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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 26  |  Issue : 2  |  Page : 193-196

Clinical and microbiological profile of liver abscess


Department of General Surgery, Government Medical College, Kozhikode, Kerala, India

Date of Submission03-Aug-2020
Date of Decision13-Aug-2020
Date of Acceptance14-Oct-2020
Date of Web Publication07-Nov-2020

Correspondence Address:
Dr. Afrah Abdurahman
Alfauz 20/1440C, VKK Menon Road, Kallai Post, Kozhikode - 673 003, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ksj.ksj_14_20

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  Abstract 


Introduction: Liver abscess may be due to bacterial, parasitic or mixed infection in the parenchyma. Materials and Methods: A cross-sectional study was directed on 51 patients admitted in one of the government medical colleges for liver abscess over 1½ years. Pertinent clinical history, physical examination and investigations were done, and the patients were exposed to ultrasound-guided needle aspiration of liver abscess. Results: The majority of the pyogenic liver abscess (PLA) patients were 40–60 years old. Males accounted for 90.2% compared to females, 9.8%. The most common symptoms were abdominal pain and fever present in 88.2% and 64.7%, respectively. Dyspnoea was present in 9.8% of the patients and pleural effusion in 17.6%. Hepatomegaly was the most common sign, followed by jaundice in 11.8% and ascites in 2% of the patients. All patients had involvement of the right lobe of the liver, with segment 7 being the most commonly involved segment (66.7%). Single abscess cavity was seen in 33% of the patients. Pyogenic abscess was more common than amoebic liver abscess (39.2%). In pyogenic abscess, the most common organism cultured was Klebsiella (39.2%). Conclusion: The majority of the patients were young males suffering from alcoholism and belonged to the lower socioeconomic group with PLAs that presented as multiple right lobe abscesses. The seventh segment was the segment most commonly implicated. In female patients, the liver abscess was rare. The average age of patients was in the forties, and the rate of mortality in patients in the seventh decade was increased. Klebsiella was the most prevalent cultured organism. Perhaps, low overall mortality was because of the use of minimally invasive drainage procedures and appropriate antimicrobials for aetiology in all patients.

Keywords: Amoebic liver abscess, liver abscess, pyogenic liver abscess, ultrasound-guided aspiration


How to cite this article:
Abdurahman A, Soman K C, Sreekanth S. Clinical and microbiological profile of liver abscess. Kerala Surg J 2020;26:193-6

How to cite this URL:
Abdurahman A, Soman K C, Sreekanth S. Clinical and microbiological profile of liver abscess. Kerala Surg J [serial online] 2020 [cited 2020 Nov 30];26:193-6. Available from: http://www.keralasurgj.com/text.asp?2020/26/2/193/300223




  Introduction Top


The general liver abscess aetiological agents are bacterial (pyogenic), Mycobacterium tuberculosis, Entamoeba histolytica (amoebic) and various fungi. Amoebic liver abscess (ALA) is primarily a disease of developing countries. They appear to affect the young population, particularly males with common complaints, abdominal pain, fever and loss of weight. It is also a significant cause of unexplained fever. In developing countries, around two-third of the cases are of amoebic aetiology; in developed countries, three-fourths are pyogenic.[1] Coexisting diarrhoea emerges in 30% of the patients, and it is quite rare to find amoebic trophozoites in stool samples.[2]

At present, amoebiasis is the third most prevalent cause of death from parasite diseases.[3] The disease is widespread due to inadequate sanitary conditions and overcrowding in tropical countries. Of all amoebiasis cases, ALA contributes to 3%–9%.[4] Biliary and colonic infection, recent gastric or duodenal surgery, haematogenous seeding, local trauma and pancreatitis are the most common causes of liver abscess. Recent studies have demonstrated the polymicrobial nature of these Enterococcus spp. infections. The primary isolates are the anaerobic bacteria.[5],[6],[7],[8],[9] Nevertheless, no connection between the microbial isolates and the predisposing conditions was identified in most of these studies.[9] In addition, the methods for isolating anaerobic bacteria were either not described or insufficient, which could result in the failure to extract all anaerobes present and the isolated species being incompletely defined.[8]

Surgical management was the mainstay for treating liver abscesses earlier.[1] Nowadays, more invasive surgical treatment has increasingly been replaced by image-guided percutaneous aspiration and abscess drainage as the first-line therapy for liver abscess. Percutaneous drainage technique has lowered the average length of hospital stay relative to the traditional treatment process.[9] The present study's concept was to assess the clinical profile and microbiological aetiology of patients diagnosed with liver abscess.


