Case Report
Tropical Doctor
A case of amoebic liver abscess
complicated by bilhaemia and
venous thrombosis
Rohan Goel1 , Akash Roy2 , Debadrita Ray3,
Sreedhara B Chaluvashetty4 and Arka De5
Abstract
Amoebic liver abscess is the most common extra-intestinal manifestation of amoebiasis. It usually responds well to
treatment with metronidazole together with drainage, if indicated. Uncommonly, the abscess may rupture into the
pleura, peritoneum or pericardium, bile duct at its hilum, or produce septic emboli. We present a patient with two
rare complications: venous thrombosis and jaundice secondary to bilhaemia.
Keywords
Amoebic liver abscess, jaundice, bilhaemia, venous thrombosis, liver abscess
Case report
A 64-year diabetic, hypertensive male presented with
fever and right-hypochondrial pain for one month
with progressive non-cholestatic jaundice for two
weeks. An MRI-abdominal scan showed a liver abscess
in segment IV with segmental thrombosis of the left
portal vein and left hepatic vein without any biliary
radicular dilatation. Despite treatment with metronida-
zole and percutaneous catheter drainage for the hepatic
abscess, jaundice and output from catheter drain per-
sisted and he was referred after a week.
On arrival, he was icteric with a firm, tender hepato-
megaly (liver span 17 cm). Complete blood count
revealed anaemia (Hb: 75 g/L) and leucocytosis
(14  109/L). Blood biochemistry showed deranged
liver (total bilirubin: 359.1 mmol/L; conjugated biliru-
bin: 222.3 mmol/L; AST: 70 U/L; ALT: 69 U/L; ALP:
2516 U/L) and renal function (creatinine: 212.21 mmol/
L). Amoebic serology was positive by ELISA testing. In
view of the markedly raised alkaline phosphatase, we
suspected cholestasis and repeated an abdominal ultra-
sound scan which showed the pigtail catheter within the
abscess cavity, but no biliary dilation. By introducing
contrast through the pigtail, we could demonstrate a
communication between the biliary system and the
abscess (Figure 1). Thus, we suspected bilhaemia as the
cause of jaundice and failure of the abscess to resolve.
An endoscopic retrograde cholangiogram revealed a
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leak of contrast through the left hepatic duct near its
primary confluence to the hepatic venous system. A
double pigtail stent was therefore deployed to stem the
leak. No anticoagulation had been started for his venous
thrombosis, though intravenous antibiotics (pipera-
cillin-tazobactam) were continued. Subsequently, the
fever declined, the drain output decreased and jaundice
diminished. After a week, the pigtail catheter was
removed and the patient was discharged with improving
liver (bilirubin: 164.16 mmol/L; ALP: 296 U/L) and renal
(creatinine: 141.47 mmol/L) function.
Discussion
Jaundice is present with amoebic liver abscess in 6–29%
cases.1–3 Reasons include parenchymal liver injury,
1
Junior Resident, Department of Internal Medicine, PGIMER, Chandigarh,
India
2
Senior Resident, Department of Hepatology, PGIMER, Chandigarh, India
3
Senior Resident, Department of Laboratory Oncology, AIIMS, New
Delhi, India
4
Assistant Professor, Department of Radiodiagnosis and Imaging,
PGIMER, Chandigarh, India
5
Assistant Professor, Department of Hepatology, PGIMER, Chandigarh,
India
Corresponding author:
Arka De, Department of Hepatology, Postgraduate Education of Medical
Education and Research, Sector 12, Chandigarh 160012, India.
Email: arkascore@gmail.com
2 Tropical Doctor 0(0)
Figure 1. Contrast liver cavity study (white arrow) shows
contrast in abscess cavity (red arrow) with a communication with
the biliary tree resulting in opacification of the undilated common
bile duct (dark arrow).
external compression, and distortion of the biliary tree
by the liver abscess and haemobilia due to bilio-vascu-
lar fistula.1–4 Ulcerogenic properties of bile prevent
healing of the fistula. The presentation of the particular
type of fistula depends on the vessel involved.
Normally, the mean pressure of the hepatic artery
and hepatic vein are 100 mmHg and 5 mmHg, respect-
ively. With arterial involvement in the bilio-vascular
fistula, the pressure gradient results in the movement
of blood into the bile duct (haemobilia). Conversely, in
the case of a portal or hepatic vein involvement, the
pressure gradient results in bile flow towards the
venous system, with resultant bile in the bloodstream
(bilhaemia) and clinical presentation with jaundice.4
In the setting of liver abscess, bilhaemia should be
suspected in a jaundiced patient with conjugated hyper-
bilirubinaemia and raised alkaline phosphatase without
dilatation of biliary radicles, as was seen in our case.
Management of bilhaemia not responding to conserva-
tive management entails biliary drainage by endoscopic
sphincterotomy, stenting, nasobiliary drainage and
rarely surgery. The underlying principle behind
endoscopic treatment is to decrease the pressure gradi-
ent across the fistula by relaxing or bypassing sphincter
of Oddi, thus causing a reversal of bile flow, which in
turn helps in natural fistula closure.4
There is scant literature about the prevalence and
management of venous thrombosis in an amoebic
liver abscess.5 Asymptomatic patients may not need
anticoagulation, as management of the abscess per se
usually leads to its resolution. However, short duration
anti-coagulation may be considered in patients with
caval involvement or those who become symptomatic
with portal hypertension or mesenteric ischaemia.5
Declaration of conflicting interests
The author(s) declared no potential conFicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
ORCID iDs
Rohan Goel https://orcid.org/0000-0003-4434-8490
Akash Roy https://orcid.org/0000-0001-5126-1655
Arka De https://orcid.org/0000-0002-8567-1676
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