|Year : 2017 | Volume
| Issue : 6 | Page : 532-535
Ruptured liver abscess: Analysis of 50 cases
Mohit Bhatia, Murtuza Ali
Department of General Surgery, VMMC and Safdarjung Hospital, New Delhi, India
|Date of Submission||07-May-2017|
|Date of Acceptance||21-Aug-2017|
|Date of Web Publication||17-Jan-2018|
Dr. Mohit Bhatia
1, Bank Colony, Opposite Old Sessions Courts, Ambala City - 134 003, Haryana
Source of Support: None, Conflict of Interest: None
Background: Liver abscess (pyogenic and amebic) is frequently encountered clinical condition; however, it can result in lethal outcome if there is a delay in diagnosis and treatment. Despite modalities to diagnose the condition early, still ruptured liver abscess presents with a common cause of acute abdomen in surgical emergency. In developing countries, ruptured liver abscess is a common cause of mortality. For contained abscess, nonsurgical options are considered; however, for ruptured liver abscess, surgical intervention is considered necessary. Materials and Methods: This was a retrospective study carried in Safdarjung hospital, New Delhi, between 2015 and 2016. All patients with ruptured liver abscess (clear signs of peritonitis) were included in this study, and those patients having other causes of peritonitis were excluded. A preformed protocol for management was followed for all the patients, and various parameters contributing to the illness and its prognosis were evaluated and assessed. Results: Out of the fifty patients assessed, male patients were mainly affected (86%). The most affected age group was 31–40 years (64%) followed by 41–50 years (22%). Right hypochondrium pain was the most common presenting complaint. Nine patients (18%) had presented with signs of toxemia. Only right lobe of the liver was affected the most in 44 patients (88%). Escherichia coli was the most common organism isolated in our study in 19 patients (38%). A total of 19 patients (38%) had diabetes in our study and total of 13 patients had mortality in our study. Conclusion: Ruptured liver abscess most commonly involves the right lobe of the liver. Males are affected far higher than the females; probable cause believed to be higher alcohol consumption. Most common affected age group falls between 30 and 60 years of age. If prompt treatment is started in time, mortality involved with it is evitable.
Keywords: Laparotomy, liver abscess, rupture
|How to cite this article:|
Bhatia M, Ali M. Ruptured liver abscess: Analysis of 50 cases. Med J DY Patil Univ 2017;10:532-5
| Introduction|| |
Liver abscess can be classified into pyogenic and amebic, both having its serious implications, especially when presented late. In developing countries like India, it forms a major cause for mortality and morbidity. With the advent of modern radiological modalities, diagnosis of hepatic abscess is possible in early stages resulting in nonsurgical management; however, fraction of patients either due to late presentation or refractory disease presents with ruptured liver abscess thereby increasing the mortality, presents with fatal disease course, and requires surgical intervention at the earliest.
Most common presenting complaints include pain in the right upper abdomen along with fever associated with chills/rigors. Alcoholism is a major contributing factor along with other causes including diabetes and immunosuppression.
Amebic liver abscess is caused by Entamoeba histolytica, a protozoan having fecal-oral transmission. It mostly affects intestinal mucosa; however, liver abscess is its most common extraintestinal manifestation.
Pyogenic liver abscess mostly presents with right hypochondrial pain, fever, and anorexia. Most common etiology is believed to be related to biliary causes. It is most commonly associated with Klebsiella, Staphylococcus aureus, and Escherichia More Details coli.
Mostly, liver abscess is multiple and affects right lobe of liver.
| Materials and Methods|| |
All patients with ruptured liver abscess admitted in our hospital between 2015 and 2016 interval are included in this study. Retrospective and prospective analysis of all the cases (proven clinically and radiologically) is carried out.
All patients with proven ruptured liver abscess are included in this study, and those patients having other causes of peritonitis have been excluded.