  Materials and Methods Top


Fifty-one patients diagnosed of liver abscess at the Department of General Surgery in a Government Medical College for 18 months from January 2017 to June 2018 were included in the study. Inclusion criteria included patients above the age of 12 years diagnosed with liver abscess of size ≥5 cm. Patients and pregnant women having organised abscess or abscesses in the close proximity to large vascular structures in the liver were excluded from the study. Prior approval was obtained from the ethics committee of our institute, and written informed consent was obtained from all patients.

After diagnosing the disease clinically and radiologically, patients were subjected to detailed history, clinical and radiological examination. Patients were enquired in detail about the clinical symptoms. Patients' general condition was assessed. Detailed clinical examination was done. A complete test for liver function, kidney function and coagulation profile (prothrombin time/international normalised ratio), haemogram, blood culture and culture of urine were submitted. Tests for HIV, hepatitis B and hepatitis C viruses were carried out. All the patients received a chest radiogram. Patients with expectorated cough symptoms were exposed to acid-fast bacillus (AFB) sputum using Ziehl–Neelsen (ZN) staining to rule out pulmonary Koch's. All patients have had ultrasound-guided liver abscess aspiration. Aspirate was collected in sterile containers and immediately sent to the AFB for microscopic examination of wet mount for E. histolytica trophozoites, Gram's staining and ZN stain.


  Results Top


The age varied from 14 to 73 years. Of the 51 patients, males were 46 (90.2%) and females 5 (9.8%). Abdominal pain was the most common symptom noted in 45 of the 51 patients [Figure 1]. Hepatomegaly was the most common sign noted in 21 patients (41.2%), followed by pleural effusion in 9 patients (17.6%) and ascites in 1 (2%). On ultrasonography, 34 (67.7%) had multiple abscesses in the right lobe and 17 (33.3%) had solitary cavities. Segment 7 was the most commonly involved segment [Table 1]. In the blood investigation, the total count was elevated in 25 patients and liver function test deranged in 6 patients. On culturing the pus, 20 were sterile [Table 2]. Among the 31 positive cultures [Figure 2], Klebsiella (29%), Escherichia coli (22.6) and Enterobacter (25.8%) were the main organisms, followed by anaerobic (9.7%), Pseudomonas (6.5%) and Streptococcus (3.2%). Appearance of the aspirate was purulent in 34 samples (67.7%) and the rest (33.3%) had anchovy sauce appearance.
Figure 1: Percentage of various symptoms

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Table 1: Frequency and percentage of the liver segments involved

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Table 2: Percentage of organisms in pus culture

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Figure 2: Percentage of microorganisms in pyogenic liver abscess

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  Discussion Top


The three main aetiologically identified causes of hepatic abscesses are pyogenic, fungal and amoebic. Given the increasing prevalence of pyogenic liver abscess (PLA) and its serious complications, early detection and prompt treatment form the standard of care.[2] E. coli, Klebsiella pneumoniae, Bacteroides, enterococci, streptococci and staphylococci are the most common pathogens of pyogenic hepatic abscesses. K. pneumoniae has overtaken E. coli over the past three decades to become the primary cause of PLA. Our data indicated that PLA-associated predominant pathogen K. pneumoniae was present in 29% of the culture-positive PLA patients which is followed by Enterobacter.

The majority of the cases were pyogenic presenting as multiple right lobe abscesses. Similar studies from New Delhi by Ghosh et al.[10] and by Mukhopadhyay et al.[11] showed a preponderance of ALA which were typically right lobe and solitary abscess. Most of the patients were young males suffering from alcohol addiction from lower socioeconomic class as per the previous research.[11] The age prevalence and gender differences may result from the high intake of alcohol by young males predisposing them to ALA. Alcohol represses liver Kupffer cells which play an important role in the clearing of amoeba. Because of good hygiene in temperate climatic regions, ALAs are rare and PLAs are aetiologically more widespread in the west. The most common aetiological agents were Gram-negative organisms. In a study by Singh et al., negative culture reports were obtained from 42 of 60 patients.[12]

In study by Kemparaj and Rehan,[13] 72% of the ALA cases were registered. Eighty per cent of the cases identified right side solitary abscess, segment VII being the most common, followed by segment VI, 18% in the left lobe and 2% in both lobes. The median patient age was 42.25 years. The ratio of male to female was 7.33:1. In this study, the most common clinical symptoms were abdominal pain and fever in 96% and 82% of the patients, respectively. Ghosh et al. reported fever in 99% of the cases, and in 78% of the cases, Sharma et al. reported abdominal pain. Thirty-nine per cent reported cough and 35% pleural effusion. According to Ghosh et al., 30% of the cases reported cough and 3.5% of the cases reported cough in Sharma et al. In 24% of the cases, Mukhopadhyay et al.[11] report pleuropulmonary involvement. The most common complication of ALA is pleuropulmonary involvement identified in 20%–30% of the patients. Patients with malignancy and those needing open surgery had a higher mortality risk.[14]

