LUNG ABSCESS AND BRONCHIAL CATHETERIZATION
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Liver abscess in the tropics: experience in the University Hospital
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Surgical management of pyogenic liver abscess
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PostgraduateMedicalJournal(1987)63,551-554
TropicalMedicine
Liverabscessinthetropics:experienceintheUniversityHospital,KualaLumpur. K.L.Goh,N.W.Wong,M.Paramsothy,M.NojegandK.Somasundaram DepartmentofMedicine,FacultyofMedicine,UniversityofMalaya,59100KualaLumpur,Malaysia.Summary:Wereviewed204casesofliverabscessseenbetween1970and1985.Ninetywerefoundtobeamoebic,24pyogenicandonetuberculous.Thecauseoftheabscessesintheremaining89patientswasnotestablished.Thepatientswerepredominantlymale,Indians,andinthe30-60agegroup.Themajorityofpatientspresentedwithfeverandrighthypochondrialpain.Themostcommonlaboratoryfindingswereleucocytosis,hypoalbnminaemiaand anelevatedserumalkalinephosphatase.Amoebicabscessesweremainlysolitarywhilepyogenicabscessesweremainlymultiple.Complicationswerefewinourpatientsandincludedruptureintothepleuralandperitonealcavitiesandsepticaemicshock.Anoverallmortalityof2.9%wasrecorded.Thedifficultyindiagnosingtheabscesstypeishighlighted.Thesinglemostimportanttestinhelpingusdiagnoseamoebicabscess,presumablythemostcommontypeofabscessinthetropics,istheEntamoebahistolyticaantibodyassay.Thistestshouldbeusedmorefrequentlyinthetropics.
Introduction
LiverabscessisafairlycommondiseaseinMalaysia.Balasegaram'reported442casesseenovera15-yearperiod.Whileitcanbesaidthathisexperienceisthatofareferralsurgicalcentre,manycasesofliverabscessarealsoseenandtreatedinsmallerhospitalsthrough-outthecountry.Thecommontypesofliverabscessseenareamoebicandpyogenicabscess.Althoughitisoftenpresumedthatthemajorityofabscessesseeninthetropicsareamoebicinorigin,theevidenceincriminatingEntamoebahistolyticaasthecausativeagenthasseldombeenproven.2Similarly,culturesforpyogenicorganismsareoftennegative.Wedescribeourexperiencewith204casesofliverabscessseenfrom1970-1985intheUniversityHosp-ital,KualaLumpur.
Materialsandmethods
Adefinitivediagnosisofliverabscesswasmadebasedononeoranycombinationofthefollowing-surgicaldrainageoraspirationofpusfromtheliveroratautopsy,radionuclidescanning,ultrasonographyorcomputedtomographic(CT)scanning.Patientswereconsideredtohaveanamoebicliverabscesswhen(i)E.histolyticatrophozoitesweredemonstratedinabiopsyoftheabscesswall;(ii)E.histolyticatrophozoitesweredemonstratedinthepus;(iii)E.histolyticaantibodytitresweregreaterthan1:64;(iv)anchovysaucewasdrainedfromtheabscess;(v)E.histolyticatrophozoitesorcystswereisolatedinthestoolswithorwithoutahistoryofdysentery;and(vi)patientsrespondedtotreatmentwithanti-amoebicdrugsalone.Patientswereconsideredtohaveapyogenicabscesswhenpusand/orbloodculturesgrewpyogenicorgan-isms,providedtheabovecriteriaforamoebicabscesswerenegativeandtherewasnootherobvioussourceofinfection.Onepatientwasdiagnosedtohaveatuberculousabscesswhenbiopsyoftheabscesswalldemonstratedgranulomaswithacid-fastbacilli.Therewasnoevidenceofpulmonaryormiliarytuberculosis.Patientswereplacedinanindeterminategroupwhenthecriteriafordiagnosisofamoebicorpyogenicabscesswerenotpresentorknown.
A)TheFellowshipofPostgraduateMedicine,1987Correspondence:K.L.Goh,M.B.,B.S.(Mal),M.R.C.P.(UK)Accepted:29January1987copyright. on May 19, 2023 by guest. Protected byhttp://pmj.bmj.com/Postgrad Med J: first published as 10.1136/pgmj.63.741.551 on 1 July 198
7. Downloaded from
552K.L.GOHetal.
