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9:4
Early symptoms during the onset of a PLA are non-specific and include malaise, nausea, anorexia and weight loss, headaches, myalgia, and arthralgia in most of the cases.
These prodromal symptoms may be present for many weeks before the appearance of more
specific symptoms, such as fever, chills and abdominal pain, although the pain is not always
localized to the right upper quadrant.
An abscess adjacent to the diaphragm may cause pleuritic type pain, cough and dyspnea, and
when this presentation is associated with the above-mentioned non-specific symptoms, it can
cause diagnostic difficulty.
Septic shock may occur in a few patients, especially in the setting of an obstructed biliary tree.
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Malignant
Gall bladder
Ampulla
Head of pancreas
Portal
Benign
Diverticulitis
Anorectal suppuration
Pelvic suppuration
Postoperative sepsis
Intestinal perforation
Pancreatic abscess
Appendicitis
Malignant
Colonic cancer
Gastric cancer
Arterial
Endocarditis
Vascular sepsis
ENT infection
Dental infection
Traumatic
Benign
Malignant
Chemoembolization
Cryptogenic
Although uncommon, some patients present with peritonitis after free rupture of an abscess into the peritoneal
cavity.
Diagnosis:
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Gram-negative aerobes
Escherichia Coli
Klebsiella pneumoniae
Pseudomonas aeruginosa
Proteus spp.
Citrobacter freundii
Streptococcus milleri
Staphylococcus aureus
Enterococcus spp.
Bacteroides spp
Fusobacterium spp.
Clostridium spp.
Peptostreptococcus spp.
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Clinical features:
Approximately 20% have a past history of dysentery and
another 10% history of diarrhoea or dysentery at the time of
diagnosis.20
Septic shock,
Clinical jaundice
Coagulopathy
Leukocytosis
Hypoalbuminemia
Multiple abscesses
Intraperitoneal rupture
On examination:
The cardinal sign of amoebic liver abscess is painful hepatomegaly. On palpation the liver is soft and smooth.
Localized tenderness in the region of the abscess, most
commonly at the lower right intercostal spaces, is frequently seen. Hepatomegaly may not be detected in patients with abscess at subdiaphragmatic location.
Investigations:
On aspiration, the amoebae are sparse in necrotic material from the centre of the abscess, but are more abundant on the marginal walls and are therefore more commonly found in the last portion of aspirated material.
Alcoholism
Malignancy
HIV infection
Malnutrition
Corticosteroid use
Homosexual activity
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Straight X-ray of abdomen and thorax: May reveal elevation of the right hemidiaphragm, pleural reaction obscuring the right costophrenic angle.
Adult dosage
Pediatric dosage
Side Effects
Amoebicidal agents
1. Metronidazole
750 mg orally three times a day for 3050 mg/kg/d for 510 days orally Psychosis, seizures, Peripheral neu510 days;
in three divided doses;
ropathy and a metallic test
500 mg IV every 6 hours for 510 15 mg/kg IV load followed by 7.5 mg/
days
kg every 6 hours (maximum, 2250
mg/d)
2.
Chloroquine (base) (used as an 600 mg/d orally for 2 days, then 300 10 mg /kg of chloroquine base
alternative or adjuvant)
mg/d orally for 14 days
3.
Luminal agents
(Used to eradicate intestinal colonization after Amoebicidal treatment)
1.
Paromomycin
2. Iodoquinol
3.
25-30 mg/kg/d orally for 7 days in 25 mg/kg/d orally for 7 days in three Diarrhoea,
three divided doses
divided doses (maximum, 2 g/d)
650 mg orally three times a day for 3040 mg/kg/d for 20 days in three Contra indicated in patients with He20 days
divided doses (maximum, 2 g/d)
patic insufficiency or hypersensitivity
to Iodine
Diloxanide furoate (Indicated in 500 mg orally three times a day for 20 mg/kg/d in three divided doses
patients who fail to respond to 10 days
Iodoquinol and Paromomycin)
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No compression effect
Seronegative abscesses
complicated ALA (ruptured in the pleural cavity / pericardial cavity/ adjacent viscera)
encephalopathy,
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REFERENCES
1.
5.
6.
Chou FF, et al. Single and multiple pyogenic liver abscesses: clinical course, etiology and results of treatment. World J Surg 1997;
21:384-9.
7.
8.
9.
Perez J, et al. Clinical course, treatment and multivariate analysis of risk factors for pyogenic liver abscess. Am J Surg 2001;
181:177-86.
10. Seeto R, et al. Pyogenic liver abscess: changes in etiology, management and outcome. Medicine 1996; 75:99-113.
11. Ng FH, et al. Sequential intravenous/oral antibiotics vs continuous
intravenous antibiotics in the treatment of pyogenic liver abscess.
Aliment Pharmacol Therap 2002; 16:1083-90.
12. Yu SC, et al. Treatment of pyogenic liver abscess: prospective randomized comparison of catheter drainage and needle aspiration.
Hepatology 2004; 39:932-8.
13. Bayraktar Y, et al. Percutaneous drainage of hepatic abscess: therapy does not differ for those with identifiable biliary fistula. Hepatogastroenterol 1996; 43:620-6.
14. Stain S, et al. Pyogenic liver abscess: modern treatment. Arch Surg
1991; 126:991-5.
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