- Email: [email protected]
Open aspiration for solitary liver abscess
Open Aspiration for Solitary Liver Abscess HUBERT
The high mortality associated with solitary abscess of the liver, no matter what the cause (pyogenic or amebit), represents the failure of early diagnosis and surgical therapy. Very close to 100 per cent mortality results if surgical drainage is not instituted [Z--6]. The use of broad spectrum antibiotics is helpful, but when used alone, they are ineffective [2,7-g]. For many years, the subtle characteristics of this condition have resulted in an all too frequent postmortem diagnosis [6]. Since the advent of hepatic scintiscan using 99” Tc sulphur colloid, there is no excuse for delay in making this diagnosis nor is there any difficulty in determining its location ]10--131 if both anteroposterior and lateral views are obtained. Lateral views are especially important [I#]. The liver scan may often appear to be normal in the presence of multiple liver abscesses [IS]. Successful open surgical drainage by the extra- or intraperitoneal route is life-saving [16--181. Yet, accruing to this method are many complications which increase morbidity and prolong hospital stay, such as hemorrhage, secondary infection of abscess cavity, prolonged drainage from a chronically infected wound, osteomyelitis, chronic draining sinus tracts, biliary fistulas, subphrenic abscess, subhepatic abscess, pleural empyema, and painful unsightly scars. Closed needle aspiration of solitary pyogenic abscess of the liver has been recommended and used by McFadzean since the early 1950’s, the results of which have not been duplicated 1191. Two medical students, Mary and Robert England, worked under McFadzean as an “elective” in Hong Kong [2CJ]. They followed up 108 of his patients with pyogenic abscesses treated by closed aspiration, reporting only one fatality. Although this method of abscess drainage has been used occasionally by others, its popularity seems never to have increased, and it has been used sparingly or ignored by the majority of surgeons in the United States 121-231. Open drainage has continued to be the surgical method of choice. When the posterior lateral approach of Nather and Ochsner 1241 furnishes a satisfactory drainage site, open or tube drainage is most satisfactory; but if abdominal intraperitoneal drainage is used, the procedure, in the past, has often been divided into two separate operative procedures to prevent general peritoneal contamination. Both surgical methods, closed drainage by From the Department of Surgery, University of North Carolina School af Medicine. Chapel Hill, North Carolina.
326
C PATTERSON,
MD, Chapel Hill, North Carolina
aspiration and open drainage, have their deficiencies. It occurred to me that celiotomy with simple aspiration might be applicable on many occasions. Abdominal exploration can be very advantageous ]2S]: The best site of drainage can be established, multiple abscesses can be found, and umbilical vein catherization for antibiotic therapy can be instituted in these cases in which it is indicated [26]; T tube cholangiographic studies can be carried out if needed [5:6] and drainage of the common biliary duct instituted if cholangitis is a factor 1171.
There has been the frequent observation that many of these abscesses are sterile: Stanford reported 100 per cent sterility [22]; Elsberg, 60 per cent 1271; Price, Joseph, and Mulder, SO per cent [17]; Rothenberg a.nd Linder, 45.8 per cent [16]; Joseph, Kahn, and Longmire, 33 per cent [6]. McFadzean, Chang, and Wong [29], Sherman and Robbins [ZS], and Bruno 1291 have also made similar observations. Certainly since the advent of antibiotics, no causative organism can be found in many instances, even after the use of special anaerobic technics. Solitary liver abscesses of amebic origin are almost always sterile [30,3f 1. Frequently anaerobic bacteria such as Bacteroidaceae which are relatively nonvirulent are cultured [18]. Thus the risk of intraperitoneal spillage and contamination during surgery is not fraught with great danger [6,17,21,32]. Experienced amebiologists recommend that all amebit abscesses of the liver can be treated satisfactorily by needle aspiration 133-361. Secondary infections after open drainage frequently result in increased morbidity and mortality. Turrill and Burnham [30] had I1 per cent secondary infections and ten fistulas in sixty-six patients. Active ameba are seldom seen in the exudate from the abscess, the wall of the abscess being a more productive place for locating ameba and causative organisms. Modern surgical technic permits intraperitoneal hepatic abscess drainage without danger of diffuse in trapleural or interperitoneal contamination. Abscesses may well be solitary but lobulated, occur in both lobes of the liver, or be multiple. With intraabdominal visualization, these entities will not be as easily overlooked. Therefore, because of the accurate localization of the liver abscess by photoscan and because of the heavy antibiotic and antiamebic coverage possible today, The American Journaf of Surgery
