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Forrschr. Röntgenstr. 123,5 (1975) 486-488 © Georg Thieme Verlag, Stuttgart
Amoebic liver abscess with biliary fistula Von K. Brøndum Nielsen and V. Hegedüs 2 Abbildungen The Department of Radiology, Glostrup Hospital Copenhagen, Denmark
A 39-year-old Pakistani worker was admitted to the surgical ward at our hospital 7 times during the period of 1971-74,
where the mass was palpable. The lesion was found to be homogenous with a few suspicious echoes.
At the time of his first admittance, the patient had been living
Laboratory findings: Sedimentation rate 60 mm/h. - Hgb 146 gm/l - WBC 12.500 cells/(fl - SGOT and SGPT and
in Denmark for 7 months. Previously, he was healthy. He had no history of earlier diarrhoea. Consecutive upper gastrointestinal series and barium enemas revealed no pathological findings. On all
occasions the cause for admittance was abdominal pain,
predominant]y epigastrïc - right upper quadrant. In August 1971 and again in November 1974 a liver abscess was diagnosed. The etiology of this was not confirmed until 1974 as being entamoeba histolytica. During none of the admissions did the routine laboratory findings indicate a liver disease or a liver abscess. Chest X-rays did not show elevation of one hemidiaphragm. In Februrary 1971 an appendectomy was performed. Histology of the appendix found changes indicating chronic inflammation. In August 1971 the patient was admitted with a 4-week history of increasing, finally almost constant upper abdominal aching distress of varying intensity, loss of appetite, and fever for 2 weeks. On physical examination the patient was found to be febrile, and a
tender, indefinite mass in the upper abdomen was palpable. Ultrasonic scanning showed a 7 X 7 x S cm cavity at the site
serum bilirubin within the normal. Because of increasing prominence of the mass, laparotomy was performed with subsequent emptying of an orange-sized abscess cavity in the left liver lobe, and removal of the abscess wall.
There were no postoperative complications. The draining tube was removed after 10 days.
The Contents of the abscess and the abscess membrane were examined microscopically for echinococcus, but not specifically for amoeba. No signs of echinococcus were found. The complement fixation test and intracutaneous test for echinococcus were negative. Recto-sigmoideoscopy with biopsy showed normal mucosa, and failed to reveal amoeba. During 1972 and 1973 the patient was
admitted 3 times to the surgical department, again with a history of acute abdominal pain. There were no gastrointestinal disturbances, no fever, and laboratory findings were negative. The gastrointestinal canal was examined radiologically, and nothing pathological was found.
Dieses Dokument wurde zum persönlichen Gebrauch heruntergeladen. Vervielfältigung nur mit Zustimmung des Verlages.
486
487
Fig. la. Arterial phase shows dislocation of coeliac axis and left hepatic artery; severe dislocation of two arteries belonging to the left liver lobe (arrows), and displacement of the stomach. No
Fig. lb. Venous phase visualizes the splenic vein. Despite 60 ml contrast used for the investigation no opacification of the portal
pathologic vessels can be found.
mass.
Fig. la and b.
vein could be seen. Also the left kidney is slightly displaced by the
Coeliacography.
In November 1974 the patient was admitted again with a history of acute upper abdominal pain, fever, and loss of weight.
On physical examination the patient was febrile (tp. 39,40 C) and very tender at palpation of the upper part of the abdomen, yet no mass was palpable. 10.300 The laboratory findings were: SR = 52 mm/h - WBC
cells/l with a shift to the left, proteinuria and slightly elevated alkaline phospatase. Ultrasonic scanning of the liver was performed, but failed to reveal any liver pathology.
