- Email: [email protected]
Conservative treatment of a chronic amebic liver abscess complicated by rupture and an intraperitoneal abscess
CONSERVATIVE TREATMENT OF A CHRONIC AMEBIC LIVER ABSCESS COMPLICATED BY RUPTURE AND AN INTRAPERITONEAL ABSCESS LIEUT.
COL.
RAY B. MCCARTY
AND
CAPT.
JEROME
G. SCHNEDORF
MEDICAL CORPS, ARMY OF THE UNITED STATES
I
T has been clearly demonstrated that most Iarge sobtary uncompbcated amebit liver abscesses can be cured by the use of emetine hydrochIoride combined with aspiration of the abscess with a very Iow mortabty rate. When the abscess is compIicated by rupture and a IocaIized open surgica1 drainage abscess forms, through an extraserous approach has been the procedure of choice with its attendant higher mortaIity rate. The case reported here is of interest in that it was compIicated by rupture with the formation of an intraperitonea1 abscess and was treated successfuIIy by the use of emetine hydrochIoride and muItipIe aspirations. CASE REPORT A sergeant, who is now thirty-eight years oId, arrived in India in May, 1942. He was hospitalized for three periods of about one month each beginning in September, 1942, because of maIaise, fever, weakness, and a watery diarrhea characterized by Fifteen to twenty stools a day, many of which contained bIood. On these occasions the diagnosis of bacilIary dysentery was made and the diarrhea cIeared up after suIfaguanidine therapy but recurred each time within a week or two after he returned to duty. His weight decreased from I 65 to I 25 pounds. He entered a hospita1 for the fourth time in February 1943 and for the First time Entameba histoIytica were found in his stooIs. No enIargement of the liver was noted at this time and sigmoidoscopic examination faiIed to show any ukeration in the Iower sigmoid colon and rectum. AIthough he received 300 gr. (18 Gm.) of carbarsone over a period of two months, he faiIed to make any substantia1 improvement and was accordingIy evacuated to the United States in May, 1943. WhiIe on board ship he again deveIoped a diarrhea and was given a tota of 5 gr. (0.30 Cm.) of
emetine hydrochIoride in daiIy I gr. (0.06 Gm.) injections with marked improvement in his symptoms. ShortIy after his arrival at a Genera1 Hospital in this country in June, 1943, his diarrhea had subsided, his weight had returned to ISO pounds, and the patient felt better than he had since his iIIness began. Abdominal examination was again essentiaIIy negative but the sigmoidoscopic examination on JuIy 4, 1943, revealed numerous shaIIow uIcers in the rectum. No ameba were found in the stools and serum aggIutination tests for the Shiga dysentery-paradysentery group were negative. The sedimentation rate was normal. He was given a ten-day course of emetine by injection, I gr (0.06 Gm.) a day and a ten-day course of carbarsone, 3,75 gr. (0.225 Gm.) twice a day. The ulceration had compIeteIy disappeared by August 2, 1943, and the patient was returned to genera1 miIitary duty as cured on August 5, 1943. He continued to perform fuI1 duty untii January IO, 1944, at which time he was admitted to a Station HospitaI because of a nonradiating pain in the upper right quadrant of his abdomen of twenty-four hours’ duration. He stated that he had been quite weak for some time and that for the month preceding the admission there had been a fuIIness in the right upper quadrant of the abdomen accompanied by dyspepsia occurring most frequentIy after eating. He had been having one soft bowe1 movement a day and recently had noted that the stooIs were a IittIe Iighter in coIor than they had been previously. His weight had dropped from 150 to 135 pounds in the month preceding his admission to the hospital. The patient attributed this to Iack of appetite. On inspection of the abdomen at the Station HospitaI a sIight rounded prominence was noted in the right upper quadrant with a sensation of deep fluctuation on palpation, aIthough this was diffrcuIt to determine due to the tenderness and IocaIized rigidity in this area. The Iiver edge of the right Iobe was paIpated about 6 cm. below
402
American Journal of Surgery
McCarty,
Schnedorf-Liver
the right costal margin and was extremely tender. The temperature on admission was $3.8”~. and ranged to IOO’F. The leukocyte
Abscess
MARCH, 1946
with a differential of neutrophils 92 per cent, lymphocytes 6 per cent, eosinophils I per cent, and monocytes I per cent. With these increas-
FIG. I. Anteroposterior roentgenogram showing amebic abscess in right Iobe of the Iiver visuaIized by air after fourth aspiration. Note that there is no abnormal elevation of the diaphragm.