Aspiration
needle aspiration under direct visualization seems a very plausible method of treatment. The last three patients with solitary liver abscesses I have seen at North Carolina Memorial Hospital in Chapel Hill have been successfully treated in this manner. Two of the abscesses were located in the right lobe and the other in the left lobe of the liver. Photoscan identification and localization of the site of each abscess was not difficult. Laparotomy was performed in the two patients in whom the abscess was located in the anterior aspect of the liver, and the twelfth rib approach was used in the third patient, in whom the abscess was in the posterior aspect of the right lobe. Technic of Open Surgical
for Liver Abscess
wound without difficulty. This tube is preferred to the Foley catheter since the tip is longer and the entire abscess cavity is thus contacted. The balloon is then inflated and gently pulled forward to make the liver abscess watertight. Saline solution is instilled, and suction is then applied. Thus the cavity is gently irrigated and flushed out by alternate instillation of saline solution and suction. When the material returned is clear, the Bailey tube is then removed. Mattress sutures of chromic material are placed in the parenchyma of the liver to close the small puncture wound, after which the abdominal wall is closed. Wire sutures are laid in the skin and subcutaneous tissue for secondary closure of the incision in forty-eight to seventy-two hours.
Aspiration
Patients with a solitary abscess of the liver should have forty-eight hours of antiamebic therapy preoperatively, if possible, because of the difficulty in differential diagnosis. During celiotomy, visual localization of a liver abscess can be rather hazy, but palpation will usually confirm an edematous softened area or a pallid area of lessened consistency over the liver surface. Initial needle aspiration is carried out after protective packing to localize any inadvertent spillage. The aspirant is then given to the bacteriologist for immediate study for ameba, stained for bacteria, and cultured for anaerobic and aerobic bacteria. An Ochsner gallbladder trochar attached to suction is then introduced through the original needle puncture wound in the liver and the remainder of the exudate is aspirated. A Bailey tube is then introduced through the trochar
Comments
This procedure was used in the two patients with anterior abscess, one in the right lobe (Figure 1) and one in the left lobe (Figure 2)) with gratifying results. The same procedure was emyloyed in the third case except that the lateral twelfth rib approach was used. (Figure 3.) The lung could be seen with its excursions observed through the pleura. An incision was made below and lateral to this area, the posterior abdominal cavity was entered, and the abscess palpated. Trochar aspiration was carried out and by the time irrigation had been instituted, the report from the laboratory showed active amebae. Previous diagnostic aspiration two days before had shown anaerobic streptococci. Irrigation with the Bailey tube was carried out using saline solution, the incision was closed with chromic gut, and the tube left in place. The tube was removed in twenty-four hours, and the skin edges were closed
Figure 1.
A and B, preoperative scans (A, 10,000 counts per minute, right lateral; B, 9,000 counts per minute, anteroposterior). C and D, postoperative scans (C, 9,000 counts per minute, right lateral; D, 6,000 counts per minute, anteroposterior). The patient (FW, NCMH f21-7657). a twentv-two vear *, old white woman, had intermittent pain in the right upper quadrant and fever of three months’ duration. Scan showed abscess in the anterior aspect of the right lobe of the liver. Alkaline phosphatase was 24 nitro-phenol units, total protein 7.3 gm per cent, and albumin 3.1 gm per cent. Celiotomy with open aspiration was performed. Cultures grew anaerobic streptococci. The patient was placed on a regimen of kanamycin and Keflin%. One year postoperatively she has gained 15 pounds. I.
