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Amoebic abscess - current

treatment guidelines

Amoebiasis
Entamoeba histolytica
y Protozoan, intestinal parasite
y Other subtypes of Entamoeba
Largely non pathogenic
e.g. E. dispar

Cyst vs trophozoite
y Cyst - infective
y Trophozoite - invasive

Entamoeba life cycle


Cysts shed in
faeces of carriers
Cysts transferred
via contaminated
food, water or
hands
y Feacal-oral
y Anal sex
y Colonic irrigation

Entamoeba life cycle


Excystation in the
small bowel
releasing
trophozoites
y Cysts resistant to
gastric acid but
broken down by
trypsin releasing
trophozoites

Entamoeba life cycle


Trophozoites migrate to
the colon and
reproduce (forming
cysts)
Within the colon
trophozoites feed on
bacteria and feacal
material
If trophozoites adhere
and then penetrate the
mucosa clinical
infection results

Entamoeba life cycle


Hepatic infection if
trophozoites enter
mesenteric venules
Trophozoites and
cysts are passed in
the feaces

Incidence
Huge global problem
y 50 million infections/ year (developing nations)
40 000 - 100 000 deaths/ year

Endemic to certain Australian populations


y
y
y

Indigenous population NT
Homosexual men, NSW
Immigrants form India/ SE Asia/ Central + Sth
America
y Returned travellers (8 - 12 week delay)

Uncommon in mainstream Australia

Risk factors in Australian


population

Immigrants
Institutionalized
Communal co-habitation
Promiscuous male homosexual sex
Immunosuppresion
y HIV
y Transplant

Clinical features
Asymptomatic
y Most common form of infestation
y carriers
These people almost never develop symptoms but can
spread disease

y
y
y

Spontaneously clear disease within 12 months


If detected on stool sample should be treated
Risk of infection 10%/year

Clinical features
Symptomatic
y Amoebic colitis
Subacute presentation (weeks)
y
y
y
y

Abdominal pain/ cramping/ distention


Diarrhoea (blood, mucus)
Fever (40%)
Tenesmus

Clinical features
Symptomatic
y Ameobic liver abscess
Most common extraintestinal manifestation
(10% of infected patients develop liver
abscesses)

Amoebic liver abscess


Trophozoites invade small vessels of the
bowel wall and reach liver via portal
circulation
Microembolization in the portal system
causes infarction and focal areas of necrosis
Amoeba cause lysis of neutrophils and the
edge of these lesions causing release of toxic
mediators and further hepatic necrosis
Usually multiple small lesions coalesce
forming the amoebic liver abscess

Amoebic liver abscess


Usually solitary lesion
Right lobe more common
y 80% of abscesses in right lobe
y Right lobe larger in volume and recieves
most of the blood from the caecum - where
trophozoites are commonly found

Amoebic liver abscess


Pathology - Anchovy
sauce
y Thick, clotty exudate,
homogenious in colour but
ranging from creamy white
to dirty brown and pink
y Sterile (unless secondary
infection)
y Protienaceous acellular
debris (hepatocellular
apoptosis) surrounded by a
rim of trophozoites

Amoebic liver abscess


Presentation
y Acute, <14d (more common)

May have preceding amoebic colitis (20-30%)


Fever, malaise, rigors, diaphoresis
RUQ pain
y
y
y

Sharp, constant, relieved by lying on left side


Radiating to shoulder tips and scapulae
Pleuritic component

Hepatomegaly

y and chronic presentations


Weight loss and vague abdominal discomfort
Can present years after amoebic colitis

Amoebic liver abscess


Rare presentations
y Pulmonary symptoms (20%)
Ameobic pulmonary abscess
Bronchopulmonary fistula
Cough, chest pain

y Jaundice (5%)
Due to large or multiple abscesses and/ or
bacterial superinfection/ or abscess at the porta

Amoebic liver abscess


Examination findings
y Common
Febrile
Tender hepatomegaly
y Often point tenderness

Epigastric mass (left sided disease)

y Uncommon
Right lower lobe pneumonia
Jaundice
Severe sepsis - usually indicates secondary bacterial
infection

Investigation
FBE
y Aneamia, leukocytosis, eosinophilia

LFTs
y Jaundice, hypoalbuminaemia
y Elevated AST (acute) and ALP (chronic)

Stool sample
y Low sensitivity (only 30% of patients have
concomitant intestinal amoebiasis)

Investigation
Serologic testing - Enzyme
immunoassay for antibodies to E
hystolitica
y Absence of antibodies after one week of
symptoms almost exclusive of Amoebic
liver abscess
y Cannot distinguish between carriage and
acute infection - largely insignificant
problem in Australia

Diagnosis
USS
y Initial diagnostic modality as imaging of
biliary tree also possible
y Sensitivity 75-80% (for liver abscess)
y Non-homogenous round or oval
hypoechoic lesions with well-defined
margins and lack prominent peripheral
echoes

Diagnosis
CT
y Greater sensitivity 88-95%
y Abscess - low density with smooth margins
and a contrast-enhancing peripheral rim.

