Amebic liver abscess Spare the knife but save the child

Amebic Liver Abscess: Spare the Knife But Save the ChildBy F. Moazam and Z. NazirKarachi, PakistanBackground/Purpose: Amebic liver abscess (ALA), the most common extraintestinal manifestation of infection with Ent- ameba histolytica, carries significant morbidity and mortality in the pediatric age group. The efficacy of metronidazole in the treatment of ALA is well established, but the role of surgical intervention remains controversial. Many investigators still advocate aggressive surgical therapy for complicated and ruptured ALA. Reports regarding management of ALA in children are sparse and deal with small numbers of patients. The objective of this study was to assess the effectiveness of parenteral metronidazole combined with judicious aspiration of ALA in obviating the need for surgical intervention.Methods: The medical records of all children admitted with the diagnosis of ALA between 1986 and 1997 to the Aga Khan University Hospital were reviewed retrospectively. The diagnosis of ALA was confirmed in 48 patients by an ultrasound scan together with elevated indirect hemagglutination (IHA) titres (250. Ages ranged from 3 weeks to 14.5 years.Resuits: Thirty-seven (75%) children were below the fifth percentile for height and weight, and 45 (93.7%) presented with a hemoglobin level of less than 10.0 g/dL. Comorbid factors included pulmonary tuberculosis n 二2, chicken pox (n = 1r tetralogy of Fallot (n = 1, and thalassemia major (n = 2). There was a mean delay of 13 days before presentation to the hospital. All patients were treated with parenteral metronidazole and broad-spectrum antibiotics. The latter were discontinued on confirmation of the diagnosis. The duration of treatment with metronidazole ranged from 2 to 5 weeks. Percutaneous aspiration of the ALA was performed under ultrasound guidance using sedation in 28 patients for one or more of the following indications; ALA greater than 7.0 cms (n = 20), left lobe involvement (n = 8), and no response after 48 hours of medical therapy (n - 6). Nine patients required more than one aspiration. One patient with peritoneal rupture of the ALA additionally underwent percutaneous aspiration of the peritoneal cavity under ultrasound guidance. One patient required insertion of a chest tube after rupture of the ALA into the right pleural cavity, and another underwent urgent bronchoscopy after rupture of the abscess into the tracheobronchial tree. The hepatobronchial fistula closed spontaneously with medical therapy. No patient required open surgical drainage, and all recovered without relapse. The mean duration of hospitalization was 12 days.Conclusion: Our experience suggests that parenteral metronidazole combined with timely aspiration of the abscess can obviate the need for surgical intervention in large and complicated ALA even in malnourished children who present late for treatment.J Pediatr Surg 33:719-122. Copyright 1998 by W.B. Saunders Company.INDEX WORDS: Amebic liver abscess, percutaneous aspiration.A MEBIASIS is the third most common cause of death MM. from parasitic diseases after malaria and schistoso miasis.1 Amebic liver abscess (ALA) is the most common extraintestinal manifestation of amebiasis and occurs in 3% to 9% of those infected.2 Predisposing factors include poor sanitation, malnutrition, and concomitant diseases causing immunosuppression. Western countries have recently experienced a resurgence of ALA associated with immigration, overcrowding, and reduced living standards.3 Although less common in children, ALA carries a significant morbidity and mortality rate in this age group. Reports regarding the management of ALA in children are sparse and deal with relatively small numbers of patients.4 6 The efficacy of metronidazole in the treatment of ALA is well established, but the role of surgical intervention remains controversial.7,8 Many investigators still advocate aggressive surgical therapy for complicated and ruptured ALA including laparotomy, peritoneal washouts, and multiple drains.910We reviewed the hospital course and outcome of allJournal of Pediatric Surgery, Vol 33, No 1 (January), 1998: pp 119-122children admitted to the Aga Khan University Hospital (AKUH), Karachi with the diagnosis of ALA over a 10-year period. The objective of the study was to review the effectiveness of parenteral metronidazole and judicious aspiration of ALA in preventing rupture and obviating the need for surgical intervention.MATERIALS AND METHODSThe medical records of patients younger than 15 years of age presenting to AKUH between 1987 and 1996 with the diagnosis of ALA were reviewed retrospectively. The diagnosis of ALA was establishedFrom the Division of Pediatric Surgery, Aga Khan University, Karachi, Pakistan.Presented at the 44th Annual International Congress of the British Association of Paediatric Surgeons, Istanbul, Turkey, July 22-25, 1997.Address reprint requests to Farhat