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Amebic Liver Abscess

Amebic liver abscess results as a complication of an amebic infection. It is diagnosed through evaluation of clinical and epidemiologic factors as well as serologic and possibly imaging studies.


Presentation

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]
  • CONCLUSIONS: In travelers with fever, abdominal pain, and hepatomegaly amebic liver abscess must be considered. Medical treatment with metronidazole is effective in more than 90%.[ncbi.nlm.nih.gov]
  • Patients with complaints of fever and right upper quadrant abdominal pain, especially men of Hispanic origin, warrant a high degree of vigilance.[ncbi.nlm.nih.gov]
  • We report a patient who presented with fever, jaundice and tender hepatomegaly and on investigation was found to have coexisting acute hepatitis E and amebic liver abscess. Incidentally, he was also an HBsAg carrier.[ncbi.nlm.nih.gov]
  • At presentation, he had pain in the right upper abdominal quadrant (RUAQ) with guarding and rigidity, accompanied by fever, vomiting and dyspnea. A diagnosis of ruptured amebic liver abscess (ALA) was made.[ncbi.nlm.nih.gov]
Weight Loss
  • Amebic liver abscess in endemic regions is associated with an acute illness consisting of fever, weight loss, and abdominal pain.[symptoma.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]
  • loss Antibiotics such as metronidazole (Flagyl) or tinidazole (Tindamax) are the usual treatment for liver abscess.[medlineplus.gov]
  • 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]
  • 28 (45.2 %) Abdominal tenderness 43 (69.4 %) 14 (22.6 %) 29 (46.8 %) Anorexia 39 (62.9 %) 14 (22.6 %) 25 (40.3 %) Hepatomegaly 37 (59.7 %) 14 (22.6 %) 23 (37.1 %) Jaundice 25 (40.3 %) 9 (14.5 %) 16 (25.8 %) Nausea 23 (37.1 %) 8 (12.9 %) 15 (24.2 %) Malaise[bmcfampract.biomedcentral.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]
  • 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]
  • ., fatigue) High risk of recurrence, e.g., through self-inoculation (hand to mouth) A chronic form is also possible, which is clinically similar to inflammatory bowel disease.[amboss.com]
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]
  • Cough (16%), chest pain (19%), and chest radiographic abnormalities (57%) were also common. The majority of patients (69%) had symptoms for less than 13 days.[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]
  • 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]
  • 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]
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
  • Common clinical symptoms were fever (93%) and abdominal pain (93%). Common signs were right upper quadrant tenderness (60%), hepatomegaly (67%).[ncbi.nlm.nih.gov]
  • CONCLUSIONS: In travelers with fever, abdominal pain, and hepatomegaly amebic liver abscess must be considered. Medical treatment with metronidazole is effective in more than 90%.[ncbi.nlm.nih.gov]
  • 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]
  • Patients with complaints of fever and right upper quadrant abdominal pain, especially men of Hispanic origin, warrant a high degree of vigilance.[ncbi.nlm.nih.gov]
  • Abstract A case report of a 36-year-old black homosexual man with right upper- and lower-quadrant abdominal pain is presented.[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]
  • Three of 45 (7%) patients with liver abscesses, who also had diarrhea at presentation, had larger and more numerous ulcers with inflammation of the surrounding mucosa of the left colon. Control patients with amebic colitis presented with diarrhea.[ncbi.nlm.nih.gov]
  • Colonic ulcers were noted in five of the six (83%) patients with active diarrhea at presentation. The ileocecal mass in all these patients was ameboma. Ulcers were seen in only one of the 11 (9%) patients without diarrhea.[ncbi.nlm.nih.gov]
  • Its diagnosis should be considered in anyone with a suspected liver abscess, jaundice, or diarrhea in whom peritonitis develops.[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]
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]
Hepatomegaly
  • Most (81%) patients had hepatomegaly on physical examination and some had a well-defined mass.[ncbi.nlm.nih.gov]
  • CONCLUSIONS: In travelers with fever, abdominal pain, and hepatomegaly amebic liver abscess must be considered. Medical treatment with metronidazole is effective in more than 90%.[ncbi.nlm.nih.gov]
  • We report a patient who presented with fever, jaundice and tender hepatomegaly and on investigation was found to have coexisting acute hepatitis E and amebic liver abscess. Incidentally, he was also an HBsAg carrier.[ncbi.nlm.nih.gov]
  • In contrast to the initial signs in adults, those in infants are nonspecific and include fever, hepatomegaly, anemia, and elevated levels of transaminases.[ncbi.nlm.nih.gov]
  • Significanct physical abnormalities were tender hepatomegaly (93%), right-sided pulmonary changes (40%), and fever (66%). All patients had abnormal liver scan, positive amebic serology, and hypoalbuminemia.[ncbi.nlm.nih.gov]
Liver Tenderness
  • 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]
  • The end-points were subsidence of fever and liver tenderness, normalization of total leukocyte count (TLC), alanine aminotransferase (ALT) and liver span.[tropicalgastro.com]
  • 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]
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]

