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CLINICAL MEDICINE JIACM 2003; 4(2): 107-11

Amoebic Liver Abscess


MP Sharma*, Vineet Ahuja**

The intestinal protozoa have gained importance during condition has undergone major changes after the advent
recent years as a result of increasing world travel, of advances in imaging and molecular biology techniques.
economic globalisation, and the growing number of This has also enabled a reappraisal of the disease with
chronically immunosuppressed people. AIDS and the recognition of the wide variety of clinical presentations
increasing use of organ transplants have led to a new and multitude of complications.
population at risk for protozoal infection. Protozoa that
infect the gastrointestinal tract include the parasite Table I : Clinical syndromes associated with E.
Entamoeba histolytica, Giardia lamblia the most common histolytica infection.
cause of waterborne disease outbreaks, and the large Intestinal amoebiasis
group of spore forming parasites (Cryptosporidia, Asymptomatic cyst passers
Cyclospora, Isospora, and Microsporidia) that share a green Acute amoebic colitis
algae symbiont and a predilection for causing chronic - Mucosal disease
diarrhoea in immunocompromised persons. Of these - Transmural disease
intestinal protozoa, Entamoeba histolytica is one of the - Ulcerative postdysentric colitis
most prevalent intestinal protozoa in developing Appendicitis
countries. Amoeboma
Amoebiasis is the infection of the human gastrointestinal Amoebic stricture
tract by Entamoeba histolytica, a parasite that is capable Extraintestinal amoebiasis
of invading the intestinal mucosa and may spread to other Amoebic liver abscess
organs, mainly the liver. Entamoeba dispar, an amoeba Perforation and peritonitis
morphologically similar to E. histolytica also colonises the Pleuropulmonary amoebiasis
human gut and has been recognised recently as a separate Amoebic pericarditis
species with no disease potential1-4. The acceptance of E. Cutaneous amoebiasis
dispar as a distinct but closely related protozoan species
has had a major implication in the epidemiology of It has been observed that the classical description of an
amoebiasis, since most asymptomatic infections are now ALA needs to be modified due to a large number of
attributed to this non-invasive amoeba. E. histolytica patients who present with variants6,7. This may be due to
infection may have intestinal as well as extra-intestinal a better understanding of the pathogenesis and
manifestations (Table I).This review shall address amoebic presentation of the disease or changing patterns of the
liver abscess which is the commonest extra-intestinal disease. Long-term follow up of patients has helped in
manifestation. identifying the factors affecting the healing pattern.
Separation of patients at high risk is of clinical relevance
Amoebic liver abscess so that more aggressive treatment can be instituted.

It is an inflammatory space- occupying lesion of the liver


Clinical presentation
caused by Entamoeba histolytica. The incidence of ALA has
been reported to vary between 3% and 9% of all cases of Amoebic liver abscess occurs most commonly in the age
amoebiasis5. In India ALA is endemic. The diagnosis of this group of 20 to 45 years. It has been noted infrequently at

* Professor, ** Assistant Professor, Department of Gastroenterology,


All India Institute of Medical Sciences, Ansari Nagar, New Delhi-110029.
the extremes of age and is seven to nine times more Variants9
common in males. ALA may present as an acute process
ALA usually occurs in the right lobe of the liver and is
or as a chronic indolent disease. It has been classified by
solitary (30% - 70%). Unusual presentations include
the duration of illness and severity into :
multiple abscesses, left lobe abscesses, abscesses
i. Acute Acute benign presenting as compressive lesion, and abscesses rupturing
into viscera. These are clinically important due to the
Acute aggressive
curable nature of this disease and potentially fatal
ii. Chronic Chronic benign outcome in untreated abscesses.
Chronic accelerated
Multiple liver abscesses : Fifteen per cent of patients may
Most patients present with an acute illness and duration have multiple abscesses.They present with fever, toxaemia,
of symptoms less than 2 weeks. The main presenting deep jaundice, and encephalopathy. Toxaemia is
features are abdominal pain, fever, and anorexia. suggestive of an added bacterial infection leading to a
Abdominal pain is usually moderate and localised to the more severe disease. E.coli and Klebseilla are the
right upper quadrant or to the epigastrium. Diffuse commonly cultured organisms. These patients present
abdominal pain, pleuritic chest pain, and radiation of right with a clinical picture indistinguishable from hepatic
upper quadrant pain to the right shoulder are not encephalopathy due to acute hepatocellular failure.
uncommon. Epigastric pain is commonly seen in left lobe Hepatic encephalopathy in ALA patients possibly results
abscesses. Fever is of moderate degree in most instances, from combination of right hepatic vein occlusion,
while high fever with chills is suggestive of secondary pylophlebitis, and occlusion of several portal vein
bacterial infection. Cough with or without expectoration radicles10,11.
and pleuritic chest pain is also seen in ALA.
Left lobe abscess : Thirty-five per cent of patients present
During the course of illness one-third of patients may with a left lobe abscess. Half of these have associated
develop clinical jaundice. Severe icterus is usually due to lesions in the right lobe while the remaining have solitary
a large abscess or multiple abscesses, or to an abscess left lobe abscess12. These patients have longer duration of
situated at the porta hepatis8. Jaundice raises diagnostic symptoms (3-4 weeks) and fever is less commonly
problems and brings in the possibilities of intra-hepatic observed as compared to right lobe abscesses. It may
obstruction or viral hepatitis. Diarrhoea and weight loss present as a large epigastric mass with minimal movement
are not commonly seen. Unfortunately diarrhoea is such with respiration. Often, to the clinicians despair, it has been
a common complaint in the tropics that it may not be confused with pseudocyst of pancreas. These patients also
given adequate consideration by the patient. Tender have weight loss with poor hepatic localisation of
hepatomegaly is detected in upto 80% of patients. The symptoms. Complications like peritonitis and toxaemia are
liver surface is generally smooth. Upper abdominal significantly more common in left lobe abscess. Needle
guarding and rigidity is seen in a minority of cases with aspiration may be more rewarding in combination with
features of generalised peritonitis. Toxaemia and anti-amoebic drugs. A high index of suspicion and early
septicaemia may be present. diagnosis are important for proper management.

