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Case Reports

Indian Pediatrics 1999; 36:190-192 

Amebic Abscess of Both Liver Lobes: Simultaneous Rupture into Pleura and Stomach


Yogender Singh
Ram Samujh
K.L. Narasimhan
K.L.N. Rao
M. Jayashree*
Sunit Singhi*

 

From the Departments of Pediatric Surgery and Pediatrics, * Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India.

Reprint requests: Dr. K.L.N. Rao, Head Department of Pediatric Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh 160012,lndia.

Manuscript Received: June 10,1998; Initial review completed: July 30, 1998;
Revision Accepted: September 1, 1998.

Amebic liver abscess (ALA) is acommon problem in India(1-4). Approximately 80% of abscesses are solitary, 83% of these are located in the right lobe and 17% are in the left lobe of liver(5). Pleuropulmonary complications of ALA are reported in 20% of cases and rupture into peritoneal cavity or into an intra-abdominal viscus 09Curs in 6-9% of patients(6).

We report a rare case of ALA in whom there was rupture of right lobe abscess into right pleural cavity and left lobe abscess into stomach. Such double rupture has not been. reported earlier and awareness of such a possibility is likely to result in optimal management.

Case Report

An 11-year-old boy was admitted with history of fever and pain in the right upper abdomen of two weeks duration. Three days before admission he felt difficulty in breathing. The chest examination revealed decreased chest movements and decreased air entry on right side. On abdominal examination, the liver was palpable 6 cm below costal margin and intercostal tenderness was present. A complete blood count showed hemoglobin of 5.4 g/dl and white cell count of 41,000 per mm3. Serum transaminase levels were normal. Serum albumin was 2.4 g/dl.

His serum bilirubin was 0.9 mg/dl and pro- thrombin time was 16 seconds (control 13 seconds). Blood urea and creatinine levels were raised on admission but became normal after adequate hydration. The chest roentgenogram showed obliteration of costophrenic angle and the right dome of diaphragm was not clearly demarcated (Fig. 1). Ultrasonography revealed 88 x 50 mm size heterogenous echotexture lesion with irregular walls in the right lobe and 48 x 40 mm size lesion in the left lobe. Ultrasound guided aspiration was tried from both lesions but only a few ml of reddish colored fluid drained and culture of this fluid was sterile. During hospital stay the patient had two bouts of hematemesis which were managed by blood transfusions and cold saline lavage of stomach.

CT scan revealed large abscesses both in right and left lobes of liver (Fig. 2), and com- munication between left lobe abscess and gastric lumen was suspected. For pleural effusion intercostal chest tube drainage was performed but there was no improvement in lung expansion. Exploratory laparotomy revealed large abscess (10 x 8 cm) in right lobe communicating with right pleural cavity and left lobe abscess (5 x 4 cm) communicating with stomach via a large anterior wall peforation. Open drainage of abscess cavities was performed.

Decortication of right pleural cavity was done via a standard thoracotomy incision. Postoperatively the patient had a few spikes of fever and bacterial cultures of all of the abscesses were negative. Amebic serology was positive (1:800). The patient was discharged home after I month of hospitalisation and anti-amebic therapy.


 

Fig. 1. Chest roentgenogram showing fluid in pleural space. Fig.2 CT Scan showing large abscess cavitites in both lobes of liver



Discussion

The basic principle. currently pursued in the treatment of uncomplicated ALA were de- scribed by Rogers in J 922(7). The standard medical treatment includes metronidazole three times daily followed by iodoquinol for 20 days(5). Medical management has been excellent for small ALA; those measuring 5 cm or less in diameter. When no clinical improvement occurs, the abscess is 6 cm or more in diameter, and the patient is septic, or there is an imminent risk of rupture, percutaneous needle aspiration in addition to medical treatment is recommended( 1,8).

Complications of ALA includes secondary infection seen in 22% ofpatients(6) and extra hepatic rupture into pleural cavity, peritoneum, pericardium or intestine(9). Secondary infection of ALA is indisputably an indication for. surgical intervention but a clear consensus has not developed regarding management of ruptured ALA(2). Porras-Ramirez et al.(8) ina study of 32 children recommended surgical treatment in all cases of ALA complicated by rupture, Eggleston and colleagues(3) in 1981 believed that surgery with drainage was indicated for ALA with intra-abdominal rupture. However, Sarda etal.(2) favored conservative management and re- ported less mortality as compared to surgical treatment in patients with intraperitoneal rupture of ALA. Thus, a clear consensus regarding role of surgery in cases of ruptured ALA still eludes us.

In order to avoid complications of ALA the practice should be to have a high index of suspicion for ALA on right upper abdominal quadrant and right lower lung syndromes and to make timely use of therapeutic trials while proceeding towards confirmation of the diagnosis(10).

 

 References

 

1. Ramani A, Ramani R, Kumar MS, Lakhkar BN, Kundaje GN. Ultrasound-guided needle aspiration of amebic liver abscess. Postgrad Med J 1993; 69: 381-383.

2. Sarda AK, Bal S, Sharma AK, Kapur MM. Intra-peritoneal rupture of amebic liver abscess. Br J Surg 1989; 76: 202-203.

3. Eggleston FC. Handa AK, Verghese M. Amebic peritonitis secondary to amebic liver abscess. Surgery 1982; 91: 46-48.

4. Jain NK, Madan A, Sharma TN, Sharma PK, Mandhana RG. Hepatopulmonary amebiasis: Efficacy of various treatment regimen containing dehydroemetime and/or metronidazole. J Assoc Phys India 1990; 38: 269-271.

5. Hibberd PL, Rubin RH. Liver abscess - pyogenic and amebic. In: Oxford Textbook of Surgery, 1st edn. Eds. Morris PJ, Malt RA. Oxford, Oxford. University Press 1994; pp 1179- 1186.

6. Schwartz S1. Liver. In: Principles of Surgery, Vth edn. Eds. Schwartz SI, Shires GT, Spence FC. New York, McGraw-Hill Book Co, 1988; .pp 1337-1340.

7. Rogers L. The varieties and treatment of amebic liver abscess. Lancet 1922; 1: 569-575.

8. Porras-Ramirez G, Hernandez-Herrera MH, Porras-Hernandez JD. Amebic hepatic abscess in children. J Pediatr Surg 1995; 30: 662-664.

9. Greaney GC, Reynolds TB, Donovan AJ. Rupture amebic liver abscess. Arch Surg 1985; 20: 551-561.

10. Reynolds TB. Amebic abscess of the liver. Gastroenterology 1971; 60: 952-954.

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