A few days later, a tender mass was felt in the upper part of the abdomen which reached 3-4 cm proximally to the umbilicus. Radioisotope scanning showed the liver to be enlarged with a big round defect in the left lobe. An amoebic abscess of the liver was suspected, and a serological test specific for amoebiasis was carried out. However, the highly
significant result for amoebiasis did not arrive until after the patient was operated. Treatment with metronidazole (Flagyl®) 800 mg X 3 was begun without awaiting the answer to the serological test. The fever and pain disappeared. 1 week later metronidazole was supplemented with chloroquine tablets 500 mg x 2 for 2 days and 250 mg x 2 for 12 days. After a few days, however, the patient was febrile again. A new isotope scanning showed increased size of the defect in the left liver lobe. Since no diagnosis was achieved, aortography and coeliacography was performed, for visualization of the vessels participating in the lesion. This investigation revealed a large, round avascular mass dislocating the coeliac origin, branches of the left hepatic artery, and compressing the inflow of the splenic vein into the portal vein (fig. 1). No patholocigal vessels were found. After this investigation the lesion could be characterized as an abscess and was opened and drained through a little incision. The abscess contained 810 ml of thick yellow nonodorous pus. The still warm pus was examined by direct microscopy without staining, but no trophozoites were found. Also a PAS-coloured microscopic preparation was examined, but again revealed no trophozoites. The pus was sterile on culture.
Cavernogram prior to removal of the drain demonstrates the shrinked cavity and the biliary fistula. Fig. 2.
Postoperatively the patient was treated additionally with Gentamycm 80 mg x 3 for 8 days and then Cephalexin 250 mg X 4 until the drain was removed to prevent secondary bacterial infection of the
cavity. The patient was afebrile and made an uninterrupted recovery. During this period subsequent cavernographies demon-
Dieses Dokument wurde zum persönlichen Gebrauch heruntergeladen. Vervielfältigung nur mit Zustimmung des Verlages.
Fortschr. Röntgenstr. 123, 5
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strated decreasing size of the lesion and a connection with the biliary system. One and a half months after the operation, no further suppuration through the drain could be observed. Before removal of the drain a control roentgen examination of the cavity was performed. This investigation showed shrinkage of the cavity around the ballon of the drain with the fistula to the left biliary
duct through which the entire biliary tree could be visualized (fig. 2).
After the removal of the drain no complications occurred. Further
controls during the last 3 months by isotope scanning, liver chemistry, consecutive examinations of the stools, and serological
tests showed no abnormalities. The cutaneous wound is healed without biliary fistula.
Discussion Diagnosis of different forms of amoebiasis - well known i11 tropical medicine - can be difficult at our latitudes, Increased tourism and exchange of labour from different geographic areas produce increasing confrontations between the European radiolo-
gist and amoebiasis. Amoebic liver abscess is not necessarily preceded by amoebic dysenteria, although the patient has an asymptomatic intestinal amoebiasis, and can therefore be difficult
to recognise (1). It is stressed that radioisotope and ultrasonic scanning can be of value (8). However, scintigraphy often cannot distinguish a puscontaining lesion from certain forms of malignancy. Difficulties can occur at ultrasonography because of the lack of a well defined acoustic border between the liver substance and abscess contents (7). At angiography the findings are surpris-
ing since no pathologic vessels could be found in our patient (angiography in amoebiasis is to our knowledge not yet published). Only displacement of the vessels indicated the size of the lesion.
when the abscess in the left liver lobe had ruptured to the biliary tree did the patient get adequate medical and surgical treatment. The diagnosis of an amoebic abscess of the liver should be considered in a patient with a tender enlarged liver who has been to endemic areas. Laboratory findings are not helpful since the liver function tests are rarely affected.
A trial of specific anti-amoebic treatment with prompt recovery will support the diagnosis. The diagnosis can be supported by plain X-ray examination of the diaphragm as it may show elevation of one dome, although in our
patient no involvement of the left diaphragm was observed. Angiography is needed only when differential diagnosis by other methods cannot be obtained. Cavernography through the draining tube is of value for demonstration of the relationship of the lesion towards the neighbouring organs (2, 3, 4). Identification of E-histolytica in pus from the abscess provides the definite proof of amoebiasis. Lamont, N. M., N. R. Pooler:
Literature
Hepatic amoebiasis: a study of 250
Alkan, W. J., B. Kalnii, M. Kalderon: The clinical syndrome of amebic
abscess of the left lobe of the liver. Ann. intern. Med. 55 (1961) 800 Faerber, E. N., F. Segal, N.
