The symposium on hepatic abscess: Controversy, analysis and addendum

Abstract

Well chosen Liver Abscess (LA) topic was started with controversy on incidences. “LA is relatively uncommon in western countries” without any literature evidence in the introduction and “increasing trend of Pyogenic Liver Abscess (PLA) and Amoebic Liver Abscess (ALA)” in demography1 are contradictory. Differential diagnosis – Article gives same presentation and incidence of jaundice both ALA and PLA without any literature evidence.1 Patients with ALA were more likely to be young males with a larger, solitary, right lobe abscess. Univariate analysis found patients with PLA more likely to be >50 years old, with a history of diabetes and jaundice, with pulmonary findings, multiple abscesses, amoebic serology titers <1:256 IU, and lower levels of serum albumin.2 Low incidence of ALA in reproductive females is well documented in books. Classification of PLA – Classification is done for the treatment or prognostication. A study with over 600 cases, PLA, they have divided into A. cryptogenic 152 (25.3%) B. Diabetic-229 (38.1%), C. Biliary tract diseases-144 (24%) D. mixed .76 (12.6%) and found biliary cause having maximum recurrence over a mean follow-up 6.06 years.3 Cryptogenic PLA – This group of PLA may herald the onset of cancer, especially hepato-biliary and colon cancer.4,5 Elevated AFP and CA19-9 could suggest liver cancer and intra-hepatic cholangiocarcinoma in cases of PLA. Contrast-enhanced computed tomography could be helpful in patients with normal AFP and CA19-9.6 Diabetic – Diabetes is a strong, potentially modifiable risk factor for PLA and is associated with a poor prognosis7 The pathogens in DM is mostly due to Klebsiella pneumoniae K1 strain carrying the virulence plasmid gives rise to recurrent PLA.8,9 Biliary cause – Underlying biliary tract disease commonest cause of recurrent abscess Irrespective of DM or cryptogenic status and Escherichia coli is mostly the causative organism.3 PLA in presence biliary obstruction requires urgent bilio-enteric continuity. Endoscopic therapy is an effective mode of treatment for biliary fistulas complicating liver abscesses.10 While percutaneous drainage is appropriate as first-line surgical treatment in most cases, Percutaneous drainage may help to optimize clinical condition prior to surgery. Open surgical drainage is prudent in cases of rupture, multiloculation, associated biliary or intra-abdominal pathology Laparoscopic drainage is a feasible surgical option with promising results in the future. Liver resection is reserved for concomitant localized intra-hepatic disease and tumor, after control of sepsis.11 Laparoscopic surgery for simultaneous treatment of PLA and biliary pathology is feasible in selected patients and the therapeutic effect is similar to that of open surgery.12 The authors have listed all the types of therapy without giving the need in specific situation. ALA – Serodiagnosis in the endemic area remains doubtful due to, high antibody titers. Two new tests pyruvate phosphate dikinase13 and parasite DNA demonstration in saliva are useful in such situation.14 A US Food and Drug Administration approved drug used for rheumatoid arthritis, “Auranofin” is found to be 10 times more active than Metronidazole against parasite.15 The references are rather old and Ref. 26 and 29 are incomplete as per MJAFI guideline.