Amebic liver abscess is a complication of amebiasis, which is transmitted via the feco-oral route through infected humans [1]. The incubation period of amebiasis spans from 1 to 4 weeks [2] although it can take days to years [3]. Risk factors for amebic liver abscess include oral-anal intercourse in homosexual men [4], poor hygiene, overcrowding, immigration from endemic regions, and immunosuppression.

The clinical picture is variable, which makes the diagnosis challenging [5]. Amebic liver abscess in endemic regions is associated with an acute illness consisting of fever, weight loss, and abdominal pain [5]. The latter is characterized as a dull, achy, and unremitting pain in the right upper quadrant (RUQ) that radiates to right shoulder or scapula. Pain exacerbation occurs with deep inspiration and coughing. Other manifestations include rigors, nausea, emesis, and diarrhea. Patients may also report a history of dysentery [1]. A minority of patients will exhibit pulmonary symptoms such as coughing and chest pain. When a bronchopleural fistula forms, the productive cough yields brown paste-like substance [6].

Complications

Although uncommon, complications include peritoneal rupture and/or involvement of organs such as the heart and lungs.

Physical exam

Fever is noted in nearly all patients. Remarkable signs on the physical exam include hepatomegaly and tenderness in the RUQ and possibly epigastric region. Also, patients with pulmonary involvement will exhibit rales and diminished breath sounds at the right lung base upon auscultation. If present, peritoneal signs include rebound tenderness, guarding, as well as the absence of bowel sounds. Finally, pleural rub and/or pericardial rub are heard in those with complications.

• Fever

  Common clinical symptoms were fever (93%) and abdominal pain (93%). Common signs were right upper quadrant tenderness (60%), hepatomegaly (67%). [ncbi.nlm.nih.gov]

• Weight Loss

  However, it can invade your colon wall, causing symptoms of: fever colitis fatigue nausea diarrhea tenesmus bloody stools intestinal gas loss of appetite severe dehydration stomach pain, cramping unintentional weight loss These symptoms typically last [healthblurbs.com]

  Amebic liver abscess in endemic regions is associated with an acute illness consisting of fever, weight loss, and abdominal pain. [symptoma.com]

  A 53-year-old man was admitted because of high fever, epigastralgia, back pain, and body weight loss. Abdominal CT scan revealed liver abscess. Abscess fluid by ultrasound-guided transhepatic drainage showed negative for bacterial culture. [ci.nii.ac.jp]

  […] of appetite Sweating Weight loss Antibiotics such as metronidazole (Flagyl) or tinidazole (Tindamax) are the usual treatment for liver abscess. [medlineplus.gov]

  […] of appetite Sweating Weight loss Exams and Tests The health care provider will perform a physical examination. [ufhealth.org]

• Chills

  RESULTS: According to our study, the common clinical symptoms and signs are abdominal pain (85.5 %), fever and chills (74.2 %), and abdominal tenderness (69.4 %). [ncbi.nlm.nih.gov]

  Most of the patients were suffering from abdominal pain (85.5 %), fever and chills (74.2 %), and abdominal tenderness (69.4 %; Table 2 ). [bmcfampract.biomedcentral.com]

  Additional symptoms caused by amebic liver abscess include: chills edema ascites jaundice sweating joint pain Without treatment, amebic liver abscess may rupture and spread into your abdominal cavity, lungs or lung lining, sac around heart and brain. [healthblurbs.com]

  But people with amebic liver abscess do have symptoms, including: Abdominal pain, more so in the right, upper part of the abdomen; pain is intense, continuous or stabbing Cough Fever and chills Diarrhea (in only one-third of patients) General discomfort [medlineplus.gov]

• Malaise

  […] abscess do have symptoms, including: Abdominal pain, more so in the right, upper part of the abdomen; pain is intense, continuous or stabbing Cough Fever and chills Diarrhea (in only one-third of patients) General discomfort, uneasiness, or ill feeling ( malaise [medlineplus.gov]

  Patients may experience general malaise or present with frank sepsis and right upper quadrant pain. [radiopaedia.org]

  Since the introduction of antibiotics, the presentation of pyogenic liver abscess has become less acute, often insidious, and characterized by malaise, low-grade fever, and dull abdominal pain that may increase with movement. [enotes.tripod.com]

• Fatigue

  However, it can invade your colon wall, causing symptoms of: fever colitis fatigue nausea diarrhea tenesmus bloody stools intestinal gas loss of appetite severe dehydration stomach pain, cramping unintentional weight loss These symptoms typically last [healthblurbs.com]