Moazam, MD, Division of Pediatric Surgery, Department of Surgery, Aga Khan University, Stadium Rd, PO Box 3500, Karachi-74800, Pakistan.Copyright 1998 by W.B. Saunders Company 0022-3468/98/33010028$03W/0119120MOAZAM AND NAZIRby ultrasonographic evidence of a hepatic abscess or abscesses in association with an elevated indirect hemagglutination (IHA) titre (1:250). Because of the expense, computed tomography scans were not performed routinely. The patient characteristics analyzed included age, sex, height and weight, comorbid factors, duration of symptoms, clinical presentation, and length of hospital stay. The ultrasonographic characteristics of the ALA (Table 1) and the management and outcome of each patient were also reviewed.At the time of admission, all patients were treated with parenteral metronidazole (50 mg/kg/d) and broad-spectrum antibiotics. The latter were discontinued after serological confirmation of the diagnosis of ALA, Criteria for aspiration included lack of clinical and ultrasonographic improvement within 48 hours of medical treatment, abscesses larger than 7.0 cm in diameter, those located in the left lobe of the liver, and those ruptured into the thoracic or peritoneal cavity. All aspirations were performed under ultrasound scan guidance in the radiology department using sedation or ketamine anesthesia.RESULTSA total of 48 children with ALA were treated at AKUH during the 10-year study period. They constituted an average of 0.13% of the annual pediatric admissions. There were 29 boys and 19 girls (M:F ratio, 1.5:1). Ages ranged between 3 weeks and 14.5 years with 73% of the patients below 10 years of age. Thirty-seven (75%) children were below the 5th percentile for height and weight, and 45 (93.7%) presented with a hemoglobin level less than 10 g/dL. Comorbid factors in six patients included pulmonary tuberculosis (n = 2), chicken pox (n = 1), tetralogy of Fallot (n = 1) and thalassemia major (n = 2). Relevant clinical and laboratory features are presented in Tables 2 and 3. The mean duration of symptoms before presenting to AKUH was 13 days (range, 3 to 45 days). Thirty-five patients had been treated with broad-spectrum antibiotics and antimalarial drugs before presentation. ALA was the admitting diagnosis in 12 of 13 patients who presented primarily to AKUH. In one patient, ALA was diagnosed after abdominal pain and fever persisted after a negative abdominal exploration for suspected appendicitis.The latter were discontinued once the diagnosis of ALA was confirmed. The mean duration of metronidazole therapy was 3 weeks (range, 2 to 5 weeks). Percutaneous aspiration of the ALA under ultrasoundTable 2. Clinical Presentation of Patients With ALAPatients (n - 48PercentageSymptomsFever48100RUQ abdominal pain3981.2Anorexia/vomiting2143.7Respiratory distress14.1History of dysentery816.6SignsTender hepatomegaly48100Abdominal distension2960.4Chest wail edema1327Epigastric mass510.4Clinical jaundice24.1guidance was petformed in 28 patients for one or more of the following indications: ALA greater than 7.0 cms (n = 20) (Fig 1); left lobe involvement (n = 8); and no response after 48 hours of medical therapy (n = 6). Nine patients required more than one aspiration. One patient with peritoneal rupture of ALA underwent percutaneous aspiration of the peritoneal cavity under ultrasound scan guidance. One patient required insertion of a chest tube for amebic empyema thoracis (Fig 2)，and another underwent an urgent bronchoscopy after sudden rupture of the abscess into the tracheobronchial tree. The hepato- bronchial fistula closed spontaneously with medical treatment. No patient required open surgical drainage, and all patients recovered without relapse. The mean duration of hospitalization was 12 days (range, 4 days to 31 days).DISCUSSIONAmebiasis affects over 450 million people worldwide and causes 75,000 deaths per year. ALA, the most common form of cxtraintestinal amebiasis, occurs in approximately 3% to 9% of infected patients, as a result of the spread of the parasite from the large bowel to the liver via the portal vein.12 Entameba histolytica largely effects inhabitants of tropical and subtropical regions. In the United States, after a dramatic decrease in the incidence of ALA around the mid century, recent reports indicate a resurgence caused by the increasing number of immigrants from Mexico and Central America.31112 Predisposing factors include poor sanitation in lowTable 1. Ultrasonographic Features of ALAFeaturesPatients (n - 48)PercentageNumberSingle4491.6Multiple48.3LocationRight lobe3675.0Left lobe816.6Both48.3Size-7.0 cms.2041.6Table 3. Laboratory Findings in Patients With ALAFeaturePatients (n - 48PercentageAnemia (Hb 11,000/cu mm)4695.8Raised total bilirubin (1.1 mg/dL)Raised SGPT/Alkaline phosphatase (twice48.3the norma! value)816.6IHA for amebiasis (titers 1:250)Stool positive for E histolytica cyst/tropho-48100zoites)48.3AMEBIC LIVER ABSCESSFig 1. Ultrasound