Vol.119.March1970
327
Patterson
B
A
secondarily with the previously placed Number 34 steel wire. All three patients had a safe and good result with no complications. Follow-up studies at two years, one year, and nine months show no evidence of recurrence. Liver scans are again useful in following resolution and regeneration with healing of the abscess cavity [22,34, 37,381. The antibiotic and antiamebic drugs were cominued for an unusually long time postoperatively. Tetracycline, chloramphenicol, and penicillin G are recommended for their effect on both anaerobic and aerobic bacteria. Chloroquine 0.5 gm per day for two months or more plus Diodoquina for two weeks to eliminate gastrointestinal trophozoites are recommended if the abscess is of amebic origin. It has been shown that no matter what form of surgical therapy was undertaken, the premature discontinuance of antibiotics may lead to recurrence [3]. The determination of red cell sedimentation rate and serum alkaline phosphatase is an excellent
Figure 2. A, preoperative scan (anteroposterior): 6, postoperative scan (7,000 counts per minute, anteroposterior). The patient (EG, NCMH #2OO&66), a fifty-six year old white man, has a fever of six weeks’ duration. A scan showed abscess in the left lobe of the liver. Alkaline phosphatase was 18.4 nitro-phenol units, total proterns 5 gm per cent, and albumin 1.5 gm ner cent. Celiotomv with ooen asoira‘tion was performed: Culture; grew ‘Batteroides. The patient was given tetracycline for three weeks. Two years postoperative/y he has gained 25 pounds.
method of following the convalescent course. One should be aware of the extremely low serum protein levels in these patients and act accordingly. When the sedimentation rate and alkaline phosphatase level return to normal, antibiotics may be safely discontinued. Summary
and Conclusions
Some form of surgical drainage is essential in the therapy of solitary abscess of the liver, whether pyogenie, amebic, or mixed. Open drainage is satisfactory but has complications which may be avoided if aspiration is successful. Morbidity and hospital stay are dccreased and nursing care is much simpler, Many liver abscesses are practically or completely sterile. so intraperitoneal exploration with aspiration of the exudate is a safe procedure. Visualization in this manner may reveal another abscess or lobular extension of a solitary abscess or even another abscess in the other lobe of the liver. The liver abscess will remain localized if the liver successfully resists invading organisms. Pre- and post-
Figure 3. A and 8, preoperative scans (A, 6,000 counts per minute right lat. eral; B, 8,000 counts per minute, anteroposterior). C and D, postoperative scans (C, 7,000 counts per minute, right lateral; D, 6,000 counts per minute, anteroposterior). The patient (RD, NCMH #22-44-06), a twenty-three year old white man, had a three week history of pain in the right upper quadrant and fever. Scan revealed an abscess in the posterior and lateral aspect of the right lobe of the liver. Preoperative aspiration revealed brown fluid which grew microaerophilic streptococci. Alkaline phosphatase was 21 nitro-phenol units, total protein, 7.0 gm per cent, and albumin 4.2 gm per cent. Operation was carried out through a posterior twelfth rib approach. Open aspiration showed active Endamoeba histolytica plus streptococci. The patient was given chloroquine, Diodoquin@, penicillin G, and chloramphenicol. Nine months postoperatively the patient has gained 23 pounds. 328
The
American
Journal
of Surgery
Aspiration
operative antibiotic care prevents further spread and sepsis. Simple aspiration of the exudate is sufficient treatment in most cases. Open aspiration and irrigation of the abscess cavity is more accurate and complete than blind needle technique. The liver then, with the backing of the antibiotics, can progress to resolution of the cavity and complete healing. References 1. Ochsner
A, DeBakey M, Murray S: Pyogenic abscess of the liver. II. An analysis of forty-seven cases with review of the literature. Amer J Surg 40: 292, 1938. 2. Chronin K: bogenic abscess of the liver. Gut 2: 53,
1961. 3. Block MA, Schuman
4.
5.
6.
7. 8. 9.
10.
11. 12.
13.
14.
15. 16.
17.
Vol.