count was 16,350 with a differential of neutrophils 88 per cent, lymphocytes g per cent, eosinophils 2 per cent, and basophils I per cent. The urinalysis was essentially normal and in one stool examination no Entameba histolytica were found. Sigmoidoscopic examination was negative. He was given an intramuscular injection of $5 gr. (0.03 Gm.) and I gr. (0.06 Gm.) of emetine hydrochloride, respectively, on two successive days and transferred to a General 12, 1944, with a diagnosis Hospital on January of amebic liver abscess. On admission the patient was still complaining of severe pain in the right upper abdominal quadrant and the physical findings were essentially as described in the Station Hospital record. The temperature was g8.8%., the pulse was regular and 80 beats to the minute, and the respiration was 22 per minute. The leukocyte count was 16,900 with a differential of neu7 per cent, trophils 85 per cent, lymphocytes eosinophils 3 per cent, and monocytes 5 per cent. The sedimentation rate was I 18 mm. per hour. Within forty-eight hours after admission the pain became diffuse over the entire abdomen, some vomiting had occurred, and generalized tenderness and rigidity of the abdomen had developed. No peristalsis could be heard. The leukocyte count rose to 17,500
ing symptoms the patient showed an increase in temperature to IOO’F. on one occasion but at no time during his subsequent course did he again develop a fever. X-ray studies of the abdomen at this time showed that there was no elevation of the diaphragm. The liver shadow was enlarged, the inferior border overshadowing the right kidney, and there was x-ray evidence of free fluid in the peritoneal cavity. Clinically it was believed that this patient had a chronic amebic liver abscess which on January g, 1944, had ruptured and formed a Iocalized intraperitoneal abscess, and that in the past forty-eight hours there probabIy had been a slight leakage into the genera1 peritoneal cavity. Immediate treatment consisted in continuing the daily intramuscular injections of I gr. (0.06 Gm.) of emetine hydrochloride for eight days, parenteral ffuids as needed, and on 150 cc. of thick, 14, 1944, about January chocolate colored pus were aspirated with a large bore needle from the right hypochondrium. The needle was inserted just below the right costal margin in the midclavicular line to a depth of about 4 cm. The impression was that the point of the needle was just through the peritoneum. The aspirated pus was negative for organisms and ameba on smear and culture.
VOL.
LXXI,
No.
3
McCarty,
Schnedorf-Liver
FoIIowing this first aspiration the diffuse abdomina1 pain and rigidity receded, and the extremeIy tender, enlarged right lobe of the liver couId again be paIpated. Some right upper quadrant pain and rigidity remained. On January 17, 1944, under IocaI infiItration anesthesia a Iarge bore needIe was inserted in approximateIy the same location but no pus was obtained until the point of the needIe, which was directed superiorIy, mediaIIy, and posteriorly, had reached a depth of about 8 cm. A definite sense of resistance was met in going through the capsuIe of the abscess. Three hundred cc. of thick yeIIow pus with chocolate streaks in it were aspirated. SimiIar aspirations were done on the 20th and 25th of January, and on the 5th of February, and 450 cc., 550 cc., and 400 cc. of typica chocoIate colored pus were obtained at each respective aspiration. A tota of 1,850 cc. of pus was removed in these five aspirations and no ameba or bacteria were found in any of the specimens. At the time of the Iast aspiration the abscess was irrigated with IOO cc. of 2 per cent chiniofon soIution through two needles. Anteroposterior and upright fXms of the abdomen taken after the fourth aspiration and a IateraI him taken during the fifth aspiration showed a Iarge ffuid and air containing cavity within the substance of the right Iobe of the Iiver. (Figs. I, 2, and 3.) The cavity was Iocated within the Iiver substance sIightIy media1 to the midcIavicuIar line and midway between the abdomina1 wal1 and the anterior margin of the vertebral bodies. The patient received a tota of 22 gr. (1.32 Gm.) of emetine hydrochloride intramuscuIarly; ISO gr. two courses of carbarsone, tota (9.0 Gm.); and two courses of chiniofon, total 720 gr. (45 Gm.) over a period of about three months. The Iatter two drugs were given to allay any latent ameba present in the coIon and rectum aIthough none had been found in the stooIs. Up to the time of his discharge to miIitary duty on JuIy 12, 1944, the patient had had no recurrence of his abdomina1 symptoms and feIt perfectIy weI1. His weight was 158 pounds, the Iiver edge was not paIpabIe, the sedimentation rate was 18 mm. per hour, the sigmoidoscopic examination was negative, and repeated stoo1 examinations were normaI. COMMENT
From an epidemioIogica1 point of view it has been pointed out that amebic liver
Abscess
American Journal of Surgery
403
abscess occurs Iess frequently in temperate chmates than in the tropics, aIthough amebiasis may be common. AIso, it is
FIG. 2. Upright fourth aspiration the Iiver abscess.