scan of a 5-year-old girl shows 11-cm x 8.0-cm, ALA in right lobe of liver.socioeconomic status, malnutrition, and concomitant diseases leading to low host resistance.2,8，13 In the present review there was a mean delay of nearly 2 weeks before presentation, with one child first seen 45 days after the onset of symptoms. A large number of children were malnourished as evidenced by hemoglobin levels of less than 10 g/dL in 93% and height and weight below the 5th percentile in 75%. Factors that may have led to a state of immunosuppression were concomitant pulmonary tuberculosis, chicken pox, and thalassemia major.ALA causes a triad of fever, right upper quadrant abdominal pain, and tender hepatomegaly. This was the most common presentation of patients included in this study. The diagnosis is confirmed in such cases by serology and imaging techniques. Although serology may not always be helpful in the diagnosis of acute intestinal amebiasis, IHA titres are usually raised in invasive amebiasis with close to 100% reliability in the presence of ALA.u，14 All patients in this study had elevated IHA titres (1:250). Ultrasonography and other imaging techniques are used widely to diagnose and monitor the response of ALA to therapeutic measures.115 Ultrasonography has the advantages of low cost, availability, and lack of radiation exposure. Ultrasound scan guidance provides a mechanism for safe aspiration of ALA and the ability to monitor resolution of the cavity. It however does not distinguish between pyogenic and amebic abscesses and should be interpreted in the light of the clinical picture and serology results.Parenteral metronidazole remains the drug of choice in the treatment of ALA. Although some investigators have recommended multiple drug therapy in children,4,5，15 our experience indicates that metronidazole in doses of 50 mg/kg/d is effective even in the face of complicated and ruptured ALA. There were no instances of recurrence orFig 2. (A) CAT scan of the abdomen of a 12-year-old boy shows a large ALA in right lobe of liver. (B) Chest x-ray of the same patient shows a right empyema thoracic caused by rupture of the ALA.121relapse in the 48 patients included in this study. We do not believe that broad-spectrum antibiotics have a role to play in the treatment of ALA. The role of routine aspiration and surgical intervention in the management of ALA remains unclear.7，1516 Several investigators recommend surgical intervention for complicated and ruptured ALA, and amebic peritonitis has been described as a surgical entity.9 Surgical procedures reported have included exploratory laparotomy, irrigation of the peritoneal cavity, and the use of multiple drains.1011，1718 Literature dealing specifically with the management of ALA in children is sparse, and studies have included relatively small numbers of patients. Several investigators have emphasized the need for surgical intervention for ALA in children. Scragg and Proctor5 believe that open drainage plays a greater role in the management of children when compared with adults. Similarly, Moore17 recommends early operative intervention in children with122M0A2AM AND NAZIRa left-sided liver abscess caused by their propensity for perforation into the pericardium. In Porras-Ramirez et als4 report of 32 children, 15 (47%) patients required surgical intervention because of rupture of m ALA.The 48 children reported in the current study presented late and had evidence of malnutrition and stunted growth when seen at AKUH. Timely aspiration of the ALA may have contributed to a smaller number of ruptures in these patients despite delays in presentation, as compared with previous reports.4，17 Based on this experience, we recommend aspiration of all ALA that are greater than 7.0 cm in diameter, those located in the left lobe，and when noREFE1. McCort JJ: Amebic liver abscess: Review of twenty-nine cases with an evaluation of imaging techniques. Maryland Med J 39:10851088,19902. Peters RS，Gitlin N，Libke, RD: Amebic liver abscess. Ann Rev Med 32:161-174, 19813. Maltz G, Knauer CM: Amebic liver abscess: A15 year experience. Am J Gastroentrol 86:704-710, 19914. Porras-Ramirez G, Hamandez-Herrera MH, Porras-Hamandez JD: Amebic hepatic abscess in children. J Pediatr Surg 30:660-664, 19955. Scragg JN, Proctor EM: Tinidazole in treatment of amoebic liver abscess in children. Arch Dis Child 52:408-410,19776. Nazir Z, Moazam F: Amebic liver abscess in children. Pediatr Infect Dis J 12:929-932, 19937. Gibney EJ: Amoebic liver abscess. Br J Surg 77:843-844,19908. Sarda AK, Bal S, Sharma AK, et al: Intrapcritoneal rupture of amoebic liver abscess. Br J Surg 76:202-203, 19899. Basile JA, Klein SR, Worthen NJ, et al; The surgeons role in management. Am J Surg 146:67-71, 198310. Chuah S, Chang-Chien C, Sheen I, et al: The prognostic factorsclinical response is evident within 48 hours of medical therapy. In the case of rupture into the peritoneal cavity, parenteral metronidazole an