Liver abscess-various modalities of treatment and its clinical outcome

Background: Liver abscesses, both amoebic and pyogenic, continue to be an important cause of morbidity and mortality in tropical countries. The primary mode of treatment of amoebic abscess is medical; however many cases may be refractory to medical therapy. In such patients with pyogenic liver abscesses, aspiration has been the traditional mode of treatment. In the present study of liver abscess of different etiology the following treatment modalities such as medical management, aspiration and percutaneous catheter drainage have been studied. Methods: The Present study was conducted in Bangalore Baptist hospital during the period from August 2010 to December 2012. All 70 patients with the diagnosis of liver abscess were included in the study. Detailed morphology of liver by radiology and ultrasound abdominal scan for abscess was examined. Routine blood and serological examinations to detect anti-amoebic antibodies by IHA were performed. After thorough examination patients were hospitalized and underwent with antibiotic therapy. Patients not responding to parenteral antibiotics therapy within 48-72 hours, were subjected to ultrasound guided aspiration if the abscess cavity was less than 5 cm in diameter and percutaneous catheter drainage for cavity more than 5 cm. Results: The age group of the study patients ranged from the 2-78 years and the incidence of sex ratio male:female was 10.6: 1. The incidence of alcohol consumption was 74% and it was more common in age group between 31 40 years. Solitary abscess was found in 59% and 41% of patients had multiple abscess. Serology for Entamoeba histolytica was positive in 88.6%. Commonest presentation was right upper quadrant pain and fever. Raised alkaline phosphatase was noted in 84.3 % of patients. Initially all patients were managed with antibiotics (ciprofloxacin and metronidazole). Patients who are not responding to antibiotics, aspiration was done in 15 patients with volume of pus 100 cc-200 cc and percutaneous catheter drainage was done in 27 patients with volume of pus >200 cc by using 18Fr Malecot’s catheter which found to have less incidence of blockage. Conclusions: In the present study abscess containing volume of pus 100-200 cc was treated with either conservative antibiotic treatment alone or aspiration of pus with antibiotics. Abscess containing volume of pus >200 cc was treated with percutaneous catheter drainage along with antibiotics. From the study, it was concluded that percutaneous needle aspiration and percutaneous catheter drainage are more effective than conservative medical management in treatment of liver abscess; however co-morbid conditions of patients and size of liver abscess also influence the outcome.

medical therapy.Also secondary bacterial infection may complicate 20% of amoebic liver abscess.In such patients and in patients with pyogenic liver abscesses, aspiration has been the traditional mode of treatment.Operative drainage is associated with significant (10 to 47%) mortality and morbidity. 2In recent years, imaging guided percutaneous drainage has been increasingly used to treat liver abscess with reported success rates ranging from 70 to 100%, surgical intervention is typically unnecessary. 2rcutaneous placement of an indwelling catheter is the method most widely preferred to drain the large liver abscesses. 3Also few studies have shown therapeutic needle aspiration to be a simpler and less costly mode of treatment, but needs repeated aspiration, with more failure rates.
In the present study the authors were interested to study the effectiveness of various treatment modalities for liver abscess, Malecot's catheter in continuous percutaneous drainage of liver abscess, aspiration as a treatment for liver abscess and also aimed at the study of usefulness of percutaneous catheter drainage procedure in morbid patients not fit for open surgical drainage, those not responding to medical line of management, recurrent abscesses following needle aspiration and multiple abscesses.

