Percutaneous catheter drainage of amoebic liver abscess

Percutaneous catheter drainage of amoebic liver abscess

Clinical Radiology (1992) 45, 187 189 Percutaneous Catheter Drainage of Amoebic Liver Abscess V. A. SARASWAT, D. K. A G A R W A L , S. S. BAIJAL*, S...

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Clinical Radiology (1992) 45, 187 189

Percutaneous Catheter Drainage of Amoebic Liver Abscess V. A. SARASWAT, D. K. A G A R W A L , S. S. BAIJAL*, S. ROY*, G. C H O U D H U R I , R. K. D H I M A N , L. B H A N D A R I * and S. R. N A I K Departments o f Gastroenterology and *Radiodiagnosis, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, lndia Fifteen patients with amoebic liver abscesses underwent percutancous catheter drainage under ultrasonographic guidance. Thirteen patients had solitary abscesses (right lobe 12, left lobe 1), two had associated subdiaphragmatic collections, while two patients had multiple abscesses. The indications for the drainage included lack of response to medical therapy: imminent rupture in five cases; ruptured liver abscesses in three; enlarging abscesses after hospitalization in three; persistent symptoms in two; and large left lobe abscesses in two. The volume of the abscesses before drainage was 102-1008 ml (mean 432 ml). Pigtail catheters (8 F) were used in nine of the patients and 12 F sump catheters in six. When multiple abscesses and associated subdiaphragmatic collection were present, each was drained separately. The catheters were removed (mean 7 days, range 3-20 days) when patients became apyrexial, catheter drainage was less than 10 ml in 24 h and cavitogram showed a negligible cavity (mean residual volume 5.5 ml, range 3-15 ml). Complications included minor blood loss through the catheter for 12 h in one patient and reappearance of the abscess in another requiring further drainage. Our experience suggests that catheter drainage of amoebic liver abscesses in selected cases is safe and effective, and results in prompt and early resolution of the abscess cavity with restoration of normal parenchyma. Saraswat, V.A., Agarwal, D.K., Baijal, S.S., Roy, S., Choudhuri, G., Dhiman, R_K., Bhandari, L. & Naik, S.R. (1992)_ Clinical Radiology 45, 187-189. Percutaneous Catheter Drainage of Amoebic Liver Abscess

Catheter drainage of pyogenic liver abscess is a well established mode of therapy that has been found to be a safe and effective form of treatment (Gerzof et al., 1981; von Sonnenberg et al., 1982a). While some workers have expressed the opinion that drainage is seldom necessary for amoebic liver abscess (ALA) since they respond uniformly well to medical therapy (Rails et al., 1987), recent reports have noted excellent results with catheter drainage in selected cases (von Sonnenberg et al., 1985; Giorgio et al., 1988; Ken et al., 1989). We have, therefore, reviewed our experience with percutaneous catheter drainage of A L A over the last one year_ P A T I E N T S AND M E T H O D S Thirty patients with A L A were seen at this tertiary referral hospital between December 1989 and December 1990. Fifteen had already responded to medical treatment which had been instituted before referral and did not require drainage. The other 15 patients underwent catheter drainage (1! males and four females with ages ranging from 12 to 50 years; mean 33.5 years). In 13 patients the abscess was solitary (right lobe 12, left lobe 1) and two patients had multiple abscesses. Two solitary right lobe abscesses were multiloculated and two other patients with solitary right lobe abscesses had associated subdiaphragmatic collections. Criteria for Diagnosis The diagnosis of A L A in these patients was based on an appropriate clinical picture: a space-occupying lesion(s) Correspondence to: Dr V. A. Saraswat, Assistant Professor, Dept. of Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Post Box No. 375, Rae Bareli Road, Lucknow 226001, India.