roentgenogram showing a
taken after fluid Ievel in
known that amebic Iiver abscess is much more common among visitors than in natives of the tropics, approximateIy ten times more common in men than women, and that it rareIy occurs in people beIow the age of twenty and seIdom above the age of sixty. AI1 these factors were unfavorabIe to our armed forces stationed in the tropics and it is reasonabIe to assume that the disease wiI1 be encountered more frequentIy as they return home. In this connection it is we11 to remember that aIthough dysentery is not a necessary precursor, the majority of amebic Iiver abscesses deveIop within one to three months after the dysenteric manifestations. Some abscesses, however, do not become evident for several years thereafter and there are cases on record occurring many years Iater. In our case the Iiver abscess became evident sixteen months after the initia1 attack of dysentery and approximateIy five months after the amebic coIitis had apparentIy been cured. CharacteristicaIIy, amebic Iiver abscesses are bacterioIogicaIIy steriIe, singIe, and usuaIIy occur in the right Iobe of Iiver. In three coIIected series of cases, respectiveIy,
404
American
Journal
of Surgery
McCarty,
Schnedorf-Liver
Ochsner and DeBakey4 found 85.1 per cent steriIe, 65 per cent singIe, and in 84.7 per cent the right Iobe was involved.
Abscess
MARCH,1946
treated with aspiration and emetine. Ochsner and DeBakey,4 in 1943, reported a mortaIity rate of 33.3 per cent in twenty-
FIG. 3. Lateral roentgenogram taken during the fifth aspiration on February 5, 1944, showing the needIe in the abscess cavity.
These authors aIso found ameba in the abscess contents in 16.5 per cent of their own series of cases and in 37.8 per cent of a coIIected series of cases. The most frequent Iocations in the right Iobe have been near the dome of the Iiver with consequent eIevation of the right diaphragm, or Iess frequentIy near the inferior surface. The abscess in our case was Iocated near the inferior margin of the Iiver with a downward enIargement of the Iiver and with no eIevation of the diaphragm evident in the x-ray. Munk2 has emphasized that in this Iocation no diaphragmatic radioIogica1 signs can be expected. It has repeatedIy been shown that the mortaIity of amebic Iiver abscess is greatIy increased with the onset of secondary infection, which in a few cases may be of hematogenous origin or, more commonIy, introduced at the time of open drainage. The avoidance of secondary infection of the abscess is therefore most important and shouId inffuence the method of treatment. In spite of scrupuIous precautions to avoid it, secondary infection invariabIy foIIows open drainage of an abscess which is reIativeIy steriIe. As earIy as 1922, Rogers5 reported a decrease in mortaIity from 56.8 per cent in patients treated by open drainage to 14 per cent in those
four patients treated by transpIeura1 drainage, 30.4 per cent in twenty-three treated by transperitonea1 drainage, 10.5 per cent in nineteen treated by simple incision over the IocaIized abscess, and 6.6 per cent in fifteen drained by the extraserous route. These authors aIso reported their experience with emetine and aspiration, and in a series of eighty-three cases the mortaIity rate was onIy 3.6 per cent. The resuIts indicate that aspiration is the procedure of choice in the great majority of cases in which evacuation of the abscess becomes necessary. It is aIso important to recognize the distinct r6Ie of emetine hydrochIoride in these cases. With amebic hepatitis or even where earIy abscess formation has occurred, emetine aIone may suffice to effect resolution and when aspiration is contempIated the preIiminary administration of emetine is obIigatory. Two of the three patients who died in the series of eighty-three cases reported by Ochsner and DeBakey4 faiIed to get emetine prior to aspiration, and the patient in the third fata case received emetine but was not aspirated. The authors beIieved that a combination of both emetine and aspiration might have prevented these deaths. As stated by Ochsner and DeBakey,4
vol..