In our study, Klebsiella was the most prevalent pathogen which in previous studies was E. coli. Most of the patients suffering from PLA fall in the age group of 40–60 years, which is also similar to previous studies. Males accounted for 90.2% compared to females, which was 9.8%. The most frequent symptoms were abdominal pain and fever that occurred in 88.2% and 64.7% of our patients, respectively. Another rare condition included dyspnoea and cough resulting from pleural effusion and deterioration of the lung parenchyma. Other causes include complications such as abscess rupture in the pleural cavity. Dyspnoea was present in 9.8% of the patients as compared to 16% in previous studies. Pleural effusion occurred in 17.6% as compared to 30% in previous research. In general, the effusion was due to reactive pathology because it vanished spontaneously after the abscess was treated. Jaundice and ascites are two rare symptoms of liver abscess. Sepsis, alcoholic liver disease, hepatocellular dysfunction and related hepatitis are possible pathogenic processes which can contribute to jaundice. The findings are detailed in [Table 3].
Table 3: Comparing results of previous studies with present one[10],[12],[13],[14]

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  Conclusions Top


The most frequent occurrence in our study was young male with PLA presenting as multiple right lobe abscesses. Alcohol addiction and low socioeconomic status were other features. The seventh segment is the segment most commonly implicated. In female patients, occurrence is rare. The average age of the patients was in the 40s, and the increased rate of death was observed in patients in the seventh decade. Cough and dyspnoea as symptoms point to considerable pleural effusion associated with it. Probably low overall mortality was due to the use of minimally invasive drainage techniques and specific antimicrobials for aetiology in all patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ochsner A, Bakey M, Murray S. Pyogenic abscess of the liver. An analysis of forty-seven cases with review of the literature. Am J Surg 1938;40:292-319.  Back to cited text no. 1
    
2.
Branum GD, Tyson GS, Branum MA, Meyers WC. Hepatic abscess. Changes in etiology, diagnosis, and management. Ann Surg 1990;212:655-62.  Back to cited text no. 2
    
3.
Greenstein AJ, Lowenthal D, Hammer GS, Schaffner F, Aufses AH Jr. Continuing changing patterns of disease in pyogenic liver abscess: A study of 38 patients. Am J Gastroenterol 1984;79:217-26.  Back to cited text no. 3
    
4.
Cuschieri A, Giles GR, Moosa AR. Essential Surgical Practice. 3rd ed. London, UK: Butterworth Heinermann; 1995.  Back to cited text no. 4
    
5.
Rustgi AK, Richter JM. Pyogenic and amebic liver abscess. Med Clin North Am 1989;73:847-58.  Back to cited text no. 5
    
6.
Gyorffy EJ, Frey CF, Silva J Jr., McGahan J. Pyogenic liver abscess. Diagnostic and therapeutic strategies. Ann Surg 1987;206:699-705.  Back to cited text no. 6
    
7.
Shimada H, Ohta S, Maehara M, Katayama K, Note M, Nakagawara G. Diagnostic and therapeutic strategies of pyogenic liver abscess. Int Surg 1993;78:40-5.  Back to cited text no. 7
    
8.
McDonald MI, Corey GR, Gallis HA, Durack DT. Single and multiple pyogenic liver abscesses. Natural history, diagnosis and treatment, with emphasis on percutaneous drainage. Medicine (Baltimore) 1984;63:291-302.  Back to cited text no. 8
    
9.
Yu SC, Ho SS, Lau WY, Yeung DT, Yuen EH, Lee PS, et al. Treatment of pyogenic liver abscess: Prospective randomized comparison of catheter drainage and needle aspiration. Hepatology 2004;39:932-8.  Back to cited text no. 9
    
10.
Ghosh S, Sharma S, Gadpayle AK, Gupta HK, Mahajan RK, Sahoo R, et al. Clinical, laboratory, and management profile in patients of liver abscess from northern India. J Trop Med 2014;2014:142382.  Back to cited text no. 10
    
11.
Mukhopadhyay M, Saha AK, Sarkar A, Mukherjee S. Amoebic liver abscess: Presentation and complications. Indian J Surg 2010;72:37-41.  Back to cited text no. 11
    
12.
Singh S, Chaudhary P, Saxena N, Khandelwal S, Poddar DD, Biswal UC. Treatment of liver abscess: Prospective randomized comparison of catheter drainage and needle aspiration. Ann Gastroenterol 2013;26:332-9.  Back to cited text no. 12
    
13.
Kemparaj T, Rehan M. Liver abscess presentation and management retrospective study. ISJ 2017;4:550-4.  Back to cited text no. 13
    
14.
Lok KH, Li KF, Li KK, Szeto ML. Clinical profile, microbiological charactersitics and management of pyogenic liver abscess in Hong Kong. J Microbiol Immunol Infect 2008;41:483-90.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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