TableIClinicalpresentation
AmoebicPyogenicIndeterminateAllabscessesn=90n=24n=89n=204Feverwithchillsandrigors80.079.288.882.7Righthypochondrialpain77.750.078.768.8Epigastricpain14.433.314.620.8Diarrhoeaordysentery19.98.315.914.7Jaundice24.416.717.019.4Tenderhepatomegaly90.087.590.989.8Rightbasaleffusionorcrackles/39.98.332.927.0rub
*Figuresareinpercentagesoftheabscesstype.Results
Of204patientsreviewed,90(44.1%)werefoundtohaveamoebicabscess,24(11.8%)pyogenicabscess,one(0.5%)tuberculousabscesswhile89(43.6%)wereconsideredindeterminate.Themajorityofpatientsweremale,withamaletofemaleratioof6:1.Indianswerethepredominantracialgroupaffectedandcomprised49.5%ofallpatientscomparedwith23.2%ofallhospitaladmis-sions(P<0.01).Theageofpatientsrangedfrom2
yearsto84years.Thepeakincidenceoccurredinthe30-60yearsage-group.Theclinicalpresentationofliverabscessisasshown(TableI).Thecommonpresentingclinicalfeaturesforallabscesstypeswerefeverwithchillsandrigors,righthypochondrialpainandatenderhepatomegaly.Only
asmallproportion(20%)ofpatientshadjaundice.Rightlowerchestsigns,chieflyarightbasaleffusionwereseenin40%ofthepatientswithamoebicabscessandin32.9%ofpatientsintheindeterminategroup.Theincidenceis,however,muchlowerinthepyogenic
group(8.3%).Thehaemoglobinlevelwaslessthan11g/I00mlin53.5%ofthepatientsandthetotalwhitecellcountwaselevatedtoabove11x109/lin81%.Alowserumalbuminleveloflessthan35g/landanelevatedserumalkalinephosphataseofgreaterthan150IU/lwerefoundinabout80%ofpatients.Serumbilirubinandalaninetransaminaselevelswereraisedin29%and24%respectively.Therewasnosignificantdifferencebetweenthepatientgroups.Themostfrequentlyusedradiologicalmodalityindiagnosisandlocalizationofabscesswasradionuclidescanning,utilizedinthree-quartersofthepatients.Recently,ultrasonographyhasbeenincreasinglyutilized.TableIIshowsthelocationofabscessesinthevarioussubgroups.Oftheamoebicabscesses86.5%
weresingle,withthemajorityintherightlobe(77.7%ofthetotal).Ontheotherhand62.6%ofpyogenicabscessesweremultiple.Thefiguresfortheindeter-minategroupapproximatedthatofamoebicabsces-
ses.ThebacteriologyofpyogenicabscessisasshowninTableIII.EscherichiacoliandKlebsiellaspecieswerethemostcommonpyogenicoganismsandtogetheraccountedformorethanhalfoftheorganismsisolated.Predisposingfactorswerelookedforinthe24patientswithpyogenicabscess.In6,therewasevidenceofbiliarydiseasewhiletherewerenoobvious
TableIIAbscesslocation*
AmoebicPyogenicIndeterminate
SingleabscessRightlobe77.725.064.0Leftlobe8.812.513.5 MultipleabscessesRightlobe8.84.27.9Leftlobe1.14.23.4Bothlobes3.354.211.2*Allfiguresinpercentagesoftheparticularabscesstype.copyright. on May 19, 2023 by guest. Protected byhttp://pmj.bmj.com/Postgrad Med J: first published as 10.1136/pgmj.63.741.551 on 1 July 198
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LIVERABSCESSINTHETROPICS553
TableIIIBacteriologyofpyogenicabscess
No.(%)
Escherichiacoli833.3Klebsiellasp.625.0Enterobactersp.312.5Streptococcusmilleri28.3Serratiamarcesens28.3Streptococcusfaecalis,Bac-1eachteroidessp.Citrobactersp.Pseudomonaspseudomallei
precipitatingfactorsintheremainder.Intheindeter-minategroup,abscessesfollowedaperforatedappen-dix,asepticabortionandin2patients,biliarydisease.Nostandardtreatmentprotocolwasadoptedinourpatients.Themajorityweretreatedwithbothantibioticsandanti-amoebicdrugsassoonasthediagnosisofliverabscesswasmade.Thepatientswereusuallyreferredearlyforasurgicalopinion.Theindicationsforneedleaspirationorsurgicaldrainageincludednon-resolutionofclinicalsignsandsymp-
