Clinico-Pathological Study and Management Stategies of Liver Abscess: a Prospective Study in Narayana General Hospital
Journal Title: New Indian Journal of Surgery - Year 2018, Vol 9, Issue 4
Abstract
Context: Liver abscess continues to be disease with considerable mortality in our country. Amoebic liver abscess, pyogenic and tubercular aetiologies should always be entertained in the differentials. The incidence of tubercular liver abscess (TLA) has increased in recent past due to increased incidence of predisposing factors like alcoholism, immunodeficiency, irrational usage of antibiotics, and emergence of multi drug resistant bacilli. Primary prevention by improving sanitation, health education, early diagnosis and prompt treatment may result in lowering mortality / morbidity associated with the disease. This study has tried to delineate clinical profile, risk factors and management strategies of liver abscesses. Aims: • To determine Demographic profile, Etiology, Clinical Spectrum, laboratory investigations in cases of liver abscess • The study the efficacy of Ultrasonogy in determining the etiology. • To study the bacteriological characteristics including it’s antibiotic sensitivity. • To study the influence of alcohol, diabetics & immunocompromised diseases in incidence of Liver abscess and, • To evaluate efficacy, recurrence rate, complications, morbidity & mortality, duration of hospital stay associated with Management Strategies followed. Settings and Design: A Prospective Clinico-Pathological study with 100 patients diagnosed to have Liver Abscess and undergoing treatment in Narayana General Hospital, Nellore between October 2012 to September 2014 inclusive of a follow up period of 6 months. Methods and Material: Inclusion criteria: • All cases of liver abscess (bacterial and parasitic0 diagnosed clinically and/or ultrasonographically. • All cases in evolving, liquified & ruptured stage with or without peritonitis Exclusion criteria: • Age <18yrs not included. • Traumatic and Past history of liver abscess Patient data collection and evaluation. Detailed history of patient was entered in proforma. Complete haemogram, LFT, PT, Ultrasound Abdomen was done on day of presentation. Patient was put on conservative line of management and followed up daily. Repeat Ultrasound / CT /MRI Abdomen & pelvis will be done immediately if patient condition does not improve/worsens or after 3-4 days as a routine. Complicated cases like ruptured liver abscess were immediately taken up for surgery. Pus was sent for gram’s stain and culture and sensitivity. Management: Percutaneous needle aspiration was done on patients who had abscesses <5cms under ultrasound guidance. Antibiotics were given according to cultures. If abscess was > 5cms or > 200cc pig tail drainage is done under local anaesthesia. Patients were examined daily for improvement of pain, fever, anorexia, hepatomegaly. Mean Hospital Stay was recorded. Laparotomy was done in cases of ruptured abscess with peritonitis. Relapses were noted and repeat aspirations were performed when necessary. Follow up of patients: Patients were followed up, monthly for first 3 months, then once after 6 months, for recurrent attacks or development of complications and to monitor the efficacy of the treatment given. Cure was defined as improvement clinically with subsidence of fever, and local signs, symptoms, decrease in WBC count and follow-up ultrasonography showed reduction in size < 3 cm in diameter and no evidence of relapses. Statistical analysis used: The Statistical software namely SPSS 15.0, used for the analysis of the data and Microsoft word and Excel have been used to generate graphs, tables etc. Results: The highest incidence occurred in the age group 31-60 years (71%) with mean age of 46 years. Males (89%) were more commonly affected. Pain abdomen and Fever were most consistently occurring symptom in 100%, 94% respectively. Diarrhoea, cough, hepatomegaly, Jaundice and shock, pleural effusion, basal consolidation was other modes of presentation. Alcohol was the single most consistent etiological factor in all patients of liver abscess. Leucocytosis, anaemia, diabetis, altered RFT and LFT, Prolonged PT, were the most common abnormal lab findings. 44 cases had amoebic liver abscess and 30 had pyogenic abscess. E.coli, Klebsiella, Staph were the most common organism isolated in pyogenic liver abscess. Ultrasonography revealed solitary abscess in 70.0% and multiple abscesses in 30.0%. Isolated right lobe abscess was seen in 66.0% and left lobe abscess in 04%. Cases of multiple small and solitary abscesses were managed conservatively. 26 cases had recurrence. 30 were subjected to percutaneous aspiration, 32 cases underwent Pig Tail Catheter Drainage, 12 required Laparotomy and Drainage along with (3%) ICD insertion for rupture into pleural cavity. Patients were followed up. Recurrences were noted in 8 cases in Conservative & aspiration management group. Out of 30 cases 25 cases underwent single aspiration, 4 cases underwent twice aspiration and 1 case underwent thrice aspiration. Cryptogenic was the most common aetiology in Amoebic liver abscess (97.1%) and Pyogenic liver abscess (73.3%). Peritoneal rupture (21.0%) was the most common complication associated with Liver abscess. In this study 3 cases were positive for HIV serology. Mortality occurred in 6 cases in our study. Conclusions: Liver abscess is a very common condition in India. India has 2nd highest incidence of liver abscess in world. Liver abscesses occurred most commonly between 30-60 years males. Pain abdomen, fever are consistently occurring symptom. Alcohol consumption was the single most important etiological factor for causation of liver abscesses. Alkaline phosphatase is the most consistently elevated among all Liver Function Tests. Raised WBC count, Alkaline phosphatise level, Diabetes, Hypoalbuminaemia, Prolonged Prothrombin time were considered as the predictive factors of complicated (Ruptured) liver abscess in this study. Diabetes mellitus was more frequently associated condition in cases of liver abscess and especially Pyogenic liver abscess cases. Liver abscess usually present as a solitary abscess most commonly in the right lobe of liver. Enterococcus was the most common organism isolated in pyogenic liver abscess. Patient management depends on number and size of abscess. Cryptogenic was the most common aetiology in Amoebic liver abscess as well as in Pyogenic liver abscess. Peritoneal rupture was the most common complication associated with Liver abscess. Mortality was seen in 6 cases in this study.
Authors and Affiliations
Muneendra Kumar
Keywords
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