LXXI,
No.
3
McCarty,
Schnedorf-Liver
of amebic hepatic “the complications abscess consist essentiaIIy of secondary infection with pyogenic organisms, direct extension or rupture of the abscess into one of the adjacent viscera or serous cavities, and thrombosis and embolism.” Extension upward with consequent pleuropuImonary involvement occurs more frequentIy than peritoneal involvement due to the more frequent location of the abscess near the convex surface of the liver. In a collected series of 2,490 cases of amebic hepatic abscess Ochsner and DeBakey4 found 13.8 per cent of cases with pIeuropuImonary complications, whereas in a collected series of 1,095 cases these authors found the incidence of rupture into the peritonea1 cavity to be 6 per cent. From the clinica course in this case it is quite obvious that the chronic amebic liver abscess was not secondariIy infected, and as it approached the surface of the Iiver 6: gradua1 extension, adhesions formed as a result of peritoneal reaction, and when the rupture occurred the abscess was quite limited by the adhesions. The generalized abdomina1 tenderness, rigidity, and vomiting which deveIoped shortIy after admission and receded rapidIy after the first aspiration probabIy indicated a slight leakage into the genera1 peritonea1 cavity. The progress in this case indicates that in certain seIective instances in which the compIication of a IocaIized extension of an amebic Iiver abscess without secondary infection is present either near the lower margin of the liver or in the subdiaphragmatic region, the use of emetine and aspiration is quite IikeIy to be successfu1 and can be accompIished with Iess danger to the patient than open drainage by an extraserous approach. Where the amebic abscess has become secondariIy infected, the practice has usuaIIy been to perform open drainage by an extraserous approach. However, two recent case reports of secondariIy infected amebic Iiver abscesses in which the suIfonamides and
Abscess
American
Journal
of Surgery
403
penicillin were successfuIIy used give promise of even a wider range of usage of the conservative treatment. AIport and GhaIiougui’ report the recovery of a patient with an amebic Iiver abscess secondariIy infected with BaciIIus pyocyaneus who was treated with repeated aspirations and the IocaI and systemic use of sulfonamides. Noth and HirshfeId3 reported the successful use of peniciIIin in a case secondariry infected with betahemoIytic streptococci. They inserted a smaI1 uretera catheter into the abscess cavity through a Iarge bore aspirating needIe. The needIe was then withdrawn and peniciIIin was injected periodicaIIy through the catheter into the abscess. The patient received a total of 830,000 units of peniciIIin over a period of fifteen days by this method and a cure resulted. SUMMARY
The case reported is that of a chronic amebic Iiver abscess which was compIicated by rupture and the formation of a IocaIized intraperitonea1 abscess with probabIe sIight Ieakage into the genera1 peritonea1 cavity. Conservative treatment with emetine hydrochIoride and muItipIe aspirations proved successfu1. The Iiver abscess manifested itseIf sixteen months after the initia1 attack of dysentery in India and approximateIy five months after the amebic colitis had apparentIy been cured. REFERENCES C. and GHALIOUGUI, P. Conservative treatment of liver abscesses. Lancet, z: 106~1065,
I. ALPORT, A.
1939. 2. MUNK, JULIUS. X-ray appearances in amebic hepatitis. Brir. J. Radial., 17: 48-53. 1944. 3. NOTH, P. H. and HIRSHFELD, J. W. Amebic abscess of the Iiver with secondary infection. J. A. M. A., I 24: 643-646, 1944. 4. OCHSNER, ALTON, and DEBAKEY, MICHAEL. Amebic hepatitis and hepatic abscess. Surgery, 13: 460493; 612-649, 1943. 5. ROGERS, LEONARD. Lettsonian Lectures on Amebic Liver Abscess. Lecture II-The varieties and treatment of amebic liver abscess. Lancet, I : 569$75, 1922.