tomswithadequatemedicaltreatment,signsofrup-tureorimpendingruptureoftheabscessandalargesizeofabscessexceeding10cm,especiallywhenlocatedintheleftlobe.Intheamoebicabscessgroup,44.4%ofpatientshadopendrainageand17.7%hadneedleaspirationoftheirabscessescarriedout.Inthepyogenicgroup,70.8%ofabscessesweresurgicallydrainedand8.3%needleaspirated.However,inthelargegroupwithindeterminateabscess27.0%ofpatientshadopendrainageand13.5%,needleaspirationperformed.Complicationswereuncommoninourgroupofpatients;7patientshadperforationsintotheperiton-ealcavity,4hadperforationsintothepleuralcavity.Twopatientswithamoebicabscessdevelopedseverefulminatingcolitisandsepticaemicshockandsuccum-bedtotheillness;bothpatientswereaborigines.Threepatientsinthepyogenicgroupandoneintheindeter-minategroupdiedfollowingsepticaemicshock.Theoverallmortalityratewas2.9%.
Discussion
Whilethediagnosisofliverabscessisreliablymadeonclinicalgroundsandeasilyconfirmedbyradionuclidescanning,ultrasonographyorCTscanning,thediag-nosisofabscesstypeisdifficult.Thisisreflectedbythelargenumberofpatientsplacedintheindeterminate
group.Thereareseveralreasonsforthisproblem.Notallabscessesaredrainedoraspiratedyieldingpusforexamination.Evenifpuswereavailable,amoebacanonlybelocatedwithdifficulty.Biopsyoftheabscesswallisnotalwaysdoneatopendrainage,andagain,ifdone,amoebamaynotbefoundbecausetheydisin-tegrateanddisappearquicklywithprecedinganti-amoebictreatment.3Pusculturesforpyogenicorgan-ismsareaffectedbypreviousantibiotictherapy-oftenthecasewithourpatientswhohavesoughttreatmentbeforecomingtohospital.Furthermore,pusculturesforanaerobicorganismsarenotroutinelydone.Thisispertinentastherearereportsthatanaerobesmayaccountforupto38%ofallpyogenicabscesses.4Associatedorprecedingdysenteryinpatientswithamoebicliverabscessisuncommonwithourpatientsandsodoesnothelpinmakingadiagnosisofamoebicabscess.Anchovysaucewhenaspiratedordrainedishighlycharacteristicofamoebicabscess.However,itmaynotbefoundinallamoebicabscesses.Entamoebahistolyticaantibodyassayisusefulinconfirmingthediagnosisofamoebicabscessastissueinvasionbytheamoebainducesastrongantibodyresponse.5Theindirectimmunofluorescentmethodisusedinourlaboratoryandhasbeenfoundtobehighlysensitive,withareactivityof96%amongconfirmedcasesofliverabscess.6Unfortunatelythistestisstillnotreadilyavailablelocally.Only4seraweretestedintheindeterminategroup;2werenon-reactivewhile2hadtitresof1in16whichwereconsiderednotsignificant.Itislikelythereforethatmanycasesofamoebicabscesswereleftundiagnosedintheindeter-minategroup.Thesexandracedistributionofourgroupofpatientswasverysimilartootherreportsfromthisregion.8'9Malepreponderanceisnotedinourseries.Indianswerethepredominantracialgroupaffectedoverall.ThisisnotsurprisingasthemajorityofIndianpatientsseekingtreatmentinthehospitalcomefromoutlyingareasaroundKualaLumpur,wherehygieneispoor.Clinicalsignsandsymptomswerefairlyreliableandconsistentinhelpingusdiagnoseliverabscess.However,theclinicalfeaturesofamoebicandpyogenicabscesseswereonthewholeremarkablysimilaranddidnothelpusdistinguishbetweenthetwo.Anexceptionistheoccurrenceofrightbasallungsignsin40%ofpatientswithamoebicabscesswhichwasonlypresentin8.3%ofpatientswithpyogenicabscess.Thiscanperhapsbeexplainedbythefactthatthemajorityofamoebicabscesseswereintherightlobeoftheliverwhereitwouldbemostlikelytocauserightbasallungsignsespeciallywhenlocatedinthediaphragmaticsurface.Thehigherproportionofabscessesintherightlobealsoexplainsthehigherratioofrighthypochondrialpaintoepigastricpaininamoebicabscess.Ontheotherhand,inpyogenicabscess,whereasignificantproportionofabscesseswereintheleftlobeorinbothlobes,epigastricpainwaspresentinanincreasedproportionofpatients.Wehaveobservedthatthenumberandlocationofcopyright. on May 19, 2023 by guest. Protected byhttp://pmj.bmj.com/Postgrad Med J: first published as 10.1136/pgmj.63.741.551 on 1 July 198
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554K.L.GOH,etal.