Workup

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].

Multiple Liver Cysts
  • Ultrasound, MRI and CT scanning will show multiple liver cysts. Treatment : this is only needed if symptoms occur. As with simple cysts, options include aspiration-sclerotherapy and deroofing. Liver transplantation is occasionally employed.[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]
  • 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]
  • 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]
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]

Treatment

  • Since treatment recommendations are still inconsistent comparing conservative and interventional treatment modalities, we evaluated treatment modalities in our patients.[ncbi.nlm.nih.gov]
  • Such drainage has proved to be safe provided that the patient is receiving antiamebic drug treatment.[ncbi.nlm.nih.gov]
  • MATERIAL AND METHODS: This study was conducted to compare the efficacy of two different treatment modalities i.e. drug treatment alone vs. drug treatment and aspiration of abscess cavity in patients with small (up to 5 cm) and large (5 cm to 10 cm) size[ncbi.nlm.nih.gov]
  • Complication by other sexually transmitted diseases is another important factor affecting the treatment of this disease.[ncbi.nlm.nih.gov]
  • We conclude that the TechLab E. histolytica II kit is a sensitive means to diagnose hepatic and intestinal amebiasis prior to the institution of metronidazole treatment.[ncbi.nlm.nih.gov]

Prognosis

  • Though the mortality rate is high in cases of ruptured amebic liver abscess, appropriate management can lead to a good prognosis.[ncbi.nlm.nih.gov]
  • Author information 1 Division of Internal Medicine, Hôpital La Croix Saint-Simon, Paris, France. vprendki@hopital-dcss.org Abstract Extensive venous thrombosis is usually seen postmortem in amebic liver abscess because of its dismal prognosis.[ncbi.nlm.nih.gov]
  • The prognosis of ALA needs to be determined to decide whether aggressive intervention therapy should be used. A prospective study was conducted to determine the factors that predicted mortality in patients with ALA.[ncbi.nlm.nih.gov]
  • What is the Prognosis of Amebic Liver Abscess? (Outcomes/Resolutions) Without proper treatment, the Amebic Liver Abscess is likely to rupture and spread the infection to other parts of the body, eventually leading to death.[dovemed.com]
  • Outlook (Prognosis) Without treatment, the abscess may break open (rupture) and spread into other organs, leading to death. People who are treated have a very high chance of a complete cure or only minor complications.[ufhealth.org]

Etiology

  • In 5% needle aspiration was performed to allow differentiation between amebic and pyogenic etiology. Metronidazole alone quickly cleared symptoms in 92% of the patients.[ncbi.nlm.nih.gov]
  • Abstract 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]
  • (Etiology) Amebic Liver Abscesses are caused by the parasite Entamoeba histolytica. When the parasite enters the body, it usually travels to the intestines.[dovemed.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]

Epidemiology

  • 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]
  • We conclude that travel to and origin in an endemic area are important risk factors for the development of ALA, and patients in these different epidemiological groups appear to have distinct clinical features.[ncbi.nlm.nih.gov]
  • Humans Liver Abscess, Amebic/diagnosis* Liver Abscess, Amebic/diagnostic imaging Liver Abscess, Amebic/drug therapy Liver Abscess, Amebic/epidemiology Male Metronidazole/therapeutic use Oxyquinoline/administration & dosage Oxyquinoline/analogs & derivatives[ncbi.nlm.nih.gov]
  • We report a case of an amebic abscess, initially unsuspected due to the absence of epidemiologic risk factors and the negative serology for amebiasis, in the early stages of the disease. [Indexed for MEDLINE] Free full text[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]
Sex distribution
Age distribution