L.
Sischy: Case report. Amoebic peri-
carditis. Brit. J. Radiol. 47 (1974) 816
Gupta, S. K., M. N. Khanna: Cavernogram for diagnosis of Amoebic liver abscess. Clin. Radiol. 23 (1972) 219
Harding, T., E. A. Lewis, S.
P.
cases. Quart. J. Med. (Oxf.) 27 (1958) 107
MacLeod, I. N., A. J. Wilmot, S. J. Powell: Amoebic pericarditis. Quat. J. Med., New Series XXXV, 138 (1966) 293
Matthews, A. W., K. R. Gough, E. R. Davies, F. G. M. Ross, A. Hinch-
life: The use of combined ultrasonic and isotope scanning in the diagnosis amoebic liver disease. Gut 14 (1973) 50 Wenger, J., J. C. Coberly: Rapid
Amoebic abscess in the liver lobe is a very dangerous situation
Bohrer: Inrra-cavitary barium sulphate
because of the high incidence of rupture towards the neighbouring
in the assessment of amoebic liver
diagnostic approach to amebic liver abscess. Amer. J. dig. Dis., New
abscess. Clin. Radiol. 21 (1970) 68
Series 14 (1969) 282
organs, as peritoneum, pleura and pericardium (2, 5, 6). Our patient has been operated on three occasions for the same disease. Despite the geographic anamnesis the removed appendix was not investigated for Entamoeba histolytica, although the predilection site for chronic intestinal amoebiasis is the coecum. Nor was half a year later a verified and emptied liver abscess submitted to appropriate diagnostic procedures. Not until at the seventh admission,
Dozent, Dr. med. Viktor Hegedüs, Associated head Department of Diagn. Radiology Glostrup Hospital Copenhagen, DK-2600 Glostrup, Denmark
Dieses Dokument wurde zum persönlichen Gebrauch heruntergeladen. Vervielfältigung nur mit Zustimmung des Verlages.
488
Fortschr. Röntgenstr. 123, S
Forrschr. Röntgenstr. 123,5 (1975) 486-488 © Georg Thieme Verlag, Stuttgart
Amoebic liver abscess with biliary fistula Von K. Brøndum Nielsen and V. Hegedüs 2 Abbildungen The Department of Radiology, Glostrup Hospital Copenhagen, Denmark
A 39-year-old Pakistani worker was admitted to the surgical ward at our hospital 7 times during the period of 1971-74,
where the mass was palpable. The lesion was found to be homogenous with a few suspicious echoes.
At the time of his first admittance, the patient had been living
Laboratory findings: Sedimentation rate 60 mm/h. - Hgb 146 gm/l - WBC 12.500 cells/(fl - SGOT and SGPT and
in Denmark for 7 months. Previously, he was healthy. He had no history of earlier diarrhoea. Consecutive upper gastrointestinal series and barium enemas revealed no pathological findings. On all
occasions the cause for admittance was abdominal pain,
predominant]y epigastrïc - right upper quadrant. In August 1971 and again in November 1974 a liver abscess was diagnosed. The etiology of this was not confirmed until 1974 as being entamoeba histolytica. During none of the admissions did the routine laboratory findings indicate a liver disease or a liver abscess. Chest X-rays did not show elevation of one hemidiaphragm. In Februrary 1971 an appendectomy was performed. Histology of the appendix found changes indicating chronic inflammation. In August 1971 the patient was admitted with a 4-week history of increasing, finally almost constant upper abdominal aching distress of varying intensity, loss of appetite, and fever for 2 weeks. On physical examination the patient was found to be febrile, and a
tender, indefinite mass in the upper abdomen was palpable. Ultrasonic scanning showed a 7 X 7 x S cm cavity at the site
serum bilirubin within the normal. Because of increasing prominence of the mass, laparotomy was performed with subsequent emptying of an orange-sized abscess cavity in the left liver lobe, and removal of the abscess wall.
There were no postoperative complications. The draining tube was removed after 10 days.