abscesseswereusefulinhelpingtodistinguishbetweenamoebicandpyogenicabscess.Asinglerightlobeabscesswasmorelikelytobeamoebicwhilemultipleabscessesinbothlobesweremorelikelytobepyogenic.Thesefindingsareconsistentwiththeobservationsofothers.8'9Notunexpectedly,theGram-negativebacilli,E.coliandKlebsiellawerethemostcommonpyogenicorganismsisolated.Bacteroideswasfoundinonlyonepatientbutasnotedbefore,thedetectionofanaerobicorganismsishamperedbycollectionandinadequateanaerobicculturingtechnique.Onepatienthadsys-temicmelioidosiswithdevelopmentofmultipleliverabscesses;Pseudomonaspseudomalleiwasculturedfrombothbloodandpus.Whileassociatedpredisposingfactorswerefoundinonlysixpatientswithpyogenicabscess,wefoundfourpatientswithdefiniteevidenceofbiliarydiseaseorintra-abdominalsepsisintheindeterminategroup.Thesepatientsarelikelytohavehadpyogenicabsces-ses.Theoverallmorbidityandmortalityratesinourpatientswerelowwhichcouldperhapsbeattributedtoapromptandaggressiveapproachtotreatment.Perforationsintotheperitonealandpleuralcavitiesbutnotintothepericardialsacweredocumented.Itisinterestingtoreporttwocasesoffulminatingamoebiccolitis,anuncommoncomplicationofamoebiasis,occurringwithliverabscess.Deathsamongourpatientsusuallyfollowedoverwhelmingsepticaemia.Finally,wehavealsonotedtheremarkablesimilarityintheepidemiologicaldata,clinicalfeatures,andlaboratoryandradiologicalresultsoftheamoebicandindeterminategroups.Itwouldbetemptingtopresumethatthemajorityofthepatientsintheindeterminategroupwereamoebic.Asamoebicserologicaltestshavebeenshowntobehighlysen-sitive,amoreconclusivediagnosisofamoebicliverabscesscouldhavebeenmadeifthesetestshadbeenperformedonmorepatients.Thiswouldhavebeenextremelyhelpfulinplanningmorepreciseanddefin-itivetreatmentofthedisease,therebycuttingdownoncostsandundesirablesideeffectsoftherapy.
Acknowledgements
WewouldliketothankMrLowTing,DepartmentofMedicine,UniversityofMalaya,forhelpinguspreparethemanuscript.
