of Gallbladder Physiology of Gallbladder Physiologic effects of pneumoperitoneum Pathology of Gallbladder Investigations Pre- operative preparation of laparoscopic cholecystectomy Contraindications Treatment modalities for gallstones. Anaesthesia
INGUINAL HERNIA HOW SURGICAL OPERATION IS DONE THYROID EXAMINATION MANAGEMENT OF SEVERELY INJURED PATIENT SEPSIS AND MULTIPLE ORGAN FAILURE CHEST TRAUMA BRONCHOGENIC CARCINOMA TETANUS AND ANAEROBIC INFECTIONS
New Page 1 SITE HOSTED BY
DR TAJ UDDIN
MBBS FCPS FRCS
ASSISTANT PROFESSOR OF SURGERY
BAQAI MEDICAL UNIVERSITY
KARACHI PAKISTAN
CONTACT DR TAJUDDIN PH NO 0300 2467670 OR EMAIL shmsqadr@cyber.net.pk
Designed by: TAJ UDDIN
MAIN LINKS
SURGERY WEB PAGE BY DR TAJ UDDIN LIVER ABSCESS SURGERY WEB PAGE by Dr. Tajuddin Qadri FCPS FRCS Assistant Professor of Surgery Baqai Medical University KARACHI PAKISTAN
SURGICAL WEBSITES BREAST DISEASE LIVER ABSCESS INGUINAL HERNIA
CHOLECYSTECTOMY KIDNEY SURGERY HOW SURGICAL OPERATION IS DONE
THYROID EXAMINATION MANAGEMENT OF SEVERELY INJURED PATIENT
SEPSIS AND MULTIPLE ORGAN FAILURE CHEST TRAUMA BRONCHOGENIC CARCINOMA TETANUS AND ANAEROBIC INFECTIONS POSTGRADUATE SURGERY
LIVER ABSCESS LIVER ABSCESS
SECTION 1 CLICK ON THE FOLLOWING LINKS
I Summary
2
II Introduction
Review of literature 6
III Historical background
IVa Embryology of liver
IVb Surface anatomy of liver.
IVc Histology of liver
VI Method of examination of liver
VII Laboratory investigation and liver function tests.
VIII Haematology of liver disease.
IX Stool examination and sigmoidoscopy.
X Radiology and hepatic imaging.
XI Needle biopsy of liver.
XIV Percutaneous needle aspiration of liver abscess.
XV Role of laparoscopy.
XVI Open drainage and other procedures.
XVII Post operative investigations to monitor liver function.
SECTION 2
XVIII Introduction
XIX Material and methods
XX Result
XXI Discussion
XXII Conclusions
XXIII References
XXIV Acknowledgement
SUMMARY
Liver abscess is a common condition in Pakistan associated with higher morbidity and mortality. Early diagnosis offers the best chance of cure. This is a prospective study from February 1997 and September 1998.
The aim of the study was to find out the factors which help in early diagnosis and to analyse the effect on the management by delay in presentation and diagnosis and secondly to analyse the effectiveness and limitations of various modes of managing the liver abscess. The importance of the history, clinical examination and investigations (biochemical and radiological) were analysed. A total of 108 patients of liver abscess were studied. For the comparison of different modes of management and their results the patients were divided in two different groups Group-1 the early presenters, there were 78 patients and in Group-2 late presenters there were 30 patients. Amoebic liver abscess was diagnosed in 91 (85%) of which 12 cases showed super added pyogenic infection on amoebic abscess and 17 (15%) had pyogenic abscess.
Most of the patients in Group 1 were treated by minimally invasive percutaneous needle aspiration where as patients in Group 2 were difficult to manage and some of them required open surgical drainage. Metronidazole was the drug of choice for the amoebic liver abscess but third generation cephalosporins were preferred for the blind therapy of pyogenic abscess before abscess culture were received.
Delay in diagnosis causes increases in severity of the disease and this delay increases the difficulty in management of the disease, the patients that could be managed easily by medical or minimally invasive management needs surgical intervention. It can be further complicated by leaking of abscess in peritoneal, pleural or pericardial cavity as is shown by the comparison between group one and two.
Key words
Liver abscess; Amebic; Pyogenic; Drainage.