  […] several years Clinical courses Intestinal amebiasis (dysentery) Loose stools with mucus and bright red blood Painful defecation, tenesmus, abdominal pain, cramps, weight loss, and anorexia Fever in 10–30% of cases and possible systemic symptoms (e.g., fatigue [amboss.com]

  These include fever, abdominal pain, fatigue, and nausea with fever being the most common symptom present in up to 90% of cases of pyogenic abscesses. [clinicaladvisor.com]

  The diagnosis was based on: 1) clinical findings (right upper quadrant pain, fever, malaise or fatigue, vomiting, weight loss, hepatomegaly, and/or dehydration signs) 2) sonographic evidence of an abscess (hypoechogenic or anechoic lesion with central [omicsonline.org]

• Cough

  A minority of patients will exhibit pulmonary symptoms such as coughing and chest pain. When a bronchopleural fistula forms, the productive cough yields brown paste-like substance. [symptoma.com]

  Each child presented with a history of fever and gastrointestinal symptoms, and two-thirds presented with cough or difficulty breathing. Most (81%) patients had hepatomegaly on physical examination and some had a well-defined mass. [ncbi.nlm.nih.gov]

  But people with amebic liver abscess do have symptoms, including: Abdominal pain, more so in the right, upper part of the abdomen; pain is intense, continuous or stabbing Cough Fever and chills Diarrhea (in only one-third of patients) General discomfort [medlineplus.gov]

• Pleural Effusion

  Gross fluid derangements including pleural effusion, edema and ascities were observed in 39% cases and 6% had rupture of abscess. All patients were treated with standard antimicrobial regimen and discharged with initial recovery. [ncbi.nlm.nih.gov]

  Pleural Effusion secondary to amoebic liver abscess 14. An amoebic liver abscess causing a bulge in the dome of the diaphragm 15. Amoebic liver abscess burst into the right pleural cavity 16. 17. 18. I. [slideshare.net]

  effusion perihepatic fluid collection gastric or colonic involvement retroperitoneal extension Ultrasound May appear as a hypoechoic lesion with low-level internal echoes and absence of significant wall echoes. [radiopaedia.org]

  In 5 patients, pleural effusion was observed in chest radiographs. IHA titer was ≥128 in 10 patients and ≥512 in 8 patients. Median days to defervescence was 2 (range 1–5 days). [wwwnc.cdc.gov]

  A worse prognosis may be expected when there is a delay in diagnosis; multiple organisms cultured from blood; jaundice; hypoalbuminemia; a pleural effusion; or other associated medical diseases. [enotes.tripod.com]

• Dry Cough

  It was followed by dry cough and occasional chest pain which was pleuritic in nature. He had consulted a local physician and taken empirical antibiotics and antipyretics for the same. [jdeonline.in]

• Abdominal Pain

  We present a case of a previously healthy 43-year-old Canadian man presenting with constitutional symptoms and right upper quadrant abdominal pain. [ncbi.nlm.nih.gov]

• Diarrhea

  They are more likely to be present if the patient has diarrhea as a presenting symptom or has had diarrhea in the recent past. [ncbi.nlm.nih.gov]

  Abdominal cramps, vomiting, diarrhea, and dizziness also may occur. Dark urine may occur from a metabolite of the drug. [emedicine.medscape.com]

• Nausea

  Although paromomycin may occasionally cause nausea, abdominal cramps, or diarrhea, it is the preferred luminal amebicidal. The details on the luminal amebicides are discussed in Medication. [emedicine.medscape.com]

  However, it can invade your colon wall, causing symptoms of: fever colitis fatigue nausea diarrhea tenesmus bloody stools intestinal gas loss of appetite severe dehydration stomach pain, cramping unintentional weight loss These symptoms typically last [healthblurbs.com]

  Other manifestations include rigors, nausea, emesis, and diarrhea. Patients may also report a history of dysentery. A minority of patients will exhibit pulmonary symptoms such as coughing and chest pain. [symptoma.com]

  The incidence of nausea and metallic taste was significantly lower in the patients given satranidazole (P < .005). [ncbi.nlm.nih.gov]

  Occasional side effects include nausea and dizziness. Tinidazole is not widely available though it is more effective than metronidazole. [en.wikipedia.org]