References
1.Balasegaram,M.Managementofhepaticabscess.CurrProblSurg1981,18:282-340.2.Vijendran,M.Thediagnosisandcurrenttreatmentofliverabscess.MedJMalaysia1977,32:133-138.3.Manson-Bahr,P.E.C.&Apted,F.I.C.Amoebiasis,giar-diasisandbalantidiasis.InManson'sTropicalDiseases.BailliereTindall,Edinburgh,London,1982,pp.121-145.4.Perera,M.R.Presentation,diagnosisandmanagementofliverabscess.Lancet1980,ii:629-632.5.Krupp,M.I.Antibodyresponseinintestinalandextrain-testinalamoebiasis.AmJTropMedHyg1970,19:57-62.6.Thomas,V.,Sinniah,B.&Yap,P.L.Assessmentofthesensitivity,specificity,andreproducibilityoftheindirectimmunofluorescenttechniqueforthediagnosisofamebiasis.AmJTropMedHyg1980,30(1):57-62.7.Fock,K.M.,Ong,N.T.&Chua,K.L.Liverabscess:atwo-yearstudy.SingaporeMedJ1985,26:350-353.8.Teh,L.B.,Ng,H.S.,Kwok,K.C.etal.Liverabscess-aclinicalstudy.AnnAcadMedSingapore1986,15(2):176-000.9.May,R.P.Difficultiesindifferentiatingamoebicfrompyogenicliverabscess.ArchIntMed1967,119:69-74.copyright. on May 19, 2023 by guest. Protected byhttp://pmj.bmj.com/Postgrad Med J: first published as 10.1136/pgmj.63.741.551 on 1 July 198
7. Downloaded from
PostgraduateMedicalJournal(1987)63,551-554
TropicalMedicine
Liverabscessinthetropics:experienceintheUniversityHospital,KualaLumpur. K.L.Goh,N.W.Wong,M.Paramsothy,M.NojegandK.Somasundaram DepartmentofMedicine,FacultyofMedicine,UniversityofMalaya,59100KualaLumpur,Malaysia.Summary:Wereviewed204casesofliverabscessseenbetween1970and1985.Ninetywerefoundtobeamoebic,24pyogenicandonetuberculous.Thecauseoftheabscessesintheremaining89patientswasnotestablished.Thepatientswerepredominantlymale,Indians,andinthe30-60agegroup.Themajorityofpatientspresentedwithfeverandrighthypochondrialpain.Themostcommonlaboratoryfindingswereleucocytosis,hypoalbnminaemiaand anelevatedserumalkalinephosphatase.Amoebicabscessesweremainlysolitarywhilepyogenicabscessesweremainlymultiple.Complicationswerefewinourpatientsandincludedruptureintothepleuralandperitonealcavitiesandsepticaemicshock.Anoverallmortalityof2.9%wasrecorded.Thedifficultyindiagnosingtheabscesstypeishighlighted.Thesinglemostimportanttestinhelpingusdiagnoseamoebicabscess,presumablythemostcommontypeofabscessinthetropics,istheEntamoebahistolyticaantibodyassay.Thistestshouldbeusedmorefrequentlyinthetropics.
Introduction
LiverabscessisafairlycommondiseaseinMalaysia.Balasegaram'reported442casesseenovera15-yearperiod.Whileitcanbesaidthathisexperienceisthatofareferralsurgicalcentre,manycasesofliverabscessarealsoseenandtreatedinsmallerhospitalsthrough-outthecountry.Thecommontypesofliverabscessseenareamoebicandpyogenicabscess.Althoughitisoftenpresumedthatthemajorityofabscessesseeninthetropicsareamoebicinorigin,theevidenceincriminatingEntamoebahistolyticaasthecausativeagenthasseldombeenproven.2Similarly,culturesforpyogenicorganismsareoftennegative.Wedescribeourexperiencewith204casesofliverabscessseenfrom1970-1985intheUniversityHosp-ital,KualaLumpur.
Materialsandmethods
Adefinitivediagnosisofliverabscesswasmadebasedononeoranycombinationofthefollowing-surgicaldrainageoraspirationofpusfromtheliveroratautopsy,radionuclidescanning,ultrasonographyorcomputedtomographic(CT)scanning.Patientswereconsideredtohaveanamoebicliverabscesswhen(i)E.histolyticatrophozoitesweredemonstratedinabiopsyoftheabscesswall;(ii)E.histolyticatrophozoitesweredemonstratedinthepus;(iii)E.histolyticaantibodytitresweregreaterthan1:64;(iv)anchovysaucewasdrainedfromtheabscess;(v)E.histolyticatrophozoitesorcystswereisolatedinthestoolswithorwithoutahistoryofdysentery;and(vi)patientsrespondedtotreatmentwithanti-amoebicdrugsalone.Patientswereconsideredtohaveapyogenicabscesswhenpusand/orbloodculturesgrewpyogenicorgan-isms,providedtheabovecriteriaforamoebicabscesswerenegativeandtherewasnootherobvioussourceofinfection.Onepatientwasdiagnosedtohaveatuberculousabscesswhenbiopsyoftheabscesswalldemonstratedgranulomaswithacid-fastbacilli.Therewasnoevidenceofpulmonaryormiliarytuberculosis.Patientswereplacedinanindeterminategroupwhenthecriteriafordiagnosisofamoebicorpyogenicabscesswerenotpresentorknown.