COL.
RAY B. MCCARTY
AND
CAPT.
JEROME
G. SCHNEDORF
MEDICAL CORPS, ARMY OF THE UNITED STATES
I
T has been clearly demonstrated that most Iarge sobtary uncompbcated amebit liver abscesses can be cured by the use of emetine hydrochIoride combined with aspiration of the abscess with a very Iow mortabty rate. When the abscess is compIicated by rupture and a IocaIized open surgica1 drainage abscess forms, through an extraserous approach has been the procedure of choice with its attendant higher mortaIity rate. The case reported here is of interest in that it was compIicated by rupture with the formation of an intraperitonea1 abscess and was treated successfuIIy by the use of emetine hydrochIoride and muItipIe aspirations. CASE REPORT A sergeant, who is now thirty-eight years oId, arrived in India in May, 1942. He was hospitalized for three periods of about one month each beginning in September, 1942, because of maIaise, fever, weakness, and a watery diarrhea characterized by Fifteen to twenty stools a day, many of which contained bIood. On these occasions the diagnosis of bacilIary dysentery was made and the diarrhea cIeared up after suIfaguanidine therapy but recurred each time within a week or two after he returned to duty. His weight decreased from I 65 to I 25 pounds. He entered a hospita1 for the fourth time in February 1943 and for the First time Entameba histoIytica were found in his stooIs. No enIargement of the liver was noted at this time and sigmoidoscopic examination faiIed to show any ukeration in the Iower sigmoid colon and rectum. AIthough he received 300 gr. (18 Gm.) of carbarsone over a period of two months, he faiIed to make any substantia1 improvement and was accordingIy evacuated to the United States in May, 1943. WhiIe on board ship he again deveIoped a diarrhea and was given a tota of 5 gr. (0.30 Cm.) of
emetine hydrochIoride in daiIy I gr. (0.06 Gm.) injections with marked improvement in his symptoms. ShortIy after his arrival at a Genera1 Hospital in this country in June, 1943, his diarrhea had subsided, his weight had returned to ISO pounds, and the patient felt better than he had since his iIIness began. Abdominal examination was again essentiaIIy negative but the sigmoidoscopic examination on JuIy 4, 1943, revealed numerous shaIIow uIcers in the rectum. No ameba were found in the stools and serum aggIutination tests for the Shiga dysentery-paradysentery group were negative. The sedimentation rate was normal. He was given a ten-day course of emetine by injection, I gr (0.06 Gm.) a day and a ten-day course of carbarsone, 3,75 gr. (0.225 Gm.) twice a day. The ulceration had compIeteIy disappeared by August 2, 1943, and the patient was returned to genera1 miIitary duty as cured on August 5, 1943. He continued to perform fuI1 duty untii January IO, 1944, at which time he was admitted to a Station HospitaI because of a nonradiating pain in the upper right quadrant of his abdomen of twenty-four hours’ duration. He stated that he had been quite weak for some time and that for the month preceding the admission there had been a fuIIness in the right upper quadrant of the abdomen accompanied by dyspepsia occurring most frequentIy after eating. He had been having one soft bowe1 movement a day and recently had noted that the stooIs were a IittIe Iighter in coIor than they had been previously. His weight had dropped from 150 to 135 pounds in the month preceding his admission to the hospital. The patient attributed this to Iack of appetite. On inspection of the abdomen at the Station HospitaI a sIight rounded prominence was noted in the right upper quadrant with a sensation of deep fluctuation on palpation, aIthough this was diffrcuIt to determine due to the tenderness and IocaIized rigidity in this area. The Iiver edge of the right Iobe was paIpated about 6 cm. below
402
American Journal of Surgery
McCarty,
Schnedorf-Liver
the right costal margin and was extremely tender. The temperature on admission was $3.8”~. and ranged to IOO’F. The leukocyte
Abscess
MARCH, 1946
with a differential of neutrophils 92 per cent, lymphocytes 6 per cent, eosinophils I per cent, and monocytes I per cent. With these increas-
FIG. I. Anteroposterior roentgenogram showing amebic abscess in right Iobe of the Iiver visuaIized by air after fourth aspiration. Note that there is no abnormal elevation of the diaphragm.