The Contents of the abscess and the abscess membrane were examined microscopically for echinococcus, but not specifically for amoeba. No signs of echinococcus were found. The complement fixation test and intracutaneous test for echinococcus were negative. Recto-sigmoideoscopy with biopsy showed normal mucosa, and failed to reveal amoeba. During 1972 and 1973 the patient was
admitted 3 times to the surgical department, again with a history of acute abdominal pain. There were no gastrointestinal disturbances, no fever, and laboratory findings were negative. The gastrointestinal canal was examined radiologically, and nothing pathological was found.
Dieses Dokument wurde zum persönlichen Gebrauch heruntergeladen. Vervielfältigung nur mit Zustimmung des Verlages.
486
487
Fig. la. Arterial phase shows dislocation of coeliac axis and left hepatic artery; severe dislocation of two arteries belonging to the left liver lobe (arrows), and displacement of the stomach. No
Fig. lb. Venous phase visualizes the splenic vein. Despite 60 ml contrast used for the investigation no opacification of the portal
pathologic vessels can be found.
mass.
Fig. la and b.
vein could be seen. Also the left kidney is slightly displaced by the
Coeliacography.
In November 1974 the patient was admitted again with a history of acute upper abdominal pain, fever, and loss of weight.
On physical examination the patient was febrile (tp. 39,40 C) and very tender at palpation of the upper part of the abdomen, yet no mass was palpable. 10.300 The laboratory findings were: SR = 52 mm/h - WBC
cells/l with a shift to the left, proteinuria and slightly elevated alkaline phospatase. Ultrasonic scanning of the liver was performed, but failed to reveal any liver pathology.
A few days later, a tender mass was felt in the upper part of the abdomen which reached 3-4 cm proximally to the umbilicus. Radioisotope scanning showed the liver to be enlarged with a big round defect in the left lobe. An amoebic abscess of the liver was suspected, and a serological test specific for amoebiasis was carried out. However, the highly
significant result for amoebiasis did not arrive until after the patient was operated. Treatment with metronidazole (Flagyl®) 800 mg X 3 was begun without awaiting the answer to the serological test. The fever and pain disappeared. 1 week later metronidazole was supplemented with chloroquine tablets 500 mg x 2 for 2 days and 250 mg x 2 for 12 days. After a few days, however, the patient was febrile again. A new isotope scanning showed increased size of the defect in the left liver lobe. Since no diagnosis was achieved, aortography and coeliacography was performed, for visualization of the vessels participating in the lesion. This investigation revealed a large, round avascular mass dislocating the coeliac origin, branches of the left hepatic artery, and compressing the inflow of the splenic vein into the portal vein (fig. 1). No patholocigal vessels were found. After this investigation the lesion could be characterized as an abscess and was opened and drained through a little incision. The abscess contained 810 ml of thick yellow nonodorous pus. The still warm pus was examined by direct microscopy without staining, but no trophozoites were found. Also a PAS-coloured microscopic preparation was examined, but again revealed no trophozoites. The pus was sterile on culture.
Cavernogram prior to removal of the drain demonstrates the shrinked cavity and the biliary fistula. Fig. 2.
Postoperatively the patient was treated additionally with Gentamycm 80 mg x 3 for 8 days and then Cephalexin 250 mg X 4 until the drain was removed to prevent secondary bacterial infection of the
cavity. The patient was afebrile and made an uninterrupted recovery. During this period subsequent cavernographies demon-
Dieses Dokument wurde zum persönlichen Gebrauch heruntergeladen. Vervielfältigung nur mit Zustimmung des Verlages.
Fortschr. Röntgenstr. 123, 5
Schaukasten
Schaukasten
Fortschr. Röntgenstr. 123, 5
strated decreasing size of the lesion and a connection with the biliary system. One and a half months after the operation, no further suppuration through the drain could be observed. Before removal of the drain a control roentgen examination of the cavity was performed. This investigation showed shrinkage of the cavity around the ballon of the drain with the fistula to the left biliary
duct through which the entire biliary tree could be visualized (fig. 2).