A)TheFellowshipofPostgraduateMedicine,1987Correspondence:K.L.Goh,M.B.,B.S.(Mal),M.R.C.P.(UK)Accepted:29January1987copyright. on May 19, 2023 by guest. Protected byhttp://pmj.bmj.com/Postgrad Med J: first published as 10.1136/pgmj.63.741.551 on 1 July 198
7. Downloaded from
552K.L.GOHetal.
TableIClinicalpresentation
AmoebicPyogenicIndeterminateAllabscessesn=90n=24n=89n=204Feverwithchillsandrigors80.079.288.882.7Righthypochondrialpain77.750.078.768.8Epigastricpain14.433.314.620.8Diarrhoeaordysentery19.98.315.914.7Jaundice24.416.717.019.4Tenderhepatomegaly90.087.590.989.8Rightbasaleffusionorcrackles/39.98.332.927.0rub
*Figuresareinpercentagesoftheabscesstype.Results
Of204patientsreviewed,90(44.1%)werefoundtohaveamoebicabscess,24(11.8%)pyogenicabscess,one(0.5%)tuberculousabscesswhile89(43.6%)wereconsideredindeterminate.Themajorityofpatientsweremale,withamaletofemaleratioof6:1.Indianswerethepredominantracialgroupaffectedandcomprised49.5%ofallpatientscomparedwith23.2%ofallhospitaladmis-sions(P<0.01).Theageofpatientsrangedfrom2
yearsto84years.Thepeakincidenceoccurredinthe30-60yearsage-group.Theclinicalpresentationofliverabscessisasshown(TableI).Thecommonpresentingclinicalfeaturesforallabscesstypeswerefeverwithchillsandrigors,righthypochondrialpainandatenderhepatomegaly.Only
asmallproportion(20%)ofpatientshadjaundice.Rightlowerchestsigns,chieflyarightbasaleffusionwereseenin40%ofthepatientswithamoebicabscessandin32.9%ofpatientsintheindeterminategroup.Theincidenceis,however,muchlowerinthepyogenic
group(8.3%).Thehaemoglobinlevelwaslessthan11g/I00mlin53.5%ofthepatientsandthetotalwhitecellcountwaselevatedtoabove11x109/lin81%.Alowserumalbuminleveloflessthan35g/landanelevatedserumalkalinephosphataseofgreaterthan150IU/lwerefoundinabout80%ofpatients.Serumbilirubinandalaninetransaminaselevelswereraisedin29%and24%respectively.Therewasnosignificantdifferencebetweenthepatientgroups.Themostfrequentlyusedradiologicalmodalityindiagnosisandlocalizationofabscesswasradionuclidescanning,utilizedinthree-quartersofthepatients.Recently,ultrasonographyhasbeenincreasinglyutilized.TableIIshowsthelocationofabscessesinthevarioussubgroups.Oftheamoebicabscesses86.5%
weresingle,withthemajorityintherightlobe(77.7%ofthetotal).Ontheotherhand62.6%ofpyogenicabscessesweremultiple.Thefiguresfortheindeter-minategroupapproximatedthatofamoebicabsces-
ses.ThebacteriologyofpyogenicabscessisasshowninTableIII.EscherichiacoliandKlebsiellaspecieswerethemostcommonpyogenicoganismsandtogetheraccountedformorethanhalfoftheorganismsisolated.Predisposingfactorswerelookedforinthe24patientswithpyogenicabscess.In6,therewasevidenceofbiliarydiseasewhiletherewerenoobvious
TableIIAbscesslocation*
AmoebicPyogenicIndeterminate
SingleabscessRightlobe77.725.064.0Leftlobe8.812.513.5 MultipleabscessesRightlobe8.84.27.9Leftlobe1.14.23.4Bothlobes3.354.211.2*Allfiguresinpercentagesoftheparticularabscesstype.copyright. on May 19, 2023 by guest. Protected byhttp://pmj.bmj.com/Postgrad Med J: first published as 10.1136/pgmj.63.741.551 on 1 July 198
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LIVERABSCESSINTHETROPICS553
TableIIIBacteriologyofpyogenicabscess
No.(%)