Pathophysiology

  • This article reviews epidemiologic features, pathophysiology, clinical features, diagnostic tests, imaging studies, treatment of amebic liver abscess, and prevention measures.[ncbi.nlm.nih.gov]
  • […] the localization of antigenic molecules of E. histolytica trophozoites and of molecules such as intercellular adhesion molecule 1 (ICAM-1), ICAM-2, and von willebrand factor in activated endothelial cells of human ALA, which could be related to the pathophysiological[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]

Prevention

  • This article reviews epidemiologic features, pathophysiology, clinical features, diagnostic tests, imaging studies, treatment of amebic liver abscess, and prevention measures.[ncbi.nlm.nih.gov]
  • Abstract We have used serum from patients with amebic liver abscess to investigate the role of antibody in the prevention of invasive amebiasis using the severe combined immunodeficient (SCID) mouse model of Entamoeba histolytica infection.[ncbi.nlm.nih.gov]
  • We concluded that EhMSP-1 is a promising antigen that warrants further study to determine its full potential as a target for therapy and/or prevention of invasive amebiasis. Copyright 2015, American Society for Microbiology. All Rights Reserved.[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]

References

Article

  1. Tanyuksel M, Petri WA Jr. Laboratory diagnosis of amebiasis. Clin Microbiol Rev. 2003;16(4):713-29.
  2. Healy GR, Garcia LS. Intestinal and urogenital protozoa. In: Murray PR, Baron EJ, Pfaller MA, Tenover FC, Yolken RH, eds. Manual of clinical microbiology. 6th ed. ASM Press, Washington, D.C.: ASM Press; 1995: 1204-1228.
  3. Garcia L, Bruckner DS. Diagnostic medical parasitology. 3rd ed. Washington, D.C.: AMA Press; 1997.
  4. Phillips SC, Mildvan D, William DC, et al. Sexual transmission of enteric protozoa and helminths in a venereal-disease-clinic population. N Engl J Med. 1981;305(11):603-606.
  5. Haque R, Mollah NU, Ali IK, et al. Diagnosis of Amebic Liver Abscess and Intestinal Infection with the TechLab Entamoeba histolytica II Antigen Detection and Antibody Tests. J Clin Microbiol. 2000;38(9): 3235-3239.
  6. Mbaye PS, Koffi N, Camara P, et al. Pleuropulmonary manifestations of amebiasis. Rev Pneumol Clin. 1998;54(6):346-52.
  7. Katzenstein D, Rickerson V, Braude A. New concepts of amebic liver abscess derived from hepatic imaging, serodiagnosis, and hepatic enzymes in 67 consecutive cases in San Diego. Medicine (Baltimore). 1982; 61(4):237–246.
  8. Otto MP, Gérôme P, Rapp C, et al. False-negative serologies in amebic liver abscess: report of two cases. J Travel Med. 2013;20(2):131-3.
  9. Restrepo MI, Restrepo Z, Elsa Villareal CL, Aguirre A, Restrepo M. Diagnostic tests for amoebic liver abscess: comparison of enzyme-linked immunosorbent assay (ELISA) and counterimmunoelectrophoresis (CIE). Rev Soc Bras Med Trop. 1996;29(1):27-32.
  10. Leo M, Haque R, Kabir M, et al. Evaluation of Entamoeba histolytica antigen and antibody point-of-care tests for the rapid diagnosis of amebiasis. J Clin Microbiol. 2006;44(12):4569-71.
  11. Bammigatti C, Ramasubramanian NS, Kadhiravan T, Das AK. Percutaneous needle aspiration in uncomplicated amebic liver abscess: a randomized trial. Trop Doct. 2013;43(1):19-22.

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Last updated: 2018-06-22 02:32