BM, Eyler WR, Truant JP, Du Sault LA: Surgery of liver abscesses: use of newer techniques to reduce mortality. Arch Surg 88: 602, 1964. Ostermiller W, Carter R: Hepatic abscess: current concepts in diagnosis and management. Arch Surg 94: 353, 1967. Robertson RD, Foster JH, Peterson CG: Pyogenic liver abscess studied by cholangiography: case report and .%-year review. Amer Surg 32: 521, 1966. Joseph WL, Kahn AM, Longmire WP: Pyogenic liver abscess: changing patterns in approach. Amer J Surg 115: 63, 1968. Flynn JE: Pyogenic liver abscess. New England J Med 234: 403, 1946. Alexander S: Solitary pyogenic liver abscess. Scot Med J 10: 112, 1965. Altemeier WA: The cause of the putrid odor of perforated appendicitis with peritonitis. Ann Surg 107: 634, 1938. Wagner HN Jr, McAfee JG, Mozely JM: Diagnosis of liver disease by radioisotope scanning. Arch Int Med 107: 324, 1961. Nagler W, Bender MA, Blau M: Radioisotope photoscanning of the liver. G~str~nterology 44: 36, 1963. Schuman BM, Block MA, Eyler WR, Du Sault t: Liver abscess: rose bengal I 131 hepatic photoscan in diagnosis and management. JAMA 187: 708, 1964. Shingleton WW, Taylor LA, Pircher FJ: Radioisotope photoscan of liver in differential diagnosis of upper abdominal disease. Ann Surg 163: 685, 1966. May RP, Lehmann JD, Sanford JP: Difficulties in differentiating amebic from pyogenic liver abscess. Arch fntern Med 119: 69, 1967. McBee JW, Kohen RR, Rabin ER, Fred HL: Clinicopathologic conference. Texas Med 63: 99, 1967. Rothenberg RE, Linder W: The single pyogenic liver abscess: a study of 24 cases. Surg Gynec Obst 59: 31, 1934. Price JE, Joseph WL, Mulder DG: Diagnosis and treat-
119, March 1970
for Liver Abscess
ment of intrahepatic abscess. Amer Surgeon 33: 820, 1967. 18. Block MA: Principles in the management of liver abscesses. Amer J Surg 115: 587, 1968. 19. McFadzean AJS, Chang KPS, Wong CC: Solitary pyogenie abscess of the liver treated by closed aspiration and antibiotics. Brit J Surg 41: 141, 1953. 20. England MJ, England RA: Hong Kong as an elective. BMQ 15: 64, 1964. 21. McKenzie CG: Pyogenic infection of liver secondary to infection in the portal drainage area. &it N J II: 1558, 1964. 22. Stanford W, Neilsen AA, Dawson RG: Hepatic abscess: review of seven patients seen at Wilford. Arch Sorg 96: 20, 1968. 23. Hirschowitz BI: Medical grand rounds from the University of Alabama Medical Center. Southern M J 58: 1034, 1965. 24. Nather C, Ochsner EWA: Retroperitoneal operation for subphrenic abscess: with the report of two cases. Surg Gynec & Obstet 37: 665, 1923. 25. Patterson DK, Ozeran RS, Glantz GJ, Miller AB, Finegold SM: Pyogenic liver abscess due to microaerophilic streptococci. Ann Surg 165: 362, 1967. 26. Piccone VA: Discussion of: Pyogenic liver abscesses: changing patterns of approach. Amer J Surg 115: 63, 1968. 27. Elsberg CA: Solitary abscess of the liver. Ann Surg 44: 217, 1906. 28. Sherman JD, Robbins SL: Changing trends in the casuistics of hepatic abscess. Amer J Med 28: 943, 1960. 29. Bruno MS, Ober WB (ed): Fever of unknown or&in, changing clinical course, and pleural effusion. hew York J Med 68: 664, 1968. 30. Turrill FL, Burnham JR: Hepatic amebiasis. Amer J Surg
111: 424, 1966. 31. 32. 33.
34. 35.
36. 37.
38.
Farley HH, Linner JH: Amebic liver abscess. Minnesota Med 50: 477, 1967. Rambo WM, Black HC: lntrahepatic abscess. Amer Surg 35: 144. 1968. Douglas G, Moore P, Patterson MA: A ten-year review of amebic abscess of the liver: 1956-1966. Amer J Dig Dis 13: 709. 1968. Johnson R, Rogers J, Zinneman H: Amebic liver abscesses. Amer J Di~z Dis 13: 822. 1968. Sodeman WA, Beave; PC: A study of the therapeutic effects of some amebacidal drugs. Amef J Med 12: 440, 1952. Le Vine MA, Kehii M, Gyorkey F: Amebic abscess of the left lobe of the liver. Southern Med J 61: 415, 1968. Czerniak P, Lubin E, Djaldetti M, Devries A: Scintillographic follow-up of amoebic abscesses and hydatid cysts of the liver. J Nucl Med 4: 35, 1963. Sheehy TV, Parmley LF Jr, Johnston GS, Boyce HW: Resolution time of an amebic liver abscess. Gastroenterology 55: 26, 1968.