Escherichiacoli833.3Klebsiellasp.625.0Enterobactersp.312.5Streptococcusmilleri28.3Serratiamarcesens28.3Streptococcusfaecalis,Bac-1eachteroidessp.Citrobactersp.Pseudomonaspseudomallei
precipitatingfactorsintheremainder.Intheindeter-minategroup,abscessesfollowedaperforatedappen-dix,asepticabortionandin2patients,biliarydisease.Nostandardtreatmentprotocolwasadoptedinourpatients.Themajorityweretreatedwithbothantibioticsandanti-amoebicdrugsassoonasthediagnosisofliverabscesswasmade.Thepatientswereusuallyreferredearlyforasurgicalopinion.Theindicationsforneedleaspirationorsurgicaldrainageincludednon-resolutionofclinicalsignsandsymp-
tomswithadequatemedicaltreatment,signsofrup-tureorimpendingruptureoftheabscessandalargesizeofabscessexceeding10cm,especiallywhenlocatedintheleftlobe.Intheamoebicabscessgroup,44.4%ofpatientshadopendrainageand17.7%hadneedleaspirationoftheirabscessescarriedout.Inthepyogenicgroup,70.8%ofabscessesweresurgicallydrainedand8.3%needleaspirated.However,inthelargegroupwithindeterminateabscess27.0%ofpatientshadopendrainageand13.5%,needleaspirationperformed.Complicationswereuncommoninourgroupofpatients;7patientshadperforationsintotheperiton-ealcavity,4hadperforationsintothepleuralcavity.Twopatientswithamoebicabscessdevelopedseverefulminatingcolitisandsepticaemicshockandsuccum-bedtotheillness;bothpatientswereaborigines.Threepatientsinthepyogenicgroupandoneintheindeter-minategroupdiedfollowingsepticaemicshock.Theoverallmortalityratewas2.9%.
Discussion
Whilethediagnosisofliverabscessisreliablymadeonclinicalgroundsandeasilyconfirmedbyradionuclidescanning,ultrasonographyorCTscanning,thediag-nosisofabscesstypeisdifficult.Thisisreflectedbythelargenumberofpatientsplacedintheindeterminate
group.Thereareseveralreasonsforthisproblem.Notallabscessesaredrainedoraspiratedyieldingpusforexamination.Evenifpuswereavailable,amoebacanonlybelocatedwithdifficulty.Biopsyoftheabscesswallisnotalwaysdoneatopendrainage,andagain,ifdone,amoebamaynotbefoundbecausetheydisin-tegrateanddisappearquicklywithprecedinganti-amoebictreatment.3Pusculturesforpyogenicorgan-ismsareaffectedbypreviousantibiotictherapy-oftenthecasewithourpatientswhohavesoughttreatmentbeforecomingtohospital.Furthermore,pusculturesforanaerobicorganismsarenotroutinelydone.Thisispertinentastherearereportsthatanaerobesmayaccountforupto38%ofallpyogenicabscesses.4Associatedorprecedingdysenteryinpatientswithamoebicliverabscessisuncommonwithourpatientsandsodoesnothelpinmakingadiagnosisofamoebicabscess.Anchovysaucewhenaspiratedordrainedishighlycharacteristicofamoebicabscess.However,itmaynotbefoundinallamoebicabscesses.Entamoebahistolyticaantibodyassayisusefulinconfirmingthediagnosisofamoebicabscessastissueinvasionbytheamoebainducesastrongantibodyresponse.5Theindirectimmunofluorescentmethodisusedinourlaboratoryandhasbeenfoundtobehighlysensitive,withareactivityof96%amongconfirmedcasesofliverabscess.6Unfortunatelythistestisstillnotreadilyavailablelocally.Only4seraweretestedintheindeterminategroup;2werenon-reactivewhile2hadtitresof1in16whichwereconsiderednotsignificant.Itislikelythereforethatmanycasesofamoebicabscesswereleftundiagnosedintheindeter-minategroup.Thesexandracedistributionofourgroupofpatientswasverysimilartootherreportsfromthisregion.8'9Malepreponderanceisnotedinourseries.Indianswerethepredominantracialgroupaffectedoverall.ThisisnotsurprisingasthemajorityofIndianpatientsseekingtreatmentinthehospitalcomefromoutlyingareasaroundKualaLumpur,wherehygieneispoor.Clinicalsignsandsymptomswerefairlyreliableandconsistentinhelpingusdiagnoseliverabscess.However,theclinicalfeaturesofamoebicandpyogenicabscesseswereonthewholeremarkablysimilaranddidnothelpusdistinguishbetweenthetwo.Anexceptionistheoccurrenceofrightbasallungsignsin40%ofpatientswithamoebicabscesswhichwasonlypresentin8.3%ofpatientswithpyogenicabscess.Thiscanperhapsbeexplainedbythefactthatthemajorityofamoebicabscesseswereintherightlobeoftheliverwhereitwouldbemostlikelytocauserightbasallungsignsespeciallywhenlocatedinthediaphragmaticsurface.Thehigherproportionofabscessesintherightlobealsoexplainsthehigherratioofrighthypochondrialpaintoepigastricpaininamoebicabscess.Ontheotherhand,inpyogenicabscess,whereasignificantproportionofabscesseswereintheleftlobeorinbothlobes,epigastricpainwaspresentinanincreasedproportionofpatients.Wehaveobservedthatthenumberandlocationofcopyright. on May 19, 2023 by guest. Protected byhttp://pmj.bmj.com/Postgrad Med J: first published as 10.1136/pgmj.63.741.551 on 1 July 198
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abscesseswereusefulinhelpingtodistinguishbetweenamoebicandpyogenicabscess.Asinglerightlobeabscesswasmorelikelytobeamoebicwhilemultipleabscessesinbothlobesweremorelikelytobepyogenic.Thesefindingsareconsistentwiththeobservationsofothers.8'9Notunexpectedly,theGram-negativebacilli,E.coliandKlebsiellawerethemostcommonpyogenicorganismsisolated.Bacteroideswasfoundinonlyonepatientbutasnotedbefore,thedetectionofanaerobicorganismsishamperedbycollectionandinadequateanaerobicculturingtechnique.Onepatienthadsys-temicmelioidosiswithdevelopmentofmultipleliverabscesses;Pseudomonaspseudomalleiwasculturedfrombothbloodandpus.Whileassociatedpredisposingfactorswerefoundinonlysixpatientswithpyogenicabscess,wefoundfourpatientswithdefiniteevidenceofbiliarydiseaseorintra-abdominalsepsisintheindeterminategroup.Thesepatientsarelikelytohavehadpyogenicabsces-ses.Theoverallmorbidityandmortalityratesinourpatientswerelowwhichcouldperhapsbeattributedtoapromptandaggressiveapproachtotreatment.Perforationsintotheperitonealandpleuralcavitiesbutnotintothepericardialsacweredocumented.Itisinterestingtoreporttwocasesoffulminatingamoebiccolitis,anuncommoncomplicationofamoebiasis,occurringwithliverabscess.Deathsamongourpatientsusuallyfollowedoverwhelmingsepticaemia.Finally,wehavealsonotedtheremarkablesimilarityintheepidemiologicaldata,clinicalfeatures,andlaboratoryandradiologicalresultsoftheamoebicandindeterminategroups.Itwouldbetemptingtopresumethatthemajorityofthepatientsintheindeterminategroupwereamoebic.Asamoebicserologicaltestshavebeenshowntobehighlysen-sitive,amoreconclusivediagnosisofamoebicliverabscesscouldhavebeenmadeifthesetestshadbeenperformedonmorepatients.Thiswouldhavebeenextremelyhelpfulinplanningmorepreciseanddefin-itivetreatmentofthedisease,therebycuttingdownoncostsandundesirablesideeffectsoftherapy.
Acknowledgements
WewouldliketothankMrLowTing,DepartmentofMedicine,UniversityofMalaya,forhelpinguspreparethemanuscript.