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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 

CASE STUDY

INTRODUCTION

Liver abscess is a known problem in the tropical region. It usually presents with fever with rigors, pain in right upper quadrant. The diagnosis of liver abscess is not always easy even in an endemic area. These cases are initially managed by the general practitioners as malaria and if the fever persists then they are referred to the hospitals. It has been seen that in the hospitals too, these cases are initially managed either as malaria, typhoid fever or rickettsial infection. The diagnostic approach of a febrile illness must be redefined because it must be recognised in priority and may also be lethal if untreated. Liver abscess has been associated with higher morbidity and mortality rates all over the world. It is suggested that, if the diagnosis can be made early, conservative treatment offers the best chance of cure for patients with liver abscess ¹⁰⁶. Recent advances in diagnosis have helped in ear1ier diagnosis of the abscess. The diagnostic and treatment modalities have developed rapidly over the past few years but morbidity and mortality. These techniques including ultrasound, computerised axial tomography and liver scanning associated with minimally invasive surgery have reduced the diagnostic delay but still a large number of cases present very late giving rise to complications.

 Increased morbidity may be partly due to factors such as the long duration of symptoms before treatment and the presence of underlying disease like tuberculosis, hepatoma and echinococcal cysts (in some patients). However the most important factor that delays the treatment is lack of attention of the treating physicians towards the incidence of liver abscess. 

            Modes of treatment offered to the patients include medical management alone, percutaneous aspiration and open surgical drainage. Late presentation decreases the chances of medical management or minimally invasive percutaneous aspiration and increases the chances of open surgical drainage.

 

 

MATERIAL AND METHODS

This is a prospectively completed data base collected in Surgical Unit of Baqai University Hospital. Between the period of February 1997 and September 1998, 108 patients with clinical diagnosis of liver abscess were included in the study. All the patients presenting with fever with rigors and pain in right upper quadrant were analysed, right from the time of admission and were included in study on confirmation of diagnosis on ultrasound. Ultrasound scan was done for all the patients presenting with pain in upper quadrant of the abdomen and after the diagnosis patient was repeatedly rescanned for analysing the progression of the abscess formation and to monitor the regression of the size in response to the medical management. Blood CP, and liver function tests chest X-ray, blood cultures and stool cultures were done routinely and serum amylase was also done as it is included in the protocol of management of upper abdominal pain in our hospital. Sigmoidoscopy was done routinely and Barium enema was done when needed. CT scanning was offered to the patients in whom diagnosis was not confirmed or there was a plan to drain under CT guidance. Patients having liver abscess but receiving chemotherapy or during pregnancy were excluded from the study due to difference in protocols of management. Patients with haemangioma of liver and hydatid cyst of liver with liver abscess were also excluded from study.

            Diagnosis was based on history, physical examination, ultrasonographic evaluation and in some cases computerised axial tomography (C.T.) scan and on aspiration of the abscess from the liver which confirms the radiological and clinical diagnosis. Using a standard pro forma, patients demographic details, presenting symptoms and signs, haematological and biochemical results, microbiological findings, diagnostic method findings, abscess characteristics, aetiology, treatment and final outcome were documented.   

            To analyse the management according to the duration of symptoms, the patients were divided into two groups. Group-1 (early presenters), which comprises of the patients who presented with in a week after the onset of symptoms and in Group-2 (late presenters) those patients were included who presented after a week of onset of symptoms. The effects of delayed presentation in terms of management offered morbidity and mortality and results obtained were recorded, compared and analysed.

 

Purpose of study

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. The different modes of management of the liver abscess which will be analysed include.

1.       Medical management mainly includes administering Metronidazole in amoebic liver abscess and broad spectrum antibiotics in pyogenic abscess, usually third generation cephalosporins were often administered before microbiological diagnosis and these are modified when sensitivities were known. All the abscesses of less than 5cm were managed conservatively.

2.       Minimally invasive percutaneous drainage using ultra sound or CT guided drainage with 18G spinal needle for collections larger than 5cm and finally, this was combined with the medical management

3.       Open surgical drainage, in chronic and cases unresponsive to non operative treatment and for very large, leaking or burst cavities or in a patient with deteriorating condition in spite of medical management and repeated drainage. Moore in his study of 124 cases of liver abscess described that patient with a solitary left sided abscess warrant early operative intervention ¹⁰⁷. The mode of management was also decided on the basis of type of abscess, which include amoebic and pyogenic and the presence of co-morbid conditions. The specimens were collected and sent for immediate microscopy for the presence of Entamoeba histolytica and for immediate culture. CT guided drainage is effective in the management of secondary abscesses in the case of liver trauma ¹⁰⁸.