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.
Entire Body System
- 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]
Respiratoric
- 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]
Gastrointestinal
- 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]
The incidence of nausea and metallic taste was significantly lower in the patients given satranidazole (P < .005). [ncbi.nlm.nih.gov]
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]
Occasional side effects include nausea and dizziness. Tinidazole is not widely available though it is more effective than metronidazole. [en.wikipedia.org]
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]
- Abdominal Tenderness
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]
Fever (100%) was the most common symptom, and abdominal tenderness (90%) and diarrhea (50%) were frequently observed. Median leukocyte count was 9,000/mm 3 (range 3,410–16,700/mm 3 ), and median CD4 cell count was 279/mm 3 (range 40–370/mm 3 ). [wwwnc.cdc.gov]
The common clinical presentations include fever, abdominal pain, and abdominal tenderness. There are clinical differences between amebic liver abscess and pyogenic liver abscess. [academic.oup.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]
Liver, Gall & Pancreas
- 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]
Skin
- 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].
X-Ray
- 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]
Ultrasound
- 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]
Pleura
- 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]
Treatment
Such drainage has proved to be safe provided that the patient is receiving antiamebic drug treatment. [ncbi.nlm.nih.gov]
Prognosis
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]
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
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]
(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]
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]
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]
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]
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
- Tanyuksel M, Petri WA Jr. Laboratory diagnosis of amebiasis. Clin Microbiol Rev. 2003;16(4):713-29.
- 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.
- Garcia L, Bruckner DS. Diagnostic medical parasitology. 3rd ed. Washington, D.C.: AMA Press; 1997.
- 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.
- 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.
- Mbaye PS, Koffi N, Camara P, et al. Pleuropulmonary manifestations of amebiasis. Rev Pneumol Clin. 1998;54(6):346-52.
- 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.
- 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.
- 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.
- 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.
- 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.