Diagnosis
MRI
Technetium white cell scanning
Hepatic angiography

Treatment

Medical
1. Eradication of invasive trophozoites

Metronidazole 750mg tds (or tinidazole) for seven days


Clinical recovery usually within 3 days

2. Eradication of colonic carriage with a luminal


amebicidal agent

Paramomycin 500mg tds for seven days


Other agents
y
y

Diloxanide furoate 500mg tds for twenty days


Iodoquinol

10% relapse rate without intestinal eradication

Treatment
Surgical
1. Aspiration of cyst
To confirm diagnosis (vs pyogenic)
If no response to antibiotic therapy after 5-7d
High risk of rupture (diameter > 5cm, abscess
wall < 10mm)
Left lobe abscess (high rate or rupture at
smaller size into peritoneum or pericardium)

Treatment
Surgical
2. Open drainage

Failed percutaneous aspiration


Ruptured cyst with generalized peritonitis

Treatment
Follow up
y Stool antigen testing after eradication and
repeat treatment as necessary
y No repeat imaging
Changes take months to years to resolve

Difficult presentations
Left lobe abscess presenting as
jaundice, sepsis and encephalopathy
Right lobe abscess with cough and foul
sputum
RUQ pain, sepsis, peritonism
Multiple abscesses

Complications
Intestinal
y Fulminant colitis
y Toxic megacolon
0.5% - usu in patients inappropriately
administered steroids (inflammatory bowel
disease)
40% mortality - perforation, peritonitis, massive
bleeding

y Perianal disease

Complications
Extraintestinal
y Liver abscess rupture
Pleuro-pulmonary disease
y Bronchopulmonary fistula

Subphrenic abscess
Intraperitoneal rupture
Pericardial rupture

y Secondary infection - pyogenic abscess


(usually S. aureus)

Complications
Rare
y Cerebral infection
y Genitourinary infection
y Cutaneous infection

Prognosis
Most cases resolve within 7 days of
treatment
Mortality is uncommon but can occur
with abscess rupture

Discuss the management of a patient


referred to you presenting with a liver mass
(on imaging) and sepsis

Assessment
y Differential diagnosis
Pyogenic liver abscess
Hydatic liver abscess
Ameobic liver abscess

y Uncommon differentials
Cholecystitis with phlegmon, Hepatic
carcinoma, Hepatitis with liver cyst any septic
syndrome with unrelated solitary liver lesion

Clinical differences between


diagnosis
Amoebic

Pyogenic

Hydatid

Duration of
symptoms

Days - weeks

Hours - days

Months - years

Features on
history

Recent travel

GI or biliary
Contact with
pathology. IVDU, sheep
immunocompro
mised

Degree of sepsis

Mild

Severe

Mild

Investigation differences
Amoebic

Pyogenic

Hydatid

Bloods

Positive
serology

Jaundice +
other LFT
derangement,
Positive blood
cultures

Eosinophilia,
positive
serology

Imaging

Large, usu
Multiple lesions Unilocular
right sided cyst
large cyst with
daughter cysts

Resuscitation
Basic bloods and imaging
If stable hydatid and amoebic serology
If unstable and low probability of hydatid
then percutaneous drainage
Chemotherapy or surgery as
appropriate

Differences with hepatic


lesions
Pyogenic - often multiple
Amoebic - often solitary (65%)

References
1.

2.

3.

4.

J van Hal S, Stark DJ, Fotedar R, Marriott D et al.


Amoebiasis: current status in Australia. Medical Journal of
Australia, vol 186 (8), 2007, 412 - 416.
Sharma MP, Ahuja V,. Management of amebic and pyogenic
liver abscess. Indian J Gastroenterol. 2001 Mar;20 Suppl
1:C33-6. Review
Salles JM, Salles MJ, Moraes LA, Silva MC. Invasive
amebiasis: an update on diagnosis and management. Expert
Rev. Anti Infect. Ther 5 (5) 2007. 893 - 901
Wells CD, Arguedas M. Amebic liver abscess. Southern
Medical Journal. 97(7), 2004. 673 - 682.

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