However, it is the protean manifestations of the variants Compression lesions : A posteriorly located ALA in the
that may be a source of consternation to the clinician. A right lobe may present as inferior vena cava
left lobe abscess may manifest as toxaemia, deep jaundice, obstruction or hepatic outflow obstruction13. This is
and encephalopathy. Ascites developing in a patients with suggested by bilateral pedal oedema, ascites, visible
ALA suggests development or presence of inferior vena veins on anterior and posterior abdominal wall, along
cava obstruction, and cough with copious expectoration with clinical, radiological, and serological features of
suggests rupture into the communication with the right ALA. These features disappear after aspiration of the
lower lobe bronchus. abscess.

108 Journal, Indian Academy of Clinical Medicine  Vol. 4, No. 2  April-June 2003
Extension of the abscess : Leakage of the abscess may monoclonal antibodies and detection of parasitic DNA by
occur into the pleural cavity, with empyema thoracis. Intra- use of nucleotide probes and PCR amplification. A
abdominal extension following perforation into the commercial ELISA kit that uses monoclonal antibodies
peritoneal cavity is usually associated with shock and directed against an amoebic adherence lectin and
generalised peritonitis and may occur in upto 7% of cases. accurately differentiates the true pathogen E. histolytica
Rupture into the colon and biliary tree has also been from E. dispar has recently been developed for clinical
reported. A subhepatic collection may also be localised use14. Detection of amoebic lectin antigen in serum
and walled off. Such presentations have however been samples from patients with amoebic liver abscess is also
rare and form a small number of cases in any series in ALA. more than 95% sensitive if used prior to treatment with
metronidazole.
The above clinical patterns have been described more
frequently with the routine availability of ultrasound and
Medical therapy
serological assays. These clinical variants are important
because of their therapeutic and prognostic significance Medical therapy may be instituted using either a single
with the best outcome occurring in patients with solitary agent or a combination of drugs for the extra-luminal
abscess. parasite. Amoebicidal drugs(Table II) may be classified into
3 groups : luminal, tissue, and mixed amoebicides.
Diagnosis Duodohydroxyquin, diloxanide furoate, and paromomycin
are luminal amoebicides. The amoebicides effective in
Ultrasound is very useful for diagnosis of amoebic liver
tissues are emetine and dehydroemetine, which act in the
abscess. The classic appearance is a non-homogeneous,
liver, intestinal wall; alongwith chloroquine which acts only
hypoechoic, round or oval mass with well defined borders.
in the liver. Emetine and dehydroemetine because of their
Complete resolution of an amoebic liver abscess may take
cardiotoxicity are currently not used. Amoebicides
upto two years. Occasionally, percutaneous diagnostic
effective in both tissues and the intestinal lumen include
needle aspiration may be needed to differentiate between
nitroimidazole derivatives-metronidazole, tinidazole, and
amoebic and pyogenic liver abscess.
ornidazole. They are the drugs of choice in invasive
Serology : Serum antibodies to amoebae develop only amoebiasis. Oral or intravenous metronidazole or
during E. histolytica infection and not during E. dispar tinidazole also leads to rapid clinical improvement of
infection.The absence of serum antibodies to E. histolytica amoebic liver abscess15. This drug should be followed by
after 1 week of symptoms is strong evidence against the a luminally active drug.
diagnosis of invasive amoebiasis of the colon or liver.
Table II : Pharmacotherapy for E. histolytica infection
Serum antibodies to amoebae are detected in 85-95% of
in adults.
all patients who present with invasive amoebiasis or liver
 Intraluminal Diloxanide furoate 500 mg tid X 20 days
abscess. However, as antibodies persist for many years,
ELISA or IHA cannot differentiate acute from remote infection Paromomycin 30 mg/kg/day X 10 days
infection in areas of high endemicity. Purified native and (in 3 divided doses)
recombinant parasitic antigens have been utilised in Iodoquinol 650 mg tid X 20 days
serological studies with good results. More than 95% of  Invasive Metronidazole 800 mg tid X 5 days
the patients with amoebic liver abscess have serum colitis Tinidazole 1 gm bd X 3 days
antibodies to the 170 KD subunit of the galactose  Amoebic Metrinidazole 800 mg tid PO X 10 days
inhibitable adherence lectin.This antigen is highly specific liver abscess (500 mg qid IV)
for differentiating acute phase serum from convalescent
phase serum in areas of high endemicity. Nitroimidazoles (including metronidazole) are effective
in over 90% of cases. Therapy should continue for at least
Newer methods : Newer diagnostic strategies involve 10 days. Relapses have been reported with this duration
detection of protein antigens in faeces or serum by of therapy and the drug may be administered for upto 3

