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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 

RESULTS

Between the period of February 1997 to September 1998 a total of 108 patients of liver abscess were studied 67 males and 41 females, shown in graph I, ranging from 6 to 85 years (mean age 36.5 median age 45.5 and mode age was 35 years). 77 patients were admitted directly and 31 patients were referred to Surgical Unit 1 of Baqai University Hospital from other departments, out of which 21 were previously diagnosed from the referring department and 10 were treated as a case of P.U.O. and referred for the diagnosis of pain in upper abdomen and right upper quadrant. The duration of symptoms before admission ranged from 1 day to 6 months, average duration of symptom was 17 days.

Fever and abdominal pain were the most prevalent symptoms at the time of diagnosis. Fever was present in all the cases, abdominal pain in 91 (83%), cases, yellow discolouration of skin in 16 patients, anorexia in 27 patients, nausea / vomiting in 21 patients and maliase in 19 patients. Important signs were Pyrexia and abdominal tenderness which were present in 110 and 97 patients respectively, hepatomegaly in 32 patients, jaundice in 16, cachexia in 2 patients and pallor/ anaemia in 17 patients. Important symptoms and signs are shown in table I and graph III. Important points in history were severe weight loss which was present in 20 patients, diarrhoea in patients and poor appetite 13 patients. 80 (74%) had leucocytosis, 44 (40%) had hyperbilirubenima, 78 (72%) raised serum alkaline phosphatase levels and 10(9%) had hyperamylasaemia. Anaemia was seen in 17 cases, raised S.G.P.T. in 30 patients and raised g- glutamyl transpeptidase in 25 patient, shown in table II and graph II. Ten patients were in septic condition. The median delay to diagnosis was 4 (1-16) days.

For the comparison of different modes of management and their results the patients are divided in two different groups and the analysis is as follows:

In Group-1 there were 78 patients and in Group-2 there were 30 patients. 64 (59%) patients had isolated abscess and 44 (40%) patients had multiple abscesses. 37(34%) were diagnosed on history and clinical examination alone. In 45(41%) there was a high suspicion, confirmed on ultrasound scan or CT scan. 26(24%) were diagnosed only after ultrasound scan for diagnosis of right upper quadrant pain. The diagnostic sensitivity of ultrasound was 85% and 100% for C.T. Scan.

            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 which is shown in graph IV. Abscess culture was positive in 29 (26%), 5 of them presented with polymicrobial infection, and showed predominance of micro-organisms from the intestinal flora. The most frequent organisms were Staphylococcus, Streptococcus and E. Coli other organisms were Enterococcus ssp, Pseudomonas, Klebsiella, Salmonella, Clostridium, and Bacteroides details are shown in Table IV. Causes leading to the development of the pyogenic liver abscess were Choledocholithiasis/ cholangitis, cholangiocarcinoma, bile duct injury with prolonged T-tube placement, infected metastasis of liver, local extension of empyaema of gallbladder into the liver parenchyma, diverticular disease, chronic pancreatitis, patients receiving chemotherapy, use of long term steroids, and a patient in which liver biopsy was performed, These causes are shown in Table IV. The differentiation was based on history, clinical examination and investigation. The presence of Entamoeba in the pus was diagnostic. The aetiology of the pyogenic liver abscess is searched for and biliary obstruction was found to be the commonest cause as shown in table V. Moderate hyperbilirubinaemia with a major rise in serum alkaline phosphatase with the presence of leucocytosis differentiated the condition from hepatitis.

Group 1. Early presenters (Patients presenting within 7 days of onset of symptoms)

            In Group 1 there were 78 patients out of which 15 patients were treated by conservative management alone. 63 patients were treated by minimally invasive percutaneous aspiration, 26 required percutaneous aspiration, 18 required twice percutaneous aspiration and 19 required multiple percutaneous aspiration. The average duration of repetition of percutaneous drainage was 5 days. None of the patient of this group required open drainage. No patient of this group developed shock and there was no mortality in this group. After drainage abscess disappeared in all patients with in one-month time.

Group 2. (Patients presenting after a 7 days of onset of symptoms)

            In Group 2 there were 30 patients out of which 2 patients were treated by conservative management alone. 17 patients were treated by minimally invasive percutaneous drainage, 3 required once drainage, 5 required twice drainage and 9 required multiple drainage. The average duration of repetition of percutaneous drainage was 4 days. 11 patients required surgery after drainage due to complications, incomplete drainage or due to intraabdominal sepsis following leak of the abscess. 8 patients presented with the signs of burst liver abscess out of which 6 were intraperitoneal burst one intrapleural and one intrapericardial leak. 10 patients of this group developed septicaemic shock and 6 patients of this group expired. Out of 6 intraperitoneal burst, laparotomy revealed 4 patients with frank burst and 2 leaking abscesses were sealed with omentum. All the patients who developed septicaemic shock and expired were from Group-2. Comparison between groups is shown in table III and graph V.

Metronidazole was the drug of choice for the amoebic liver abscess but third generation cephalosporins were preferred for the blind therapy of pyogenic abscess. If the infection is polymicrobial which was proved after culture and sensitivity requires antimicrobial agents that are active against the expected enteric pathogens both aerobic and anaerobic; we commonly use various antibiotics like third generation cephalosporins, augmentin, gentamicin, quinolones and metronidazole in various combinations according to culture and sensitivity. Our study showed that the patients who presented earlier and had abscess of less than 5 cm and were easily cured with the medical management. The patients who presented late developed larger abscess and were managed with little difficulty. Percutaneous drainage was a safe procedure but several precautions were taken before attempting for this procedure, which include clotting profile, but one of the patient developed frank leak after attempting the percutaneous drainage and emergency laparotomy had to be done.

 

 

Sr No	Clinical Details	No of Patients
A	Symptoms
1	Fever	108
2	Abdominal pain	91
3	Anorexia	27
4	Nausea or vomiting	21
5	Malaise	19
6	Yellow discolouration of skin /Jaundice	16
B	Signs
1	Pyrexia	108
2	Abdominal tenderness	97
3	Hepatomegaly	32
4	Jaundice	16
5	Pallor / Anaemia	17
6	Cachexia	2
C	Other important point in history
1	Weight loss	20
2	Diarrhoea	15
3	Poor appetite	13

 

 

Table I.  Important symptoms and signs noted in the patients with liver  abscess.