329
The high mortality associated with solitary abscess of the liver, no matter what the cause (pyogenic or amebit), represents the failure of early diagnosis and surgical therapy. Very close to 100 per cent mortality results if surgical drainage is not instituted [Z--6]. The use of broad spectrum antibiotics is helpful, but when used alone, they are ineffective [2,7-g]. For many years, the subtle characteristics of this condition have resulted in an all too frequent postmortem diagnosis [6]. Since the advent of hepatic scintiscan using 99” Tc sulphur colloid, there is no excuse for delay in making this diagnosis nor is there any difficulty in determining its location ]10--131 if both anteroposterior and lateral views are obtained. Lateral views are especially important [I#]. The liver scan may often appear to be normal in the presence of multiple liver abscesses [IS]. Successful open surgical drainage by the extra- or intraperitoneal route is life-saving [16--181. Yet, accruing to this method are many complications which increase morbidity and prolong hospital stay, such as hemorrhage, secondary infection of abscess cavity, prolonged drainage from a chronically infected wound, osteomyelitis, chronic draining sinus tracts, biliary fistulas, subphrenic abscess, subhepatic abscess, pleural empyema, and painful unsightly scars. Closed needle aspiration of solitary pyogenic abscess of the liver has been recommended and used by McFadzean since the early 1950’s, the results of which have not been duplicated 1191. Two medical students, Mary and Robert England, worked under McFadzean as an “elective” in Hong Kong [2CJ]. They followed up 108 of his patients with pyogenic abscesses treated by closed aspiration, reporting only one fatality. Although this method of abscess drainage has been used occasionally by others, its popularity seems never to have increased, and it has been used sparingly or ignored by the majority of surgeons in the United States 121-231. Open drainage has continued to be the surgical method of choice. When the posterior lateral approach of Nather and Ochsner 1241 furnishes a satisfactory drainage site, open or tube drainage is most satisfactory; but if abdominal intraperitoneal drainage is used, the procedure, in the past, has often been divided into two separate operative procedures to prevent general peritoneal contamination. Both surgical methods, closed drainage by From the Department of Surgery, University of North Carolina School af Medicine. Chapel Hill, North Carolina.
326
C PATTERSON,
MD, Chapel Hill, North Carolina
aspiration and open drainage, have their deficiencies. It occurred to me that celiotomy with simple aspiration might be applicable on many occasions. Abdominal exploration can be very advantageous ]2S]: The best site of drainage can be established, multiple abscesses can be found, and umbilical vein catherization for antibiotic therapy can be instituted in these cases in which it is indicated [26]; T tube cholangiographic studies can be carried out if needed [5:6] and drainage of the common biliary duct instituted if cholangitis is a factor 1171.
There has been the frequent observation that many of these abscesses are sterile: Stanford reported 100 per cent sterility [22]; Elsberg, 60 per cent 1271; Price, Joseph, and Mulder, SO per cent [17]; Rothenberg a.nd Linder, 45.8 per cent [16]; Joseph, Kahn, and Longmire, 33 per cent [6]. McFadzean, Chang, and Wong [29], Sherman and Robbins [ZS], and Bruno 1291 have also made similar observations. Certainly since the advent of antibiotics, no causative organism can be found in many instances, even after the use of special anaerobic technics. Solitary liver abscesses of amebic origin are almost always sterile [30,3f 1. Frequently anaerobic bacteria such as Bacteroidaceae which are relatively nonvirulent are cultured [18]. Thus the risk of intraperitoneal spillage and contamination during surgery is not fraught with great danger [6,17,21,32]. Experienced amebiologists recommend that all amebit abscesses of the liver can be treated satisfactorily by needle aspiration 133-361. Secondary infections after open drainage frequently result in increased morbidity and mortality. Turrill and Burnham [30] had I1 per cent secondary infections and ten fistulas in sixty-six patients. Active ameba are seldom seen in the exudate from the abscess, the wall of the abscess being a more productive place for locating ameba and causative organisms. Modern surgical technic permits intraperitoneal hepatic abscess drainage without danger of diffuse in trapleural or interperitoneal contamination. Abscesses may well be solitary but lobulated, occur in both lobes of the liver, or be multiple. With intraabdominal visualization, these entities will not be as easily overlooked. Therefore, because of the accurate localization of the liver abscess by photoscan and because of the heavy antibiotic and antiamebic coverage possible today, The American Journaf of Surgery