METHODS
The Present study was conducted in Bangalore Baptist hospital during the period from August 2010 to December 2012.All 70 patients with the diagnosis of liver abscess were included in the study.Patients with ruptured abscess and liver abscess associated with suspected malignancy were excluded from the study.
Patients with following symptoms and signs were selected for screening of liver abscess.Pain abdomen (upper -RUQ), fever with chills, history of chronic alcoholism and smoking, tender hepatomegaly, right basal pleural and pulmonary pathology, jaundice and patients with other signs and symptoms like loss of weight, hiccoughs, right shoulder pain, diarrhea, nausea/vomiting and distention of abdomen were subjected to complete ultrasound abdomen examination to visualize almost all part of liver.Intercostal and sub costal planes were used.All the liver lesions suggestive of liver abscess were examined in detail (other abdominal organs were also scanned for any abnormalities).
Detailed morphology of liver for abscess was examined with special attention to size of liver assessed for hepatomegaly, identification of number of abscess and their locations in relation to lobes/segmental anatomy of liver, contiguity of abscess to the liver capsule, size and volume of abscess and echogenecity of the abscess (hyperechoic, hypoechoic, anechoic).
Routine blood examinations like haemoglobin, random blood sugar, blood urea, serum creatinine, total leukocyte count, leukocyte differential counts were done.Urine, stool, liver function tests and chest X-ray including upper abdomen radiographs was done.Pus if aspirated was sent for aerobic culture and antibiotic sensitivity and also for microscopy to see for Entamoeba histolytica Serology examination was done to detect anti-amoebic antibodies by IHA, in which the IHA titre was measured and the type of abscess was diagnosed as per the titre values.The IHA titre values >256 were considered to be positive for amoebic and <256 were pyogenic abscess.
After history, clinical examination, radiological and ultrasound abdomen investigations, with the help of diagnostic criteria a provisional diagnosis of liver abscess was made.All patients were hospitalized and depending upon hydration status they were hydrated and started on parenteral ciprofloxacin/third generation cephalosporin and metronidazole therapy.Patients not responding to parenteral antibiotics therapy within 48-72 hours were subjected to ultrasound guided aspiration if the abscess cavity was less than 5 cm in diameter and percutaneous catheter drainage for cavity more than 5 cm.

Procedure of percutaneous catheter drainage
The selected area was in filtered with xylocaine with strict asepsis.Infiltration should include diaphragm and tissues up to capsule of liver.Patient was instructed to breathe slowly during the procedure to minimize the liver trauma.For guiding the aspiration needle a right angle approach can be used.By preliminary scans after choosing the site of lesion and finalizing course of the needle, the transducer is placed exactly at right angles along the course of the needle.This allows clear visualization of the needle along its path into the abscess cavity.Under ultrasound guidance the needle tip is followed into the abscess cavity with uniform guarded pressure.Once the needle enters the cavity, pus often rushes out under pressure.Then the stylette is removed and catheter was introduced well in to the cavity which is confirmed by ultrasound.Catheter is fixed to the skin and connected to a drainage bag.The patient should be watched for vital signs for a period of 24 hours.During the hospital stay all patients who had undergone percutaneous drainage, the volume of pus drained each day was measured.Patients who showed improvement following percutaneous drainage were discharged with the drain in situ.

Catheter care and follow up
Daily estimation of volume, colour and consistency of the drainage fluid was recorded.Catheter was kept in situ till the drain became less than 20 ml.The duration varied in individual cases depending on the quantity of pus, or presence of biliary fistula.Follow up was done using ultrasonography to note the shrinkage in size of the cavity

Incidence of age
The age group of the study patients ranged from the 2-78 years.Highest incidence of age was found between 3 rd -6 th decades with 65.71%.Youngest was 2 years old female and oldest 78 years male.In this study group 64 cases were male and 6 cases are female and sex incidence, ratio being, male:female was 10.6:1.

History of alcoholism
In this study the incidence of alcohol consumption was 74% and it was more common in age group between 31 to 40 years.

Chest X ray
All patients were subjected to screening of chest with chest x-ray including upper abdomen.34 (48.57%)cases had elevated or right dome of the diaphragm with restricted movements.The elevated right dome of the diaphragm was due to upper enlargement of liver, which occurs, in liver abscess as shown in Figure 2. 33 (47.14%) cases had right sided pleural effusion.Cardiomegaly and involvement of pericardium was not seen in any of the cases.

Ultrasound abdomen
USG is a very important tool, both in diagnosis and therapeutic management of liver abscess.

Size, volume and number of abscesses
In the present study, the size of abscess was determined by long axis measurement and varied from 3×2 to 11×9 cms.Volume of abscess was also measured, the smallest was 9 cc and the largest was 1092 cc.In the present study, 41 cases (58.6%) had solitary abscess and 29 (41.4%)cases showed multiple abscesses.involving both lobes and also many abscesses in same lobe.Out of 29 cases of multiple abscesses, both lobe involment was in 6 cases and 2 abscesses found in same lobe either right or left in 22 cases and 3 abscesses in one lobe seen in 1 case.4.