• Loss of Appetite

  However, it can invade your colon wall, causing symptoms of: fever colitis fatigue nausea diarrhea tenesmus bloody stools intestinal gas loss of appetite severe dehydration stomach pain, cramping unintentional weight loss These symptoms typically last [healthblurbs.com]

  […] of appetite Sweating Weight loss Antibiotics such as metronidazole (Flagyl) or tinidazole (Tindamax) are the usual treatment for liver abscess. [medlineplus.gov]

  […] of appetite Sweating Weight loss Exams and Tests The health care provider will perform a physical examination. [ufhealth.org]

• Right Upper Quadrant Tenderness

  Common signs were right upper quadrant tenderness (60%), hepatomegaly (67%). Most of the patient had single abscess (80%) and location of abscess was predominantly in the right lobe (77%). [ncbi.nlm.nih.gov]

• Hepatomegaly

  Most (81%) patients had hepatomegaly on physical examination and some had a well-defined mass. [ncbi.nlm.nih.gov]

• Liver Tenderness

  tenderness, liver span, TLC, and ALT on days 8 and 15 in Groups 1 and 2. [tropicalgastro.com]

  RESULTS: (i) Mean body temperature, liver tenderness, total leukocyte count (TLC), serum alanine aminotransferase (ALT) and liver span were significantly decreased in the aspiration group on days 8 and 15 as compared to non-aspiration group especially [ncbi.nlm.nih.gov]

  Physical examination: Fever (low-grade or high spiking) Hepatomegaly and liver tenderness, which is accentuated by movement or percussion. Splenomegaly is unusual, except with a chronic abscess. [enotes.tripod.com]

• Liver Mass

  Abdominal computed tomographic scan showed an enlarged liver mass, and massive pericardial effusion suggested cardiac tamponade. [ncbi.nlm.nih.gov]

• Night Sweats

  Night sweats. Nausea and vomiting. Anorexia and weight loss. Cough and dyspnoea due to diaphragmatic irritation. Referred pain to the right shoulder. [patient.info]

Patients suspected to have an amebic hepatic abscess are assessed with a review of their personal history and risk factors, physical exam findings, and the appropriate studies.

Laboratory tests

The workup should include a complete blood count (CBC), which will likely reveal leukocytosis and possibly anemia. Furthermore, analysis of liver function tests (LFTs) in acute illness will reflect elevated aspartate aminotransferase (AST) levels while cases of chronic liver abscess are associated with normal AST levels and increased alkaline phosphatase. The latter is typically high in most cases.

Diagnostic tests

Since most individuals with amebic liver abscess do not have coexistent intestinal amebiasis, only a small percentage will have detectable cysts in stool [5] [7]. Hence, stool analysis is not typically useful. Among the various stool studies, antigen or DNA detection of E. histolytica is the preferred diagnostic technique [5].

Serologic studies, which are commonly used to diagnose an amebic liver abscess, yield positive results despite a discrepancy with negative stool tests [8]. The enzyme immunoassay (EIA) test is sensitive, rapid and inexpensive [9]. Also, an amebic liver abscess can be diagnosed through the detection of the E. histolytica galactose lectin antigen using enzyme-linked immunosorbent assay (ELISA). This method is sensitive and rapid [1]. Additionally, there are antibody and antigen point-of-care tests currently under investigation [10].

Imaging

A liver abscess can be detected by various imaging modalities although they do not identify the etiology (amebic versus pyogenic ) [5]. Abdominal ultrasonography, the recommended initial study, demonstrates a sensitivity of 75% to 90% and differentiates an abscess from solid lesions such as tumors. Computed tomography (CT) scan is associated with an up to 95% sensitivity and contrast-enhancement helps distinguish an abscess from a tumor. Magnetic resonance imaging (MRI), like CT, is sensitive but not specific for the diagnosis of an abscess.

Other

Percutaneous needle aspiration of the hepatic abscess can be performed if needed [11].