Aspiration
needle aspiration under direct visualization seems a very plausible method of treatment. The last three patients with solitary liver abscesses I have seen at North Carolina Memorial Hospital in Chapel Hill have been successfully treated in this manner. Two of the abscesses were located in the right lobe and the other in the left lobe of the liver. Photoscan identification and localization of the site of each abscess was not difficult. Laparotomy was performed in the two patients in whom the abscess was located in the anterior aspect of the liver, and the twelfth rib approach was used in the third patient, in whom the abscess was in the posterior aspect of the right lobe. Technic of Open Surgical
for Liver Abscess
wound without difficulty. This tube is preferred to the Foley catheter since the tip is longer and the entire abscess cavity is thus contacted. The balloon is then inflated and gently pulled forward to make the liver abscess watertight. Saline solution is instilled, and suction is then applied. Thus the cavity is gently irrigated and flushed out by alternate instillation of saline solution and suction. When the material returned is clear, the Bailey tube is then removed. Mattress sutures of chromic material are placed in the parenchyma of the liver to close the small puncture wound, after which the abdominal wall is closed. Wire sutures are laid in the skin and subcutaneous tissue for secondary closure of the incision in forty-eight to seventy-two hours.
Aspiration
Patients with a solitary abscess of the liver should have forty-eight hours of antiamebic therapy preoperatively, if possible, because of the difficulty in differential diagnosis. During celiotomy, visual localization of a liver abscess can be rather hazy, but palpation will usually confirm an edematous softened area or a pallid area of lessened consistency over the liver surface. Initial needle aspiration is carried out after protective packing to localize any inadvertent spillage. The aspirant is then given to the bacteriologist for immediate study for ameba, stained for bacteria, and cultured for anaerobic and aerobic bacteria. An Ochsner gallbladder trochar attached to suction is then introduced through the original needle puncture wound in the liver and the remainder of the exudate is aspirated. A Bailey tube is then introduced through the trochar
Comments
This procedure was used in the two patients with anterior abscess, one in the right lobe (Figure 1) and one in the left lobe (Figure 2)) with gratifying results. The same procedure was emyloyed in the third case except that the lateral twelfth rib approach was used. (Figure 3.) The lung could be seen with its excursions observed through the pleura. An incision was made below and lateral to this area, the posterior abdominal cavity was entered, and the abscess palpated. Trochar aspiration was carried out and by the time irrigation had been instituted, the report from the laboratory showed active amebae. Previous diagnostic aspiration two days before had shown anaerobic streptococci. Irrigation with the Bailey tube was carried out using saline solution, the incision was closed with chromic gut, and the tube left in place. The tube was removed in twenty-four hours, and the skin edges were closed
Figure 1.
A and B, preoperative scans (A, 10,000 counts per minute, right lateral; B, 9,000 counts per minute, anteroposterior). C and D, postoperative scans (C, 9,000 counts per minute, right lateral; D, 6,000 counts per minute, anteroposterior). The patient (FW, NCMH f21-7657). a twentv-two vear *, old white woman, had intermittent pain in the right upper quadrant and fever of three months’ duration. Scan showed abscess in the anterior aspect of the right lobe of the liver. Alkaline phosphatase was 24 nitro-phenol units, total protein 7.3 gm per cent, and albumin 3.1 gm per cent. Celiotomy with open aspiration was performed. Cultures grew anaerobic streptococci. The patient was placed on a regimen of kanamycin and Keflin%. One year postoperatively she has gained 15 pounds. I.