count was 16,350 with a differential of neutrophils 88 per cent, lymphocytes g per cent, eosinophils 2 per cent, and basophils I per cent. The urinalysis was essentially normal and in one stool examination no Entameba histolytica were found. Sigmoidoscopic examination was negative. He was given an intramuscular injection of $5 gr. (0.03 Gm.) and I gr. (0.06 Gm.) of emetine hydrochloride, respectively, on two successive days and transferred to a General 12, 1944, with a diagnosis Hospital on January of amebic liver abscess. On admission the patient was still complaining of severe pain in the right upper abdominal quadrant and the physical findings were essentially as described in the Station Hospital record. The temperature was g8.8%., the pulse was regular and 80 beats to the minute, and the respiration was 22 per minute. The leukocyte count was 16,900 with a differential of neu7 per cent, trophils 85 per cent, lymphocytes eosinophils 3 per cent, and monocytes 5 per cent. The sedimentation rate was I 18 mm. per hour. Within forty-eight hours after admission the pain became diffuse over the entire abdomen, some vomiting had occurred, and generalized tenderness and rigidity of the abdomen had developed. No peristalsis could be heard. The leukocyte count rose to 17,500
ing symptoms the patient showed an increase in temperature to IOO’F. on one occasion but at no time during his subsequent course did he again develop a fever. X-ray studies of the abdomen at this time showed that there was no elevation of the diaphragm. The liver shadow was enlarged, the inferior border overshadowing the right kidney, and there was x-ray evidence of free fluid in the peritoneal cavity. Clinically it was believed that this patient had a chronic amebic liver abscess which on January g, 1944, had ruptured and formed a Iocalized intraperitoneal abscess, and that in the past forty-eight hours there probabIy had been a slight leakage into the genera1 peritoneal cavity. Immediate treatment consisted in continuing the daily intramuscular injections of I gr. (0.06 Gm.) of emetine hydrochloride for eight days, parenteral ffuids as needed, and on 150 cc. of thick, 14, 1944, about January chocolate colored pus were aspirated with a large bore needle from the right hypochondrium. The needle was inserted just below the right costal margin in the midclavicular line to a depth of about 4 cm. The impression was that the point of the needle was just through the peritoneum. The aspirated pus was negative for organisms and ameba on smear and culture.
VOL.
LXXI,
No.
3
McCarty,
Schnedorf-Liver
FoIIowing this first aspiration the diffuse abdomina1 pain and rigidity receded, and the extremeIy tender, enlarged right lobe of the liver couId again be paIpated. Some right upper quadrant pain and rigidity remained. On January 17, 1944, under IocaI infiItration anesthesia a Iarge bore needIe was inserted in approximateIy the same location but no pus was obtained until the point of the needIe, which was directed superiorIy, mediaIIy, and posteriorly, had reached a depth of about 8 cm. A definite sense of resistance was met in going through the capsuIe of the abscess. Three hundred cc. of thick yeIIow pus with chocolate streaks in it were aspirated. SimiIar aspirations were done on the 20th and 25th of January, and on the 5th of February, and 450 cc., 550 cc., and 400 cc. of typica chocoIate colored pus were obtained at each respective aspiration. A tota of 1,850 cc. of pus was removed in these five aspirations and no ameba or bacteria were found in any of the specimens. At the time of the Iast aspiration the abscess was irrigated with IOO cc. of 2 per cent chiniofon soIution through two needles. Anteroposterior and upright fXms of the abdomen taken after the fourth aspiration and a IateraI him taken during the fifth aspiration showed a Iarge ffuid and air containing cavity within the substance of the right Iobe of the Iiver. (Figs. I, 2, and 3.) The cavity was Iocated within the Iiver substance sIightIy media1 to the midcIavicuIar line and midway between the abdomina1 wal1 and the anterior margin of the vertebral bodies. The patient received a tota of 22 gr. (1.32 Gm.) of emetine hydrochloride intramuscuIarly; ISO gr. two courses of carbarsone, tota (9.0 Gm.); and two courses of chiniofon, total 720 gr. (45 Gm.) over a period of about three months. The Iatter two drugs were given to allay any latent ameba present in the coIon and rectum aIthough none had been found in the stooIs. Up to the time of his discharge to miIitary duty on JuIy 12, 1944, the patient had had no recurrence of his abdomina1 symptoms and feIt perfectIy weI1. His weight was 158 pounds, the Iiver edge was not paIpabIe, the sedimentation rate was 18 mm. per hour, the sigmoidoscopic examination was negative, and repeated stoo1 examinations were normaI. COMMENT
From an epidemioIogica1 point of view it has been pointed out that amebic liver
Abscess
American Journal of Surgery
403
abscess occurs Iess frequently in temperate chmates than in the tropics, aIthough amebiasis may be common. AIso, it is
FIG. 2. Upright fourth aspiration the Iiver abscess.