in the liver on imaging and strongly positive serology ( > 1:512 titre on indirect haemagglutination). The diagnosis was further confirmed by the aspiration of pus in patients undergoing catheter drainage. The ALA was considered to be superinfected when other pathogenic organisms were grown on aerobic culture of the pus. Indications for Drainage All patients had received antiamoebic medical treatment in adequate doses before hospitalization and this was continued for a suitable period after hospitalization, Indications for performing catheter drainage included non-response to medical therapy: imminent rupture in five cases; ruptured liver abscesses in three; enlarging abscesses after hospitalization in three; persistent symptoms in t w o ; and catheter drainage was necessary for large left lobe abscesses in two patients. Lack of response to medical therapy was considered to be present when fever, toxaemia, pain and local signs persisted despite antiamoebic therapy in adequate doses for adequate periods, when imminent rupture of the abscess was suspected because of pointing in the abdominal wall and/or demonstration of a very thin rim of the liver tissue around the abscess on sonography, or when increase in size of the liver abscess was noted on serial sonography. Catheter Drainage Catheter drainage of the liver abscess was performed using standard techniques described previously (Gerzof et al., 1981; von Sonnenberg et al., 1982a). Under ultrasound guidance, either an 8 F pigtail catheter (nine cases) or a 12 F sump drainage catheter (six cases) was inserted into the abscess. Two separate catheters were placed in three patients: for right and left lobe abscesses in

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one patient and for right lobe abscess and subdiaphragmatic collections in two patients. Pus was aspirated as completely as possible after catheter insertion following which a baseline sinogram was performed to assess cavity size. A sample of the pus was routinely sent for microbiology (gram stain, culture and sensitivity). Monitoring and Catheter Removal Following the procedure, regular catheter irrigation was performed and the volume of pus drained was noted daily. Cavity size was monitored periodically by ultrasound and sinograms. Catheters were removed when the patient became asymptomatic, pus drainage was less than 10 ml in 24 h for 2 consecutive days and the sinogram showed a negligible cavity.

RESULTS Successful catheter drainage was achieved in all patients. Pus similar to anchovy sauce was aspirated in eight patients while creamy white or blood stained pus was aspirated in the other seven. Pyogenic organisms were isolated on aerobic culture in three patients, all of whom were treated with appropriate antibiotics. Amoebic serology was strongly positive in all patients ranging from 1 : 1024 to 1:4096 (mean 1:2048). Catheter drainage was necessary for 3 20 days (mean 7 days). Favourable clinical response was noted in all patients after catheter drainage, with resolution of temperature, control of toxaemia and subsidence of pain. Subdiaphragmatic collections in two patients with ruptured liver abscesses also resolved after catheter drainage_ Serial ultrasound and sinogram assessments of liver abscess volume showed progressive diminution and eventual disappearance of the abscess cavity over the period of drainage. The initial abscess volume ranged from 102 ml to 1008 ml (mean 432 ml) whereas, when the catheter was withdrawn, the abscess volume ranged from 3 ml to 15 ml (mean 5.5 ml). There was no mortality or major morbidity related to the procedure. Mild oozing of the blood through the catheter was noted in one patient which ceased spontaneously after 12 h and no blood transfusion was necessary. Reappearance of the abscess was noted in one patient after withdrawal of the catheter necessitating its reinsertion; the patient responded well to the second drainage. All patients were discharged in good health from the hospital.

DISCUSSION Fifteen of the 30 patients with A L A (50%) seen by us were considered to require drainage of the abscess. While ultrasound-guided drainage of A L A has been performed by other workers, it has generally been found necessary in fewer patients in earlier series. Thus Ralls et al. (1987) drained only 13.5% (13 of 96 cases) of their series and drainage was for diagnostic rather than therapeutic purposes in the majority. Von Sonnenberg et al. (1985) resorted to catheter drainage in 33% (20 of 60 cases) of