DISCUSSION
The management of liver abscess has drastically changed with significant reduction in mortality and morbidity after the advent of imaging modalities and antibiotics.Percutaneous placement of indwelling catheter provides continuous drainage, hence the problem of incomplete evacuation and re-accumulation are not associated with catheter drainage and this method achieved good success rate as reported in earlier studies.[6][7] Pain in abdominal associated with fever were the most common symptom observed in our study and is comparable with the study of Rajak et al. 2 The common signs in most of the patients observed was right upper quadrant tenderness in 67 (94.28%) cases and fever >102 o F in 43 patients.In our study the major comorbidity associated with liver disease was diabetes found in 6 patients followed by hypertension, ischemic heart disease, renal failure and cerebrovascular damage.The abscess characteristics like site of abscess, location of abscess, no of abscesses was comparable with the same study and other standard studies.The mean duration of drainage in our study was 16 days, as compared to Rajak, et al (7 days), Wong (25 days), Sonnenberg (4 days). 2,5,6Jaipal Singh et al showed an average duration of 4.5 days and Gerzof showed a mean drainage period of 18 days. 10,6The studies of Jaipal Singh and Sonnenberg were on amoebic abscesses and Wong and Gerz of studied only on pyogenic abscesses with other comorbid conditions such as malignancy and biliary stents, which prolonged the duration of drainage.In our study there were no complications noted during in both aspiration and percutaneous drainage.Only in percutaneous drainage group, local wound infection was noted in 3 cases which were treated with daily dressings with betadine and saline.

CONCLUSION
Liver abscess is a very common condition in India.India has 2 nd highest incidence of liver abscess in world.Liver abscesses occurred most commonly between 30-60 years.Males were affected more than females.Most of the cases had an acute presentation, and right lobe is most commonly affected.Out of 70, 67 cases had pain in abdomen as the most common symptom.It was found that alcohol consumption was one of the most important etiological factors for causation of liver abscesses.Alkaline phosphatase is the enzyme most consistently elevated among all liver function.Elevated WBC count, alkaline phosphatase level, presence of diabetes, hypoalbuminemia, prolonged prothrombin time were considered as the prognostic factors of complicated abscess in this study.Diabetes mellitus was more frequently associated condition in cases of liver abscess and especially in case of pyogenic liver abscess.Percutaneous needle aspiration and percutaneous catheter drainage are more effective than conservative medical management in treatment of liver abscess; however comorbid conditions of patients and size of liver abscess also influence the outcome.
Christopher S et al.Int Surg J. 2016 Nov;3(4):1868-1874 International Surgery Journal | October-December 2016 | Vol 3 | Issue 4 Page 1869 Christopher S et al.Int Surg J. 2016 Nov;3(4):1868-1874   International Surgery Journal | October-December 2016 | Vol 3 | Issue 4 Page 1870 every 7 th day.Removal of catheter was decided based on the amount of pus drained (<20 ml for three consecutive days), relief of symptoms and sonological evidence of collapsing cavity or decrease in the size of cavity.Patients were followed up weekly for 1 month and monthly for next 3 months with repeat ultrasonography.Treatment was considered successful if the patient improved clinically with relief of pain, fever and other symptoms and the imaging of liver showed resolution of the abscess.

Figure 2 :
Figure 2: Chest X-ray raised dome of right side of diaphragm.

Figure 4 :
Figure 4: Pus drained by percutaneous drainage.Management 70 cases of liver abscess were directed with conservative management, aspiration and pigtail insertion.Out of which 28 (40%) cases were treated with antibiotics alone, 15 (21.42%) cases were treated with antibiotics and aspiration, 27 (38.57%)cases were subjected to catheter drainage yielding varying quantities of pus from 200 ml to 1000cc, depending on the size of the abscess.All patients showed good response and proceeded towards Christopher S et al.Int Surg J. 2016 Nov;3(4):1868-1874 International Surgery Journal | October-December 2016 | Vol 3 | Issue 4 Page 1873

Funding:
No funding sources Conflict of interest: None declared Ethical approval: The study was approved by the institutional ethics committee

Table 6 : Comorbidities associated with liver abscess.
Routine blood examinations and liver function tests were presented in Table7and Table8.

Table 9 and
10 describes culture sensitivity in liver abscess and IHA titres.

Table 12 : The volume of abscess and the mode of treatment.
Mean volume drained after insertion of pigtail equal to 243.19 cc.Mean volume draining during the hospital stay on the 1 st day is 173.54 cc, 2nd day is 86.63 cc, 3 rd day 54.11 cc and 4 th day 42.45 cc as shown in Figure

Table 14 : Comparision of patient and abscess characteristics in two studies. Characteristics Our study Tiwari et al Rajak et al No of patients Percentage No of patients Percentage No of patients Percentage
International Surgery Journal | October-December 2016 | Vol 3 | Issue 4 Page 1874 10,[5][6][7]