Vol.119.March1970
327
Patterson
B
A
secondarily with the previously placed Number 34 steel wire. All three patients had a safe and good result with no complications. Follow-up studies at two years, one year, and nine months show no evidence of recurrence. Liver scans are again useful in following resolution and regeneration with healing of the abscess cavity [22,34, 37,381. The antibiotic and antiamebic drugs were cominued for an unusually long time postoperatively. Tetracycline, chloramphenicol, and penicillin G are recommended for their effect on both anaerobic and aerobic bacteria. Chloroquine 0.5 gm per day for two months or more plus Diodoquina for two weeks to eliminate gastrointestinal trophozoites are recommended if the abscess is of amebic origin. It has been shown that no matter what form of surgical therapy was undertaken, the premature discontinuance of antibiotics may lead to recurrence [3]. The determination of red cell sedimentation rate and serum alkaline phosphatase is an excellent
Figure 2. A, preoperative scan (anteroposterior): 6, postoperative scan (7,000 counts per minute, anteroposterior). The patient (EG, NCMH #2OO&66), a fifty-six year old white man, has a fever of six weeks’ duration. A scan showed abscess in the left lobe of the liver. Alkaline phosphatase was 18.4 nitro-phenol units, total proterns 5 gm per cent, and albumin 1.5 gm ner cent. Celiotomv with ooen asoira‘tion was performed: Culture; grew ‘Batteroides. The patient was given tetracycline for three weeks. Two years postoperative/y he has gained 25 pounds.
method of following the convalescent course. One should be aware of the extremely low serum protein levels in these patients and act accordingly. When the sedimentation rate and alkaline phosphatase level return to normal, antibiotics may be safely discontinued. Summary
and Conclusions
Some form of surgical drainage is essential in the therapy of solitary abscess of the liver, whether pyogenie, amebic, or mixed. Open drainage is satisfactory but has complications which may be avoided if aspiration is successful. Morbidity and hospital stay are dccreased and nursing care is much simpler, Many liver abscesses are practically or completely sterile. so intraperitoneal exploration with aspiration of the exudate is a safe procedure. Visualization in this manner may reveal another abscess or lobular extension of a solitary abscess or even another abscess in the other lobe of the liver. The liver abscess will remain localized if the liver successfully resists invading organisms. Pre- and post-
Figure 3. A and 8, preoperative scans (A, 6,000 counts per minute right lat. eral; B, 8,000 counts per minute, anteroposterior). C and D, postoperative scans (C, 7,000 counts per minute, right lateral; D, 6,000 counts per minute, anteroposterior). The patient (RD, NCMH #22-44-06), a twenty-three year old white man, had a three week history of pain in the right upper quadrant and fever. Scan revealed an abscess in the posterior and lateral aspect of the right lobe of the liver. Preoperative aspiration revealed brown fluid which grew microaerophilic streptococci. Alkaline phosphatase was 21 nitro-phenol units, total protein, 7.0 gm per cent, and albumin 4.2 gm per cent. Operation was carried out through a posterior twelfth rib approach. Open aspiration showed active Endamoeba histolytica plus streptococci. The patient was given chloroquine, Diodoquin@, penicillin G, and chloramphenicol. Nine months postoperatively the patient has gained 23 pounds. 328
The
American
Journal
of Surgery
Aspiration
operative antibiotic care prevents further spread and sepsis. Simple aspiration of the exudate is sufficient treatment in most cases. Open aspiration and irrigation of the abscess cavity is more accurate and complete than blind needle technique. The liver then, with the backing of the antibiotics, can progress to resolution of the cavity and complete healing. References 1. Ochsner
A, DeBakey M, Murray S: Pyogenic abscess of the liver. II. An analysis of forty-seven cases with review of the literature. Amer J Surg 40: 292, 1938. 2. Chronin K: bogenic abscess of the liver. Gut 2: 53,
1961. 3. Block MA, Schuman
4.
5.
6.
7. 8. 9.
10.
11. 12.
13.
14.
15. 16.
17.
Vol.
