Amoebic liver abscess: The Evolving Concept Of Management

Afzal Anees; M.A. Khan; M.I. Zea; A. Pervez; M. Khalid

摘要

BackgroundAmoebic liver abscess (ALA) affects mainly rural, male population in endemic zone. Ultrasound guided aspiration and other surgical intervention is still a wide practice by treating personnel in all cases of ALA. Perhaps this approach further aggravates the suffering. So, aim was to evaluate the treatment protocol for ALA in order to have some guidelines in the management of ALA at our place.Methods and material86 confirmed cases of ALA were treated according to the formulated protocol. Follow up was done and analysis was carried out.Results82% cases were treated by drug therapy only. In ALA of < 500ml size, success rate of non invasive management was 98.1%. Conclusion 80% cases may be treated by medical treatment. Adjunct Surgical intervention required in a very few complicated cases. Percutaneous catheter drainage is a viable option in drug resistant cases. Introduction The Entamoeba involves about 10% of world population, fortunately only 10% of infected cases develop the clinical syndrome of amoebic manifestation. 1 Out of this, only 3-9% cases develop amoebic liver abscess (ALA). The incidence is definitely 3-5 times more in developing countries of tropical regions. The prevalence is as high as 50% in endemic regions. According to one study estimated 40,000 deaths occur annually because of invasive amoebiasis. 2 Poor socio-economic status, poor sanitation, over crowding, unsafe drinking water, cultural habits are still the predisposing factors in a developing countries. The morbidity increases and at time mortality occurs if diagnosis is delayed. Drug therapy alone is the mainstay of management. However there is wide practice of aspiration and drainage in all cases with belief that aspiration hastens the clinical recovery with no procedural morbidity as supported by a study. 3 Whereas other have shown that aspiration has no impact on clinical recovery. 4 This study was undertaken to evaluate the easily available ultrasonography both as diagnostic and therapeutic tool and to evaluate the treatment protocol of amoebic liver abscess as suggested by world literature. Material And Method Our Institution, a tertiary centre in northern India providing health care to adjoining 8-10 rural districts, located in endemic zone for amoebiasis. Between Dec.2003 to nov.2006, we came across 130 suspected cases of amoebic liver abscess. Out of this, 86 patients were confirmed for ALA. Diagnosis of ALA was made on history, examination, ultrasonography and if required diagnostic aspiration. Serological test was not done routinely being endemic region and financial constraints. Other routine investigations including X-ray chest were carried out in all patients. Culture and sensitivity was reserved for suspected secondary infection. Treatments were given according to the criteria formulated on basis of different clinical trails.Selection Criteria Suggestive clinical presentation. USG finding in all cases. Diagnostic aspiration if required. CT scan was deferred in selected cases. Inclusion Criteria All patients of amoebic liver abscess. Patients received the complete treatment. Patients came for follow up as advised. Exclusion Criteria Patients of pediatric age group. Patients who later diagnosed as having other disease. Patients lost on early follow up Patients having pyogenic liver abscess. USG Criteria For Diagnosis Wall – echo poor, fine echogenic, or thick echogenic Content – hyper and hypo echoic mixed pattern, homogenous hypo echogenic pattern, hypo echoic and anechoic pattern Associated right pleural effusion as evidence of rupture Aspiration of typical anchovy sauce pus under ultrasound guidance Treatment Modalities Four groups of different treatment modalities were formed. Drug therapy only USG guided aspiration + Drug. Percutaneous Catheter Drainage (PCD) + Drug. Laparotomy and drainage + Drug Criteria For Conservative Treatment Only All non complicated abscesses. No features of rupture /impeding rupture. No compression effe

机译：背景阿米巴肝脓肿（ALA）主要影响流行地区的农村男性人口。在所有ALA病例中，通过对人员进行治疗，超声引导抽吸术和其他手术干预仍然是广泛的实践。也许这种方法进一步加剧了痛苦。因此，本研究旨在评估ALA的治疗方案，以期对ALA的治疗提供指导。根据制定的方案，对ALA的方法和材料进行了86例确诊。结果：82％的病例仅接受药物治疗。在小于500毫升的ALA中，无创治疗的成功率为98.1％。结论80％的病例可以通过药物治疗。在极少数复杂的情况下需要辅助手术干预。经皮导管引流在耐药病例中是可行的选择。简介Entamoeba约占世界人口的10％，幸运的是，只有10％的感染病例发展了阿米巴病表现的临床综合征。 1其中只有3-9％的病例会发生阿米巴肝脓肿（ALA）。在热带地区的发展中国家，发病率肯定是其3-5倍。流行地区的患病率高达50％。根据一项研究，由于侵入性阿米巴病，估计每年有40,000例死亡。 2社会经济地位低下，卫生条件差，拥挤，饮用水不安全，文化习惯仍然是发展中国家的诱因。如果延迟诊断，发病率会增加，并且有时会导致死亡。药物治疗本身就是管理的支柱。然而，在所有情况下都存在广泛的抽吸和引流实践，并相信，抽吸能够促进临床康复，并且没有研究支持的程序性发病率。 3其他研究表明，抽吸对临床恢复没有影响。 4这项研究的目的是评估易于诊断的超声作为诊断和治疗工具，并评估世界文献所建议的阿米巴性肝脓肿的治疗方案。资料和方法我们的机构是印度北部的一家第三中心，为阿米巴病流行区附近的8-10个农村地区提供卫生保健。在2003年12月至2006年11月之间，我们发现了130例疑似阿米巴肝脓肿病例。其中，有86名患者被确认患有ALA。根据病史，检查，超声检查和必要的诊断穿刺诊断ALA。由于流行地区和经济状况的限制，没有定期进行血清学检查。所有患者均进行了其他常规检查，包括X光胸片检查。培养和敏感性保留用于疑似继发感染。根据不同的临床试验制定的标准给予治疗。选择标准提示临床表现。 USG在所有情况下均能找到。诊断抽吸（如果需要）。在某些情况下，CT扫描被推迟。纳入标准所有阿米巴肝脓肿患者。患者接受了完整的治疗。患者按照建议进行随访。排除标准小儿年龄组的患者。后来被诊断患有其他疾病的患者。早期随访失败的患者化脓性肝脓肿的患者。 USG诊断壁标准–回声差，回声细或厚回声含量–高回声和低回声混合模式，均一的低回声模式，低回声和无回声模式伴有右胸腔积液作为破裂的证据超声下典型an鱼酱脓液的抽吸指导治疗方式形成了四组不同的治疗方式。仅USG指导的药物治疗+药物治疗。经皮导管引流（PCD）+药物。剖腹和引流+保守治疗的药物标准所有非复杂性脓肿。没有破裂/阻碍破裂的特征。无压缩效果

Amoebic liver abscess: The Evolving Concept Of Management

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