All the patients were kept nil per oral with Ryles tube care and were subjected to intravenous antibiotics (injection monocef 1 g intravenous (i.v) bd along, injection metronidazole 500 mg i.v tds along with analgesics and antacids). Patients were subjected to radiological investigations such as chest X-ray and abdominal X-ray along with ultrasonography whole abdomen. Blood investigations were evaluated for complete hemogram, total leukocyte counts, liver function tests, and coagulation profile. Patients with deranged coagulation profiles were given injection Vitamin K Intra-muscular for 3 days and fresh frozen plasma. Patients were subjected to exploratory laparotomy with thorough peritoneal lavage, and abdominal drains were kept in the right subhepatic space and left drain in pelvis and pus was sent for culture sensitivity. Patients were kept for regular follow-ups.
| Results|| |
In our study, out of fifty patients, 43 (86%) were males and seven patients (14%) were females [Table 1]. Males are believed to be affected more probably because of alcohol consumption.
Most common age group affected in our study is 31–40 years comprising of 32 patients (64%), 11 patients between 41 and 50 years (22%), five patients between 51 and 60 years (10%), and two patients between 21 and 30 years (4%) [Table 2].
Most of the patients presented with complaints of right hypochondrial pain specifically 43 patients (86%). Thirty-four patients (68%) complained of nausea and vomiting, 17 patients (34%) had presented with complaints of anorexia and loss of appetite, and 37 patients (74%) had presented with high fever along with chills and rigors [Table 3].
All fifty patients (100%) had right hypochondrial tenderness and 43 patients (86%) had generalized guarding/rigidity. Moreover, nine patients (18%) had signs of severe toxemia on presentation.
Forty-six patients (92%) had increased total leukocyte counts whereas 17 patients (34%) had hemoglobin levels <9 g/dl.
Out of fifty patients, 44 patients (88%) had liver abscess confined to right lobe only; in five patients (10%), it involved both right and left lobe, and in one patient (2%), it involved only left lobe [Table 4].
Out of fifty patients, 19 patients (38%) had diabetes mellitus, 14 patients (28%) had hypertension, and three patients (6%) had chronic liver disease.
Out of fifty patients, 19 patients (38%) yielded E. coli in pus culture sensitivity reports, whereas seven patients (14%) showed Klebsiella, and 11 patients (22%) showed polymicrobial growth. Moreover, in rest of the patients, pus culture reports were not conclusive [Table 5].
Out of fifty patients, 13 patients (26%) had mortality. Moreover, in three patients (6%), rupture was seen in pleural cavity as well, and these patients were subjected to intercostal drainage. However, 21 patients (42%) had mild-to-moderate pleural effusion on the right side.
| Discussion|| |
Management of ruptured liver abscess includes placement of catheters, laparoscopic drainage, and open surgical methods are superior than laparoscopic methods for total resolution.
As in our study suggestive of abdominal pain as the most presenting complaint, Rajak et al. too concluded in their study with similar results.
Our study showed male predominance in patients affected with ruptured liver abscess with 43 patients (86%), similar results were shown by Tiwari et al.
Pang et al. in their study concluded the majority of patients affected were in age group of 50–65 years. However, our study suggested the majority of patients affected in age group of 31–40 years (64%). Similar results were shown in a study by Oschner et al.
In our study, 88% patients had abscess confined to the right lobe only, and similar results were shown by Sharma et al in his study concluded the same result with high propensity for right lobe.
| Conclusion|| |
Liver abscess (ruptured) is a surgical challenge which needs to be addressed in early stages to reduce the mortality. Most common affected age group falls between 30 and 60 years of age with male predominance being affected. Alcoholics and patients with diabetes and immunosuppression are at high risk for developing liver abscess. Right hypochondrium pain along with fever and chills/rigor forms main presenting features with increased total leukocyte counts. Surgical exploration with thorough peritoneal lavage improves the patients' condition; however, disease onset, patients general condition, and presence/absence of comorbid conditions play an important role in final outcome and prognosis of the patient.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]