Premium quality web hosting!

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 

DISCUSSION

            Although the incidence of the liver abscess is higher in our region but still cases are diagnosed very late. Most of the cases in our series were treated as that of malaria initially before being referred to us by general practitioners. Delay in diagnosis causes increase in severity of the disease which is further complicated by leaking of abscess in peritoneal, pleural or pericardial cavity as is shown by the comparison between group one and two. In a study by Zia et al Leukocytosis, raised ESR, elevated levels of alkaline phosphatase, raised right hemidiaphragm and right sided pleural effusion were the important diagnostic criteria for the liver abscess ¹⁰⁹. Delay in presentation also increases the morbidity and mortality. In a retrospective study carried out in Karachi mean delay in presentation was reported to be 13 days which confirms a trend in delayed presentation to hospital ¹¹⁰. Peritonitis was established either at operation or, in the conservatively managed group by aspiration from the abdominal cavity. The same criteria is supported by Sarda ¹¹¹. Patient with burst liver abscess again presents with septicaemia and signs relating to cavity in which it is perforated. Perforation in pleural cavity is usually confused with lung abscess, pericardial rupture can be misdiagnosed as pericardial effusion and intra-peritoneal rupture can be confused with other condition of acute abdomen. Presence of pleural effusion on routine chest X ray occasionally get primary importance and main diagnosis is missed. This was observed in the cases in which the abscess was near diaphragm. Patient with hepatic abscess developing sepsis and multiple organ failure has increased risk of mortality. Local findings, such as rupture of the abscesses, multiple abscesses, and gas-forming abscesses, were not independent factors. Percutaneous drainage is always considered if the condition of the patient can not be improved with antibiotic therapy. Percutaneous drainage under ultrasound control is the preferred initial drainage procedure in high-risk patients ¹¹². It is recommended as preferred primary method of treating liver abscess ¹¹³. Operative treatment is indicated if the patient is unresponsive to medical treatment and percutaneous drainage or if the patient has complications of biliary tract stone or rupture of the abscess ¹¹⁴.

Administration of broad spectrum antibiotics prior to diagnosis gives negative blood cultures which make the management ineffective especially if the pyogenic abscess is polymicrobial. Late diagnosis usually give rise to very large cavities or multiple cavities which does not obliterate even after successful management and may persist for year and can get reinfected especially by haematogenous route. In western literature the incidence is very low but mortality is as high as 88%, which is decreased by after the advent of advanced imaging techniques. Some authors have reported increased precision of C.T. Scan over ultrasound scan. Without early and specific therapy liver abscess may become fatal. Amoebic liver abscess can present with vasculitis and spontaneous pneumoperitoneum can develop secondary to rupture of a gas-producing organism.

In a study by Hashimoto et al 56 cases of pyogenic liver abscess were treated. The most frequently used treatment was percutaneous drainage of the abscess under computed tomography (CT) guidance (39 patients), followed by multiple CT-guided aspiration (10 patients). Six patients were initially treated by open operative drainage; another five were operated upon after CT guided drainage had failed. One patient with advanced pancreatic cancer was treated with antibiotics only. Operative drainage was reserved for patients who fail to respond to percutaneous drainage or in whom surgery is indicated for other purposes ¹¹⁵.

            The preoperative use of antiamoebic drugs directly influence the result of surgery ¹¹⁶. The management of the liver abscess is a problem because of the various aetiological factors, but the complication arises when the duration of illness is more which increases the extent of disease. The management is based on the extent of disease.

Diagnosis of burst liver abscess is very important to prevent mortality. According to Chou et al the only significant clinical findings that differentiates the two (ruptured and non-ruptured) conditions are abdominal pain and septic shock, other symptoms, such as fever, chills, and jaundice, were similar in ruptured and nonruptured groups. Laboratory findings indicated that the group with ruptured liver abscess had higher levels of bilirubin, blood glucose, and aspartate aminotransferase than the non-ruptured group. Surgical intervention--draining the abscess and cleaning the abdominal cavity--was the only means of saving the patients' lives. The overall mortality rate was higher in this group (43.5%) than in the nonruptured group (15.5%) ¹¹⁷. The mortality rates for pyogenic liver abscess alone reported in the literature is high. In a study by Chou et al the overall hospital mortality rate was 18%. In a study by Shah et al Reasons for surgical intervention were failure of nitroimidazole, secondary bacterial infection, left lobe abscess, multiple liver abscess, impending rupture of abscess, rupture of abscess with peritonits ¹¹⁸. Pyogenic liver abscess is still a disease with significant mortality. Early diagnosis and prompt treatment are necessary to further improve results of management ¹¹⁹. Imminence of complication was evidenced by: 1. Clinical worsening of the patient despite adequate medical treatment, 2. Presence of an abscess of 6 cm or more in presence of intraabdominal sepsis, or 3. Clinical or ultrasonographic findings of an abscess on the verge of rupture ¹²⁰.

 

CONCLUSION

Liver abscess should be diagnosed early to decrease morbidity and mortality. Early diagnosis offers the best chance of cure. This study was helpful in finding out the factor helpful in early diagnosis and effective management of liver abscess and analysed the effects on the management by delay in presentation and diagnosis. This study has also analysed 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 are divided in two different groups. In 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 where as patients in Group 2 were difficult to manage and some of them required open surgical drainage which shows early presentation decreases the complication rates. Metronidazole was the drug of choice for the amoebic liver abscess but third generation cephalosporins were preferred for the blind therapy of pyogenic abscess.

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.