their cases for various reasons. However, Giorgio et al. (1988) reported a series of 20 patients with AEA who were managed by catheter drainage and noted short hospital stay and early complete resolution of the abscess cavity in their patients. Drainage was performed for standard, well established indications in our series (von Sonnenberg et al_, 1985; Ralls et al., 1987; Giorgio et al., 1988). Patients showing satisfactory response to medical therapy were not offered drainage even if they had moderate to large abscesses. The high proportion of patients with indications requiring drainage in this series is likely to be related to the tertiary referral nature of our hospital where patients tend to be admitted after having failed to respond to treatment elsewhere. An additional factor prompting drainage was the suspicion of secondary bacterial infection of ALA, although this was substantiated in only three (20%) of our patients. Percutaneous catheter drainage has seldom been performed for ruptured ALA. This dreaded complication, reported in up to 2% of cases with ALA, is the usual cause of mortality in this disease (Nuguid, 1978; Eggleston et al., 1978)_ A mortality of 23-42% has been reported when this complication occurs (Adams and Macleod, 1977; Eggleston et al., 1982). Predictive factors have been identified and include large abscesses (5-10 cm diameter), enlarging abscesses and left lobe abscesses (Abuabara et al., 1982). This complication has usually been managed by emergency surgical drainage of the abscess and involved serosal cavity, along with anti-amoebic drugs (Adams and Macleod, 1977; Verlenden and Frey, 1980; Greany et al_, 1985). Recently Ken et al. (1989) have reported successful catheter drainage of ruptured abscesses in five seriously ill patients. Three of our patients, two with intraperitoneal and one with pleuropulmonary rupture, were managed by catheter insertion into the liver abscess as well as into subdiaphragmatic and pleural collections. All three made a satisfactory recovery and were discharged in good health. Thus catheter drainage appears to be a safe and effective option for treating this serious complication. We found catheter drainage to be very effective therapy for ALA. Fever, pain, toxaemia and local signs improved rapidly in all patients after catheter drainage and usually resolved within 72 h. Catheter drainage was required for a mean of 7 days in these patients, all of whom had large abscess cavities (mean volume 432 ml). Progressive diminution in size of abscess cavity was noted over this period and, at the end of 3 weeks, abscess cavity had disappeared and sonographic restitution to normal anatomy documented in all patients. This experience is in marked contrast to the observation of persisting, nonresolving, space-occupying lesions reported by others who treated their patients with drugs alone (Ralls et al., 1983; Berry et al., 1986). Thus Ralls et al. (1983) noted complete sonographic resolution of A L A over periods of up to 23 months (mean 7 months) after starting medical therapy, while Berry et al. (1986) noted complete restitution of liver parenchyma in only three of 44 patients (6_8%) at 6 months after medical therapy. However, Giorgio et al. (1988), using repeated needle aspiration for drainage of large liver abscesses, noted complete resolution of abscess cavities over 2 8 weeks. The policy of a single aspiration to decompress the abscess along with appropriate drug therapy has its proponents but runs the risk of leakage of pus from punctured and inadequately decompressed abscess, with peritoneal contamination

PERCUTANEOUS CATHETERDRAINAGE requiring emergency surgery. It also leaves the p a t i e n t with a residual lesion in the liver necessitating repeated follow-up visits to the hospital, time off work a n d the a t t e n d a n t i m p l i c a t i o n that the individual is still unwell. I n contrast, using catheter drainage, complete resolution was noted within 3 weeks in our patients. Earlier reports on catheter drainage have n o t e m p h a sized the d u r a t i o n of d r a i n a g e necessary, the completeness of resolution of abscess cavity at the end of drainage period a n d the criteria followed for catheter withdrawal. A l t h o u g h early catheter r e m o v a l has been suggested by some workers in A L A patients (von S o n n e n b e r g et al., 1985), these authors also n o t e d a significant risk of recurrence of abscess. O u r experience suggests that m o s t abscesses need drainage for a week a n d that it is safe to pull out the catheters w h e n the patient is asymptomatic, pus drainage has decreased to less than 10 ml in 24 h a n d there is a negligible residual cavity. A L A cavities behave no differently from pyogenic liver abscess cavities following drainage a n d usually tend to disappear completely. I n our series, catheter drainage was a safe procedure with m i n i m a l complications. There was no mortality a n d no m a j o r procedure-related morbidity. N o p a t i e n t required surgical drainage. While complications of percutaneous catheter drainage have been described, including perforation o f hollow viscera, haemorrhage, peritoneal spillage, catheter displacement or blockage a n d septicaemia ( G e r z o f e t al., 1981, 1985; Gyorffy et al., 1987; v o n S o n n e n b e r g et al., 1982b), these have been m a i n l y in patients with pyogenic abscess where a mortality a n d failure rate of 10-30% has been described. F o r t u n a t e l y none of these problems were n o t e d in our patients, or in other series (yon S o n n e n b e r g et al., 1985; Ralls et al., 1987; G i o r g i o et al., 1988; K e n et al., 1989). In conclusion, p e r c u t a n e o u s catheter drainage of A L A in selected patients is a safe a n d effective m o d e of therapy that results in p r o m p t relief of symptoms, a short hospital stay a n d early resolution of abscess cavity with restoration of n o r m a l p a r e n c h y m a .

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REFERENCES

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