INTRODUCTION
Liver abscess is a common condition in Pakistan associated with higher morbidity and mortality. It is a common disease of the tropical region. Abscess develops in the liver due to various reasons but is broadly classified into amoebic and pyogenic. In Pakistan the amoebic variety is common. Colonic amoebae are mainly responsible for the development of the abscess. Amoebicidal drugs have improved the management of the amoebic liver abscess. Pyogenic variety is managed by antibiotics. Ultrasonograpy and CT scanning play a vital role in the diagnosis and the management of the disease. Lot of research has been published locally as well as in international journals describing about different approaches in the management of the disease. Sometimes it is very difficult to manage this problem when presented in a very advanced stage. Other underlying disease may give rise to pyogenic liver abscess and which should be managed accordingly. The options in managing this disease are medical management, percutaneous drainage and open surgical drainage. There are different views and protocols for the management of this disease. This study was designed to find out which mode is helpful and ideal for a particular patient with reference to its severity of disease and time of presentation and response to other modes of management. Several other factors were also analysed in detail. The outcome of the disease after early or late presentations were compared. Recurrent liver abscess was difficult to treat and sometimes the cavities persist for a longer time, which could get secondarily infected. All these problems were discussed, analysed and compared in detail to get a conclusion. Effective management of the disease will help in decreasing morbidity and mortality associated with the disease and will also help in finding the ways of decreasing the incidence of the disease.
REVIEW OF LITERATURE
HISTORICAL BACKGROUND
Hippocrates (460-377 BC) contemporary of Herodotus and Socrates, and considered to be the first to reject superstition about disease and to base practice of medicine on observation and study, has described large hepatic abscesses which must have been amoebic in nature. He speculated that the prognosis is related to the type of fluid 1. In his ‘Aphorisms’, it is apparent that he considered hepatic abscesses to be of two types: one with pus which “was pure and white” and the other with pus which “resembles less of oil as it flows”. He also noted that the later condition was associated with a higher mortality.
Hippocrates was well aware of drainage of a liver abscess as a form of therapy. Although he insisted that the physician must assist nature’s own tendency to heal the sick and take great care that “his treatment shall at least do no harm”, he also stated that “Desperate diseases need desperate remedies!”
Shortly after the death of Hippocrates, in 356 BC Alexander the Great was born. When still young, he became the King of Macedon and Emperor of vast empire. In his eastern campaign, he reached as far as the Indus and for a short while stepped into an area where amoebiasis must have been endemic. Badly exhausted by sickness, insomnia and injured in ferocious fighting he made his way back over the Gedrosia dessert and died at the young age of 33 years at Babylon probably of an amoebic liver abscess. It was first reported in the literature by Annesely 2.
The association of a hepatic disease with dysentery has been suspected since the time of Galen. He described that the humoral excess should manifest itself as pus-filled swelling, it might be incised and drained 3. In 1776, during an epidemic of dysentery in Mexico, Joaquin Pio Eguia y Lugo observed that many deaths were due to a liver disease. Ballingall in 1818 made note of an officer in a Madras establishment who while fighting a duel, had an abscess of the liver opened by a fortunate shot and thus obtained a complete cure.
Napoleon Bonaparte, Emperor of France, was exiled in the tropical island of St Helena by the British after his defeat at Waterloo. Now bloody dysentery (amoebiasis?) was very common on this island and Napoleon soon contracted what was diagnosed by two successive naval surgeons as tropical hepatitis. However, as it was not in the interest of the Troy Government, then in England, to disclose the true nature of Napoleon’s disease, these two surgeons were arrested. On Napoleons demand, his family appointed a special Physician, Antommarchi. After an attack suggestive of amoebic liver abscess (pain and tender swelling in the epigastrium associated with fever and diarrhoea) he finally died in 1821, shortly after a violent attack of vomiting, haematemesis and melaena. At the post-mortem Antommarchi noticed a “cancerous ulcer which has its centre at the superior part along the small curve of the stomach communicating with the liver”. It thus appears that the Napoleon died not as commonly supposed due to cancer of stomach, but of an amoebic liver abscess of the left lobe which had ruptured into stomach!
At the other end of the earth, in the India, the high incidence of dysentery prompted workers to deal amply with it. Annesely (1828) in his book “ Researches on the diseases of India” mentioned about the tropical liver abscess. Parks also acknowledged a certain relationship between dysentery and hepatitis 4.
However, it is Charles Morehead who is accredited with having reported the first case of hepatic abscess in 1848. Later he described a similar case in a patient with dysentery. In his book “Clinical researches on diseases in India” he stated that hepatic abscess is not “exceedingly rare among Asciatics” and from his clinical material concluded, that the co-existence of tropical hepatic abscess and the ulceration of the mucous membrane of the large intestine was frequently observed”.