roentgenogram showing a
taken after fluid Ievel in
known that amebic Iiver abscess is much more common among visitors than in natives of the tropics, approximateIy ten times more common in men than women, and that it rareIy occurs in people beIow the age of twenty and seIdom above the age of sixty. AI1 these factors were unfavorabIe to our armed forces stationed in the tropics and it is reasonabIe to assume that the disease wiI1 be encountered more frequentIy as they return home. In this connection it is we11 to remember that aIthough dysentery is not a necessary precursor, the majority of amebic Iiver abscesses deveIop within one to three months after the dysenteric manifestations. Some abscesses, however, do not become evident for several years thereafter and there are cases on record occurring many years Iater. In our case the Iiver abscess became evident sixteen months after the initia1 attack of dysentery and approximateIy five months after the amebic coIitis had apparentIy been cured. CharacteristicaIIy, amebic Iiver abscesses are bacterioIogicaIIy steriIe, singIe, and usuaIIy occur in the right Iobe of Iiver. In three coIIected series of cases, respectiveIy,
404
American
Journal
of Surgery
McCarty,
Schnedorf-Liver
Ochsner and DeBakey4 found 85.1 per cent steriIe, 65 per cent singIe, and in 84.7 per cent the right Iobe was involved.
Abscess
MARCH,1946
treated with aspiration and emetine. Ochsner and DeBakey,4 in 1943, reported a mortaIity rate of 33.3 per cent in twenty-
FIG. 3. Lateral roentgenogram taken during the fifth aspiration on February 5, 1944, showing the needIe in the abscess cavity.
These authors aIso found ameba in the abscess contents in 16.5 per cent of their own series of cases and in 37.8 per cent of a coIIected series of cases. The most frequent Iocations in the right Iobe have been near the dome of the Iiver with consequent eIevation of the right diaphragm, or Iess frequentIy near the inferior surface. The abscess in our case was Iocated near the inferior margin of the Iiver with a downward enIargement of the Iiver and with no eIevation of the diaphragm evident in the x-ray. Munk2 has emphasized that in this Iocation no diaphragmatic radioIogica1 signs can be expected. It has repeatedIy been shown that the mortaIity of amebic Iiver abscess is greatIy increased with the onset of secondary infection, which in a few cases may be of hematogenous origin or, more commonIy, introduced at the time of open drainage. The avoidance of secondary infection of the abscess is therefore most important and shouId inffuence the method of treatment. In spite of scrupuIous precautions to avoid it, secondary infection invariabIy foIIows open drainage of an abscess which is reIativeIy steriIe. As earIy as 1922, Rogers5 reported a decrease in mortaIity from 56.8 per cent in patients treated by open drainage to 14 per cent in those
four patients treated by transpIeura1 drainage, 30.4 per cent in twenty-three treated by transperitonea1 drainage, 10.5 per cent in nineteen treated by simple incision over the IocaIized abscess, and 6.6 per cent in fifteen drained by the extraserous route. These authors aIso reported their experience with emetine and aspiration, and in a series of eighty-three cases the mortaIity rate was onIy 3.6 per cent. The resuIts indicate that aspiration is the procedure of choice in the great majority of cases in which evacuation of the abscess becomes necessary. It is aIso important to recognize the distinct r6Ie of emetine hydrochIoride in these cases. With amebic hepatitis or even where earIy abscess formation has occurred, emetine aIone may suffice to effect resolution and when aspiration is contempIated the preIiminary administration of emetine is obIigatory. Two of the three patients who died in the series of eighty-three cases reported by Ochsner and DeBakey4 faiIed to get emetine prior to aspiration, and the patient in the third fata case received emetine but was not aspirated. The authors beIieved that a combination of both emetine and aspiration might have prevented these deaths. As stated by Ochsner and DeBakey,4
vol..