Journal, Indian Academy of Clinical Medicine  Vol. 4, No. 2  April-June 2003 109
weeks. The dose of metronidazole is 40 mg/kg/day in disappearance of the sonographic abnormality is 6-9
divided dosages. Tinidazole has been used in a dosage of months. Relapses are very uncommon and the
1.2 g per day for 7 days , but this dosage has not been sonographic abnormality does not warrant continued
firmly established. Chloroquine, emetine, and therapy. The patterns of resolution that have been seen
dehydroemetine may also be used. Single-agent therapy on sonographic follow-up include: type I, where complete
with metronidazole yields excellent results and the disappearance of the cavity occurs within 3 months
alternative toxic drugs are indicated rarely and used (29.8%); type II, where a rapid reduction till 25% of the
mostly in seriously ill patients when the risk of failure of original cavity size and then a delayed resolution occurs
therapy is unacceptable. The response to anti-amoebic (5.9%).
drugs is usually evident within 48-72 hours with the
Factors influencing healing time include the size of
subsidence of toxaemia, abdominal pain, anorexia,
abscess cavity at admission, hypoalbuminaemia, and
jaundice, guarding, and tenderness in the right
anaemia. The type of clinical presentation, nature of
hypochondrium, and hepatomegaly.
therapy, number or location of abscesses, and time for
clinical resolution of multiple liver abscesses are similar
Aspiration or drainage of abscess
to those of solitary abscess and the number of abscesses
Routine aspiration of liver abscess is not indicated for does not significantly influence the healing patterns or
diagnostic or therapeutic purpose16. A combination of rates. The total abscess volume of all the cavities is the
ultrasonographic finding with a positive serology in the most important factor that influences resolution time in
appropriate clinical setting is adequate to start drug multiple abscesses. As clinical resolution does not
therapy. Aspiration has been indicated in the following correlate with ultrasonographic resolution, therefore
circumstances: lack of clinical improvement in 48-72 hours, clinical criteria, rather than ultrasonography, should
left lobe abscess, thin rim of liver tissue around the abscess monitor the result of therapy.
(< 10 mm) and seronegative abscesses17. The aspirate is
anchovy sauce type in half of the patients. The chocolate Prognostic markers
colour is due to admixture of blood with liver tissue.
There are two major categories of patients with ALA: those
Anti-amoebic therapy alone is as effective as routine with a good prognosis and those with a poor prognosis.
needle aspiration combined with anti-amoebic therapy These groups can be easily identified by evaluation of
in the treatment of patients with uncomplicated amoebic clinical, biochemical, and sonographic criteria. Bilirubin
liver abscess18,19. level > 3.5 mg/dL, encephalopathy, volume of abscess
cavity, and hypoalbuminaemia (serum albumin level < 2.0
Surgical intervention g/dL) are independent risk factors for mortality21. The
duration of symptoms and the type of treatment do not
Open surgical drainage is rarely indicated and may be influence mortality.
required in the setting of a large abscess with a poor yield
on needle aspiration or clinical deterioration despite
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