• Atelectasis

  When an abscess is situated near the dome of the liver, the patient may experience pain in the right shoulder or a cough as a result of diaphragmatic irritation or atelectasis. [enotes.tripod.com]

  May be atelectasis or pleural effusion. Ultrasonography can show abscess and also allow guided percutaneous aspiration and drainage. Aspirated fluid should be sent for culture and sensitivity. It also allows biliary tree examination. [patient.info]

• Multiple Liver Cysts

  No patients were under the age of 40. [ 1 ] Cystic lesions of the liver include: Simple cysts. Multiple cysts due to polycystic liver disease. Neoplastic cysts. Hydatid (echinococcal) cysts. Abscesses. [patient.info]

• Pleural Effusion

  Gross fluid derangements including pleural effusion, edema and ascities were observed in 39% cases and 6% had rupture of abscess. All patients were treated with standard antimicrobial regimen and discharged with initial recovery. [ncbi.nlm.nih.gov]

  Pleural Effusion secondary to amoebic liver abscess 14. An amoebic liver abscess causing a bulge in the dome of the diaphragm 15. Amoebic liver abscess burst into the right pleural cavity 16. 17. 18. I. [slideshare.net]

  effusion perihepatic fluid collection gastric or colonic involvement retroperitoneal extension Ultrasound May appear as a hypoechoic lesion with low-level internal echoes and absence of significant wall echoes. [radiopaedia.org]

  In 5 patients, pleural effusion was observed in chest radiographs. IHA titer was ≥128 in 10 patients and ≥512 in 8 patients. Median days to defervescence was 2 (range 1–5 days). [wwwnc.cdc.gov]

  A worse prognosis may be expected when there is a delay in diagnosis; multiple organisms cultured from blood; jaundice; hypoalbuminemia; a pleural effusion; or other associated medical diseases. [enotes.tripod.com]

• Pleural Rub

  Finally, pleural rub and/or pericardial rub are heard in those with complications. [symptoma.com]

  Diaphragmatic irritation from abscess might refer pain to the right shoulder or result in cough or pleural rub. Classified by presumed origin: Bacterial: Up to 50% develop from biliary tract ( cholangitis ). [hopkinsguides.com]

Such drainage has proved to be safe provided that the patient is receiving antiamebic drug treatment. [ncbi.nlm.nih.gov]

Extensive venous thrombosis is usually seen postmortem in amebic liver abscess because of its dismal prognosis. [ncbi.nlm.nih.gov]

Prognosis The mortality rate for patients with hepatic abscesses treated with antibiotics and percutaneous drainage is 16%. [enotes.tripod.com]

How has the prognosis of these patients evolved? To answer these questions, this study examined a sample of patients diagnosed with ALA in a regional referral center from the West of Mexico. [omicsonline.org]

Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. [icd10coded.com]

Amebic pericarditis is an extremely rare complication of liver abscess and an uncommon etiology of sterile pericardial effusion with cardiac tamponade. [ncbi.nlm.nih.gov]

Imaging A liver abscess can be detected by various imaging modalities although they do not identify the etiology (amebic versus pyogenic ). [symptoma.com]

PubMed Google Scholar Branum GD, Tyson GS, Branum MA, Meyers WC: Liver abscess: changes in etiology, diagnosis, and management. Ann Surg. 1990, 212: 655-62. [bmcfampract.biomedcentral.com]

Epidemiologically, amebiasis occurs in clusters in the United States with person-to-person transmission predominant in spread. Infection is associated with poor sanitation and crowding. [ncbi.nlm.nih.gov]

This article reviews epidemiologic features, pathophysiology, clinical features, diagnostic tests, imaging studies, treatment of amebic liver abscess, and prevention measures. [ncbi.nlm.nih.gov]

Chronic alcoholics - prone to get this infection Entamoeba histolytica is endemic in many parts of the world Pathophysiology The amoebic cyst is ingested Cyst develops into the trophozoite form in the colon Reaches the liver through portal circulation [slideshare.net]

Singh V, Bhalla A, Sharma N, et al ; Pathophysiology of jaundice in amoebic liver abscess. Am J Trop Med Hyg. 2008 Apr78(4):556-9. [patient.info]

References: [1] [3] Pathophysiology Clinical features Incubation period Intestinal amebiasis : 1–4 weeks Extraintestinal amebiasis : a few weeks to several years Clinical courses Intestinal amebiasis (dysentery) Loose stools with mucus and bright red [amboss.com]

This article reviews epidemiologic features, pathophysiology, clinical features, diagnostic tests, imaging studies, treatment of amebic liver abscess, and prevention measures. [ncbi.nlm.nih.gov]

A drug such as paromomycin or diloxanide must also be taken to get rid of all the ameba in the intestine and to prevent the disease from coming back. This treatment can usually wait until after the abscess has been treated. [ufhealth.org]

Standard treatment for amebiasis is typically metronidaloze, an antibiotic. and there’s no vaccine to prevent this variety of dysentery . [healthblurbs.com]

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