LXXI,
No.
3
McCarty,
Schnedorf-Liver
of amebic hepatic “the complications abscess consist essentiaIIy of secondary infection with pyogenic organisms, direct extension or rupture of the abscess into one of the adjacent viscera or serous cavities, and thrombosis and embolism.” Extension upward with consequent pleuropuImonary involvement occurs more frequentIy than peritoneal involvement due to the more frequent location of the abscess near the convex surface of the liver. In a collected series of 2,490 cases of amebic hepatic abscess Ochsner and DeBakey4 found 13.8 per cent of cases with pIeuropuImonary complications, whereas in a collected series of 1,095 cases these authors found the incidence of rupture into the peritonea1 cavity to be 6 per cent. From the clinica course in this case it is quite obvious that the chronic amebic liver abscess was not secondariIy infected, and as it approached the surface of the Iiver 6: gradua1 extension, adhesions formed as a result of peritoneal reaction, and when the rupture occurred the abscess was quite limited by the adhesions. The generalized abdomina1 tenderness, rigidity, and vomiting which deveIoped shortIy after admission and receded rapidIy after the first aspiration probabIy indicated a slight leakage into the genera1 peritonea1 cavity. The progress in this case indicates that in certain seIective instances in which the compIication of a IocaIized extension of an amebic Iiver abscess without secondary infection is present either near the lower margin of the liver or in the subdiaphragmatic region, the use of emetine and aspiration is quite IikeIy to be successfu1 and can be accompIished with Iess danger to the patient than open drainage by an extraserous approach. Where the amebic abscess has become secondariIy infected, the practice has usuaIIy been to perform open drainage by an extraserous approach. However, two recent case reports of secondariIy infected amebic Iiver abscesses in which the suIfonamides and
Abscess
American
Journal
of Surgery
403
penicillin were successfuIIy used give promise of even a wider range of usage of the conservative treatment. AIport and GhaIiougui’ report the recovery of a patient with an amebic Iiver abscess secondariIy infected with BaciIIus pyocyaneus who was treated with repeated aspirations and the IocaI and systemic use of sulfonamides. Noth and HirshfeId3 reported the successful use of peniciIIin in a case secondariry infected with betahemoIytic streptococci. They inserted a smaI1 uretera catheter into the abscess cavity through a Iarge bore aspirating needIe. The needIe was then withdrawn and peniciIIin was injected periodicaIIy through the catheter into the abscess. The patient received a total of 830,000 units of peniciIIin over a period of fifteen days by this method and a cure resulted. SUMMARY
The case reported is that of a chronic amebic Iiver abscess which was compIicated by rupture and the formation of a IocaIized intraperitonea1 abscess with probabIe sIight Ieakage into the genera1 peritonea1 cavity. Conservative treatment with emetine hydrochIoride and muItipIe aspirations proved successfu1. The Iiver abscess manifested itseIf sixteen months after the initia1 attack of dysentery in India and approximateIy five months after the amebic colitis had apparentIy been cured. REFERENCES C. and GHALIOUGUI, P. Conservative treatment of liver abscesses. Lancet, z: 106~1065,
I. ALPORT, A.
1939. 2. MUNK, JULIUS. X-ray appearances in amebic hepatitis. Brir. J. Radial., 17: 48-53. 1944. 3. NOTH, P. H. and HIRSHFELD, J. W. Amebic abscess of the Iiver with secondary infection. J. A. M. A., I 24: 643-646, 1944. 4. OCHSNER, ALTON, and DEBAKEY, MICHAEL. Amebic hepatitis and hepatic abscess. Surgery, 13: 460493; 612-649, 1943. 5. ROGERS, LEONARD. Lettsonian Lectures on Amebic Liver Abscess. Lecture II-The varieties and treatment of amebic liver abscess. Lancet, I : 569$75, 1922.