After the removal of the drain no complications occurred. Further
controls during the last 3 months by isotope scanning, liver chemistry, consecutive examinations of the stools, and serological
tests showed no abnormalities. The cutaneous wound is healed without biliary fistula.
Discussion Diagnosis of different forms of amoebiasis - well known i11 tropical medicine - can be difficult at our latitudes, Increased tourism and exchange of labour from different geographic areas produce increasing confrontations between the European radiolo-
gist and amoebiasis. Amoebic liver abscess is not necessarily preceded by amoebic dysenteria, although the patient has an asymptomatic intestinal amoebiasis, and can therefore be difficult
to recognise (1). It is stressed that radioisotope and ultrasonic scanning can be of value (8). However, scintigraphy often cannot distinguish a puscontaining lesion from certain forms of malignancy. Difficulties can occur at ultrasonography because of the lack of a well defined acoustic border between the liver substance and abscess contents (7). At angiography the findings are surpris-
ing since no pathologic vessels could be found in our patient (angiography in amoebiasis is to our knowledge not yet published). Only displacement of the vessels indicated the size of the lesion.
when the abscess in the left liver lobe had ruptured to the biliary tree did the patient get adequate medical and surgical treatment. The diagnosis of an amoebic abscess of the liver should be considered in a patient with a tender enlarged liver who has been to endemic areas. Laboratory findings are not helpful since the liver function tests are rarely affected.
A trial of specific anti-amoebic treatment with prompt recovery will support the diagnosis. The diagnosis can be supported by plain X-ray examination of the diaphragm as it may show elevation of one dome, although in our
patient no involvement of the left diaphragm was observed. Angiography is needed only when differential diagnosis by other methods cannot be obtained. Cavernography through the draining tube is of value for demonstration of the relationship of the lesion towards the neighbouring organs (2, 3, 4). Identification of E-histolytica in pus from the abscess provides the definite proof of amoebiasis. Lamont, N. M., N. R. Pooler:
Literature
Hepatic amoebiasis: a study of 250
Alkan, W. J., B. Kalnii, M. Kalderon: The clinical syndrome of amebic
abscess of the left lobe of the liver. Ann. intern. Med. 55 (1961) 800 Faerber, E. N., F. Segal, N.
L.
Sischy: Case report. Amoebic peri-
carditis. Brit. J. Radiol. 47 (1974) 816
Gupta, S. K., M. N. Khanna: Cavernogram for diagnosis of Amoebic liver abscess. Clin. Radiol. 23 (1972) 219
Harding, T., E. A. Lewis, S.
P.
cases. Quart. J. Med. (Oxf.) 27 (1958) 107
MacLeod, I. N., A. J. Wilmot, S. J. Powell: Amoebic pericarditis. Quat. J. Med., New Series XXXV, 138 (1966) 293
Matthews, A. W., K. R. Gough, E. R. Davies, F. G. M. Ross, A. Hinch-
life: The use of combined ultrasonic and isotope scanning in the diagnosis amoebic liver disease. Gut 14 (1973) 50 Wenger, J., J. C. Coberly: Rapid
Amoebic abscess in the liver lobe is a very dangerous situation
Bohrer: Inrra-cavitary barium sulphate
because of the high incidence of rupture towards the neighbouring
in the assessment of amoebic liver
diagnostic approach to amebic liver abscess. Amer. J. dig. Dis., New
abscess. Clin. Radiol. 21 (1970) 68
Series 14 (1969) 282
organs, as peritoneum, pleura and pericardium (2, 5, 6). Our patient has been operated on three occasions for the same disease. Despite the geographic anamnesis the removed appendix was not investigated for Entamoeba histolytica, although the predilection site for chronic intestinal amoebiasis is the coecum. Nor was half a year later a verified and emptied liver abscess submitted to appropriate diagnostic procedures. Not until at the seventh admission,
Dozent, Dr. med. Viktor Hegedüs, Associated head Department of Diagn. Radiology Glostrup Hospital Copenhagen, DK-2600 Glostrup, Denmark
Dieses Dokument wurde zum persönlichen Gebrauch heruntergeladen. Vervielfältigung nur mit Zustimmung des Verlages.
488