Antony Von Leeuwenhoek discovered protozoa. Rosel van Rosenhof, an amateur lens grinder and microscopist, in 1775 described a microscopic being that was constantly changing the shape. Hence he called it “the a little proteus”. In 1849Gros described the first amoeba living as a parasite in man – the Amoeba Gingivalis. Later in 1875, Fedor Aleksandrevitich Losch of St Petesburgh (now Leningrad) found amoeba in the stools of a patient with dysentery and suggested it as the causative factor.
In 1887 after centuries of impunity, the amoeba was finally identified as the etiological agent in tropical liver abscess. The honour of this discovery goes to none other than Robert Koch who while studying cholera in Egypt and India came across the cases of liver abscess. He demonstrated Entamoeba Histolytica near the wall of the abscesses, which were similar to those found in the stool. The aetiological relationship between amoebic dysentery and the tropical liver abscess was soon confirmed by Kartulis in Egypt (1887) when he found amoeba in 20 cases of amoebic liver abscess. The idea of suppuration being caused by amoebae was inconceivable to him. He therefore postulated that amoebae carried bacteria from the colon to the liver thus causing suppuration.
There still existed a school of thought (Andrew Duncan School of Medicine) which denied the general association between the amoebic dysentery and liver abscess. This was probably due to failure to demonstrate amoebae in the pus of larger abscess. The scholarly monograph of Councilman and LaFleur in 1891 on intestinal and hepatic amoebiasis substantiated the contentions of Kock and Kartilus. In their monograph, they insisted on occurrence of hepatic abscess as a complication of dysentery even in patients who did not have any symptom of the later disease. They also coined the term amoebic abscess of the liver.
Leonard Rogers, in 1902 published a paper based on thirty seven cases of amoebic liver abscess. In thirty five of the abscesses amoebae were demonstrated. However in spite of similar several reports by numerous workers, comments: “to what extent amoeba is concentrated in the production of tropical liver abscess, it is yet impossible to state”.
Excellent work done by Ochsner and DeBakey, they provided classic treatises on pyogenic and amoebic liver abscess 5. The work by these to physcians has a pivotal role in the diagnosis and management of liver abscess. Lamont and Pooler (1958), Paul Milory (1960): Wilmont (1962) and many others have clarified many aspects of amoebic liver abscess. Amoebic liver abscess is, even today, considered a desperate disease and it is no wonder that many desperate measures, however empirical, have been tried in an attempt to cure this condition. In the late eighteenth and early nineteenth century ‘depletion’ was a common form of therapy. This was achieved rapidly by ‘blood letting’ (a simple procedure of making a nick in the vein); if one required a slower ‘depletion’, the use of leeches applied to the abdomen or the use of a ‘blister’ over the liver area could be resorted to. Moreover in this era administration of laxatives and mercurial purgatives in large doses, was a routine.
Throughout the nineteenth century, surgical procedures like open drainage and later, trocar aspirations were commonly utilised. Ballingall even recommended the introduction of a seton (a strip of a linen or a strand of horse hair used as a drain) as a curative measures of such abscesses. As might be expected, with then prevailing surgical techniques and standards of asepsis the mortality rate was high.
The use of Quinine was also tried in few such cases. Although ipecacuanha was known as a patent remedy for ‘bloody flux’ in the population of Brazil in sixteenth century, it was not routinely used in the therapy of liver abscess until after the definite association between amoebiasis and liver abscess was established. Later in 1912 he introduced emetine in the treatment of amoebic abscess. In his book “The salt of Emetine”, he recounted the early history of ipecacuahana, the isolation of its alkaloid emetine by Pelletier and the discovery of the rapid cure of amoebic dysentery and liver abscess with hypodermic injection of this alkaloid.
A needle biopsy of the liver was said to have been first performed by Paul Ehrlich in 1883. In a study of glycogen content of the diabetic liver and later in 1895 by Lucatello in Italy for the diagnosis of tropical liver abscess 6. The first published series was by Schüpfer (1907) in France, where the technique was used for the diagnosis of cirrhosis and hepatic tumours. The method, however, never achieved early popularity until the 1930s when Huard and co-workers in France and Baron in United States used it for general purpose.
Hippocrates firmly believed that order reigned in nature and that the earnest seeker may discover its character by patient investigation. In the recent past traditional treatment of the liver abscess comprises antibiotic therapy and surgical drainage but more recently the role of ultrasound guided percutaneous drainage in the management of this condition has been emphasised 7.
As more advanced facilities for investigations are now available, amore concrete picture of liver abscess is evolving. Much work however remains to be done. What is required now is patience and a lot of dedication. The story has not yet ended: it has only just begun.
Email: shmsqadr@cyber.net.pk
You Are Visitor
Washington, DC Registry
Last modified: Friday, 22-Jul-2005 08:31:51 EDT |
