Amebic Liver Abscess


Article Author:
Vidhya Prakash


Article Editor:
Tony Oliver


Editors In Chief:
Rhonda Coffman
Lindsay Iverson
Heather Templin


Managing Editors:
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Frank Smeeks
Kristina Soman-Faulkner
Benjamin Eovaldi
Radia Jamil
Sobhan Daneshfar
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Hajira Basit
Phillip Hynes


Updated:
4/1/2019 2:52:33 PM

Introduction

Amebiasis is an infection caused by the protozoan, Entamoeba histolytica. It is transmitted through fecal-oral route. The infection can manifest ranging from an asymptomatic state to liver abscess. Amebic liver abscess is the most common extraintestinal manifestation of amebiasis. Men between the ages of 18 and 50 are most commonly affected. Areas with high rates of amebic infection include India, Africa, Mexico, and Central and South America. Approximately 80% of patients with this disease will develop symptoms within 2 to 4 weeks, including fever and right upper quadrant abdominal pain with 10% to 35% of patients experiencing associated gastrointestinal symptoms.  The diagnosis is based on the clinical symptoms and relevant epidemiology coupled with radiographic studies and serologic tests. Optimal treatment includes the use of Metronidazole followed by a luminal agent such as Paromomycin. Rarely, therapeutic aspiration is indicated. [1],[2] Sir William Osler diagnosed the first case of liver abscess in the USA[3]

Etiology

Amebic liver abscess is caused by the invasive enteric protozoan Entamoeba histolytica. Many Entamoeba species, namely E. dispar and E. moshkovskii infect humans, but only E. histolytica causes amebiasis. This organism is distributed throughout the world, posing a substantial risk in countries without adequate sanitation of municipal water supplies. [4]

Epidemiology

Amebic liver abscess is uncommon in children and ten times more common in men than in women, particularly in individuals between the ages of 18 and 50. The reason for such a striking difference is not clear but thought to be due to factors such as hormonal effects and alcohol consumption. In the United States, most cases are found in immigrants from endemic areas and people living in states bordering Mexico. Worldwide, areas with high rates of infection include India, Africa, and Mexico and parts of Central and South America. Most individuals are infected by ingesting contaminated food or water although other modes of transmission include oral and anal sex, particularly among men who have sex with men.[5][4]  Around 2% to 5% of patients with intestinal amebiasis may end up with liver abscess.[3]

Pathophysiology

The life cycle of Entameba Histolytica was first explained by Clifford Dobell in 1928. The organism has 2 stages of life, the cystic stage which is the infective stage and the trophozoite stage which ends up causing invasive disease[3]Upon ingestion of contaminated food and water; the infection starts with ingestion of the quadrinucleate cyst of E. histolytica. Excystation in the small intestinal lumen is followed by production of motile, potentially invasive trophozoites. In most infections, the trophozoites form new cysts and are limited to the intestinal mucin layer. In other cases, the trophozoites adhere to and lyse the colonic epithelium with subsequent invasion of the colon. Neutrophils respond, resulting in further cellular damage at the invasion site. Once the trophozoites invade the colonic epithelium, subsequent spread to extraintestinal sites such as the liver (by hematogenous spread through the portal circulation) and peritoneum can occur. [6]The organism causes hepatic inflammation followed by necrosis which results in an abscess formation[7]

Toxicokinetics

Adherence of E. histolytica to colonic epithelial cells is thought to be through the galactose/N-acetylgalactosamine-specific lectin. E. histolytica carries cytolytic capabilities and also kills mammalian cells through programmed apoptosis. Once E. histolytica trophozoites reach the liver, they create abscesses comprising well-circumscribed areas of cellular debris, dead hepatocytes, and liquefied cells. The lesion is surrounded by a rim of connective tissue with some inflammatory cells and amebic trophozoites. In humans, the small number of organisms compared to the actual dimensions of the abscess supports the concept that E. histolytica can destroy hepatocytes without contact with the cells.

History and Physical

Patients can present with amebic liver abscess months to years after travel to an endemic area, making a thorough travel history and knowledge of epidemiologic risk factors imperative. In the United States, the typical patient with an amebic liver abscess is an immigrant (usually Hispanic male) between the ages of 20 and 40. Eighty percent of patients will develop symptoms within 2 to 4 weeks of exposure, including fever, dull and aching right upper quadrant or epigastric abdominal pain, and cough. Patients who present subacutely will have weight loss and less frequent development of fever and abdominal pain. Ten percent to 35% of patients have gastrointestinal symptoms including nausea, vomiting, abdominal cramps, diarrhea, constipation, or abdominal distension. On exam, hepatomegaly with point tenderness either over the liver, below the ribs, or in the intercostal spaces is typical for liver abscess.