BM, Eyler WR, Truant JP, Du Sault LA: Surgery of liver abscesses: use of newer techniques to reduce mortality. Arch Surg 88: 602, 1964. Ostermiller W, Carter R: Hepatic abscess: current concepts in diagnosis and management. Arch Surg 94: 353, 1967. Robertson RD, Foster JH, Peterson CG: Pyogenic liver abscess studied by cholangiography: case report and .%-year review. Amer Surg 32: 521, 1966. Joseph WL, Kahn AM, Longmire WP: Pyogenic liver abscess: changing patterns in approach. Amer J Surg 115: 63, 1968. Flynn JE: Pyogenic liver abscess. New England J Med 234: 403, 1946. Alexander S: Solitary pyogenic liver abscess. Scot Med J 10: 112, 1965. Altemeier WA: The cause of the putrid odor of perforated appendicitis with peritonitis. Ann Surg 107: 634, 1938. Wagner HN Jr, McAfee JG, Mozely JM: Diagnosis of liver disease by radioisotope scanning. Arch Int Med 107: 324, 1961. Nagler W, Bender MA, Blau M: Radioisotope photoscanning of the liver. G~str~nterology 44: 36, 1963. Schuman BM, Block MA, Eyler WR, Du Sault t: Liver abscess: rose bengal I 131 hepatic photoscan in diagnosis and management. JAMA 187: 708, 1964. Shingleton WW, Taylor LA, Pircher FJ: Radioisotope photoscan of liver in differential diagnosis of upper abdominal disease. Ann Surg 163: 685, 1966. May RP, Lehmann JD, Sanford JP: Difficulties in differentiating amebic from pyogenic liver abscess. Arch fntern Med 119: 69, 1967. McBee JW, Kohen RR, Rabin ER, Fred HL: Clinicopathologic conference. Texas Med 63: 99, 1967. Rothenberg RE, Linder W: The single pyogenic liver abscess: a study of 24 cases. Surg Gynec Obst 59: 31, 1934. Price JE, Joseph WL, Mulder DG: Diagnosis and treat-
119, March 1970
for Liver Abscess
ment of intrahepatic abscess. Amer Surgeon 33: 820, 1967. 18. Block MA: Principles in the management of liver abscesses. Amer J Surg 115: 587, 1968. 19. McFadzean AJS, Chang KPS, Wong CC: Solitary pyogenie abscess of the liver treated by closed aspiration and antibiotics. Brit J Surg 41: 141, 1953. 20. England MJ, England RA: Hong Kong as an elective. BMQ 15: 64, 1964. 21. McKenzie CG: Pyogenic infection of liver secondary to infection in the portal drainage area. &it N J II: 1558, 1964. 22. Stanford W, Neilsen AA, Dawson RG: Hepatic abscess: review of seven patients seen at Wilford. Arch Sorg 96: 20, 1968. 23. Hirschowitz BI: Medical grand rounds from the University of Alabama Medical Center. Southern M J 58: 1034, 1965. 24. Nather C, Ochsner EWA: Retroperitoneal operation for subphrenic abscess: with the report of two cases. Surg Gynec & Obstet 37: 665, 1923. 25. Patterson DK, Ozeran RS, Glantz GJ, Miller AB, Finegold SM: Pyogenic liver abscess due to microaerophilic streptococci. Ann Surg 165: 362, 1967. 26. Piccone VA: Discussion of: Pyogenic liver abscesses: changing patterns of approach. Amer J Surg 115: 63, 1968. 27. Elsberg CA: Solitary abscess of the liver. Ann Surg 44: 217, 1906. 28. Sherman JD, Robbins SL: Changing trends in the casuistics of hepatic abscess. Amer J Med 28: 943, 1960. 29. Bruno MS, Ober WB (ed): Fever of unknown or&in, changing clinical course, and pleural effusion. hew York J Med 68: 664, 1968. 30. Turrill FL, Burnham JR: Hepatic amebiasis. Amer J Surg
111: 424, 1966. 31. 32. 33.
34. 35.
36. 37.
38.
Farley HH, Linner JH: Amebic liver abscess. Minnesota Med 50: 477, 1967. Rambo WM, Black HC: lntrahepatic abscess. Amer Surg 35: 144. 1968. Douglas G, Moore P, Patterson MA: A ten-year review of amebic abscess of the liver: 1956-1966. Amer J Dig Dis 13: 709. 1968. Johnson R, Rogers J, Zinneman H: Amebic liver abscesses. Amer J Di~z Dis 13: 822. 1968. Sodeman WA, Beave; PC: A study of the therapeutic effects of some amebacidal drugs. Amef J Med 12: 440, 1952. Le Vine MA, Kehii M, Gyorkey F: Amebic abscess of the left lobe of the liver. Southern Med J 61: 415, 1968. Czerniak P, Lubin E, Djaldetti M, Devries A: Scintillographic follow-up of amoebic abscesses and hydatid cysts of the liver. J Nucl Med 4: 35, 1963. Sheehy TV, Parmley LF Jr, Johnston GS, Boyce HW: Resolution time of an amebic liver abscess. Gastroenterology 55: 26, 1968.
329