Evaluation

Patients with an amebic liver abscess will typically have evidence of leukocytosis, elevated serum transaminases, alkaline phosphatase on laboratory evaluation. On imaging, most amebic liver abscesses will be found in the right lobe. Imaging modalities include ultrasound which might show around, hypo-echoic mass, CT scan can identify a low-density mass with peripheral enhancing rim, and MRI typically shows low signal intensity on the T1-weighted image and high signal intensity on T2-weighted image, which are fairly sensitive but without absolute specificity for an amebic liver abscess. Travel history to an endemic area, coupled with typical signs and symptoms and visualization of lesions on imaging should make one consider this entity and should be followed by doing the serologic testing. Serum antigen detection has a sensitivity of over 95% with serologic testing (indirect hemagglutination) having a sensitivity of 70% to 80% in acute disease and greater than 90% in the convalescent  state. It should be noted that in the first week of the disease course, there may be false-negative serologic tests. On the other hand, stool microscopy, has a sensitivity of only 10% to 40%. [8]

Treatment / Management

Treatment entails the use of a Nitroimidazole, preferably Metronidazole at a dose of 500 mg to 750 mg by mouth 3 times per day for 7 to10 days. Alternatively, Tinidazole 2 gm by mouth daily for 3 days can be used.  Since the parasites can persist in the intestine in 40% to 60% of patients, treatment with a Nitroimidazole should always be followed with a luminal agent such as Paromomycin 500 mg 3 times a day for 7 days or Iodoquinol  650 mg three times a day for 20 days[7]. Metronidazole and Paromomycin should not be given at the same time because diarrhea, a common side effect of paromomycin, can make assessing response to therapy difficult. Around 15% of patients with amebic liver abscess fail medical treatment. Therapeutic aspiration  can be done either by percutaneous needle aspiration or by percutaneous catheter drainage. These options should be considered in patients with no clinical response to antibiotics within 5 to 7 days, in those with a high risk of abscess rupture (cavitary diameter over 5 cm or presence of lesions in the left lobe), or in cases of bacterial coinfection of amebic liver abscess.[9]. Between  percutaneous needle aspiration and percutaneous catheter drainage, studies have shown that the latter is superior with higher success rate and quicker resolution[10]

Differential Diagnosis

  • Bacterial Liver abscess
  • Echinococcus Granulosus
  • Candida
  • Salmonella Typhi

Prognosis

For simple abscess, the prognosis is excellent.

Complex abscesses and large abscesses can rupture and may be associated with a high mortality.

Overall, most patients have a favorable outcome with prompt treatment.

Complications

An amebic liver abscess may rupture into the chest, abdomen or pericardium

Rare complications include Inferior vena cava Thrombosis, Hepatic vein thrombosis, Intra abdominal mass

Consultations

  • General surgeon
  • interventional Radiologist
  • Infectious disease

Deterrence and Patient Education

Preventive measures include reducing fecal contamination of food and water and emphasizing the use of safe sexual practices, particularly in men who have sex with men. An effective vaccine would be instrumental in improving health in developing countries, particularly in children. Once considered a fatal infection, amebic liver abscess is now considered a curable condition.

Pearls and Other Issues

Diligence in maintaining local water sources and emphasis on counseling men who have sex with men regarding safe sexual practices are of paramount importance in preventing amebiasis.

Stool studies have less than 50% positive results

Serology studies can be negative in the first week of infection

Treatment with a Nitroimidazole should always be followed with a luminal agent

Enhancing Healthcare Team Outcomes

The care of amebic liver abscess depends on the complexity of the liver abscess. The treatment of amebic liver abscess requires an interprofessional team to lower the morbidity and mortality of the disorder. [11]

  1. The laboratory technologist is essential for the diagnosis. Serum antigen detection and stool microscopy are often the first laboratory studies ordered to make the diagnosis and rule out other pathologies.
  2. For complex abscesses, Interventional radiologist will need to be consulted for image-guided drainage.
  3. If the abscess is multi-locular, then the general surgeon may have to perform an open or laparoscopic surgery to help drain the collections.
  4. Because many of the drugs used to treat amebic liver abscess have adverse effects, the pharmacist will need to monitor the patients. Emetin is used as a second-line drug, but it is important to monitor the patient as the drug can cause cardiac arrhythmias.
  5. The nurse may need to monitor the patient in outpatient clinics to ensure that the patient is symptom-free. More importantly, the nurse plays a vital role in public education regarding sanitary measures, personal hygiene, and food washing.
  6. Patients considering travel to areas where amebiasis is endemic may wish to schedule an infectious disease consult on precautions to take such as boiling drinking water, washing food regularly, and changing sexual practices to avoid fecal-oral contamination.

Outcomes

When an interprofessional team approach is undertaken, the prognosis for most patients with an amebic liver abscess is excellent.[12] To avoid complications like rupture into the lung, pericardium, or abdomen, patients with amebic liver abscess need a prompt referral to an infectious disease expert for treatment. Current evidence reveals that drainage of complex abscess can improve outcomes as opposed to medical management.[13] (Level III)


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Amebic Liver Abscess - Questions

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What treatment is rarely utilized for an amebic liver abscess?



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Which is true of an amebic abscess?



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A 17-year-old male from Mexico presents with right upper quadrant pain and episodic diarrhea. He describes his pain as constant, dull, and aching. He says that he has not been feeling well for a few weeks, has no appetite, and has had a fever for the past 24 hours. Bloodwork shows leukocytosis and an elevated alkaline phosphatase. An enzyme-linked immunosorbent assay is positive for Entamoeba histolytica. What is the appropriate initial management?



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A liver aspirate is odorless, thick, yellowish brown, and anchovy paste-like. One would suspect what pathology?



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What is the initial treatment of an amebic liver abscess?



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What is the best initial treatment for a small liver abscess of amebic etiology?



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A patient with an amebic liver abscess will have what clinical feature on a physical exam?



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An adult female, who returned from South America 3 months ago, presents with right upper quadrant pain, diarrhea, and weight loss. She has a fever, hepatomegaly, right upper quadrant tenderness without rebound or guarding, and no other abnormalities on an exam. What is the best diagnostic test?



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A patient presents after return from a trip to the Amazon with complaints of fever and right upper quadrant pain. She states that while hiking in the forests, he often drank stream water and ate uncooked vegetables. His abdominal pain started six weeks ago, and the fever soon followed. He now has anorexia. He did develop diarrhea for a few days, but this has subsided. On physical examination, she had a fever of 102.3 F and marked tenderness in the right upper quadrant. Blood work revealed leucocytosis and elevated aspartate aminotransferase and alkaline phosphatase. Stool examination reveals the presence of Charcot-Leyden crystal protein. Her CT scan is shown. Which of the following is true about her condition?

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Amebic Liver Abscess - References

References

Kale S,Nanavati AJ,Borle N,Nagral S, Outcomes of a conservative approach to management in amoebic liver abscess. Journal of postgraduate medicine. 2017 Jan-Mar     [PubMed]
Lübbert C,Wiegand J,Karlas T, Therapy of Liver Abscesses. Viszeralmedizin. 2014 Oct     [PubMed]
Kouamé N,N'goan-Domoua AM,Akaffou E,Konan AN, [Multidisciplinary management of amebic liver abscesses at the University Hospital of Yopougon, Abidjan, Côte d'Ivoire]. The Pan African medical journal. 2010     [PubMed]
Lardière-Deguelte S,Ragot E,Amroun K,Piardi T,Dokmak S,Bruno O,Appere F,Sibert A,Hoeffel C,Sommacale D,Kianmanesh R, Hepatic abscess: Diagnosis and management. Journal of visceral surgery. 2015 Sep     [PubMed]
Wijewantha HS, Liver Disease in Sri Lanka. Euroasian journal of hepato-gastroenterology. 2017 Jan-Jun     [PubMed]
Kannathasan S,Murugananthan A,Kumanan T,de Silva NR,Rajeshkannan N,Haque R,Iddawela D, Epidemiology and factors associated with amoebic liver abscess in northern Sri Lanka. BMC public health. 2018 Jan 10     [PubMed]
Kannathasan S,Murugananthan A,Kumanan T,Iddawala D,de Silva NR,Rajeshkannan N,Haque R, Amoebic liver abscess in northern Sri Lanka: first report of immunological and molecular confirmation of aetiology. Parasites     [PubMed]
Albenmousa A,Sanai FM,Singhal A,Babatin MA,AlZanbagi AA,Al-Otaibi MM,Khan AH,Bzeizi KI, Liver abscess presentation and management in Saudi Arabia and the United Kingdom. Annals of Saudi medicine. 2011 Sep-Oct     [PubMed]
Wong WK,Foo PC,Olivos-Garcia A,Noordin R,Mohamed Z,Othman N,Few LL,Lim BH, Parallel ELISAs using crude soluble antigen and excretory-secretory antigen for improved serodiagnosis of amoebic liver abscess. Acta tropica. 2017 Aug     [PubMed]
Waghmare M,Shah H,Tiwari C,Khedkar K,Gandhi S, Management of Liver Abscess in Children: Our Experience. Euroasian journal of hepato-gastroenterology. 2017 Jan-Jun     [PubMed]
Arellano-Aguilar G,Marín-Santillán E,Castilla-Barajas JA,Bribiesca-Juárez MC,Domínguez-Carrillo LG, A brief history of amoebic liver abscess with an illustrative case. Revista de gastroenterologia de Mexico. 2017 Oct - Dec     [PubMed]
Cai YL,Xiong XZ,Lu J,Cheng Y,Yang C,Lin YX,Zhang J,Cheng NS, Percutaneous needle aspiration versus catheter drainage in the management of liver abscess: a systematic review and meta-analysis. HPB : the official journal of the International Hepato Pancreato Biliary Association. 2015 Mar     [PubMed]
Wuerz T,Kane JB,Boggild AK,Krajden S,Keystone JS,Fuksa M,Kain KC,Warren R,Kempston J,Anderson J, A review of amoebic liver abscess for clinicians in a nonendemic setting. Canadian journal of gastroenterology = Journal canadien de gastroenterologie. 2012 Oct     [PubMed]

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