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Amoebic liver abscess’ (ALA) are an important cause of morbidity and mortality in tropical countries. Predisposing factors include alcohol ingestion, cirrhosis, individuals with diabetes mellitus, and immunodeficiency. The patients usually present with fever, pain upper abdomen, and hepatic tenderness and outcomes are influenced strongly by early diagnosis and treatment. Diagnosis depends on the identification of a fluid collection in the liver, usually by ultrasound. There is a controversy regarding the maximum size of abscess that can be managed conservatively.¹ Amoebicidal drug therapy alone is generally effective in uncomplicated and small liver abscess. However, additional interventions like percutaneous needle aspiration (PNA) and percutaneous catheter drainage(PCD) are usually warranted in ALA with left lobe involvement, thin rim of liver tissue around the abscess (< 1 cm), seronegative abscesses, and lack of clinical improvement in 48-72 hours of medical therapy.² PCD is indicated for symptomatic larger abscess(>10cm), having either thick content or features of secondary bacterial infection, refractory to drug therapy and after the failure of 2-3 procedures of PNA.³ We describe our experience of amoebic liver abscess in this study. 

We retrospectively analyzed the records of patients of ALA admittedin the gastroenterology department of SMS Medical College, Jaipur, Rajasthan, India. Between January 2018 to June 2018, 136 patients were diagnosed as ALA based on clinical picture, ultrasonography, and amoebic serol-ogy. The mean age of these patients was 39.1 ±12.4 years, and 130(95.55%) were male.Ninety-six patients (70.6%) were successfully managed conservatively. Thirty-two patients (23.5%) patients required image-guided drainage in the form of PNA. The indications for these were left lobe involvement, abscess with impending rupture, and non-response to conservative treatment. Significant clinical improvement occured in 27 patients, while 5 patients remained symptomatic and underwent PCD. PCD was done in total of 13 patients (9.5%) with larger abscesses, thick viscous content, and after failed single time PNA, all of whom had significant clinical improvement. The mean duration of hospital stay was 5.2 ± 1.0 days. At discharge, all patient were afebrile and had atleast 50% reduction in pain abdomen.The patients were on regular follow-up every two weeks following discharge. On follow-up, ten patients from the PNA group presented with persistent right hypochondrial pain. Of them, eight patients had right lobe ALA, and two had involvement of both lobes of the liver. Six patients had multiple liver abscesses, and 4 had a single abscess cavity. Initially, the mean size of the liver abscess was 12.7cm (range 10.5 – 14.6 cm), and reduced to 11.8 ± 1.47 (range 9.5 – 13.7 cm) on follow-up. 245 ± 99.7 ml (range 150- 400 ml) of clear, thin abscess fluid was aspirated. A significant decrease in pain was noted post aspiration, and the patient discharged on the same day with five days of empirical antibiotics. Patients remain asymptomatic at six months of follow up.

Although debatable, many studies in the past advocate the role of aspiration in large liver abscess to hasten clinical recovery in patients receiving anti-ameobicidal agents.^4,5 PNA is less invasive, cost-effective, requires less expertise, and multiple cavities can be aspirated in a single setting. Rajak et al. found that PNA appears to be less effective than PCD, though both procedures were safe, without major complications or death.⁶ They believed that large abscesses are more difficult to evacuate completely in a single attempt, which may be why many centers prefer PNA for abscesses <5 cm, and PCD for larger abscesses.⁶ Ramani et al. concluded that aspiration resulted in a better initial response and early clinical improvement, but the long-term outcome was similar between aspirated and conservatively managed groups.¹ Singh et al. found that both procedures were equally effective in the management of large liver abscesses, but PCD appears to be better in quicker symptomatic improvement, duration of intravenous antibiotics needed, and complete resolution of the abscess cavity.⁷ Ultrasound abdomen findings depend on the content of abscess cavity, the phases of development, organization, and repair; Thus, may be variable.⁸ In the early stages, the necrosed liver cells are not yet liquefied, giving an echogenic appearance, and subsequent liquefaction results in hypoechoic appearance.⁹

Considering the natural course of evolution of the abscess cavity, sometimes in early stages, optimal aspiration is not possible because of solidified components. Thus a subset of patients may have persistent right hypochondrial pain due to residual abscess cavity. On follow up necrosed liver cells and debris in the abscess cavity undergo liquefaction, which can then be aspirated in a single setting, resulting in reduced abscess cavity and relief of pressure symptoms.

Thus, conservative treatment was successful in the majority of uncomplicated amoebic liver abscesses of lesser size. The initial success rate of PNA was 84.3%. PCD had a 100% success rate. A subset of patients of large ALA may become asymptomatic initially after single aspiration but may develop symptoms later on requiring respiration. To conclude, patients of large ALA who respond initially to a single needle aspiration should be carefully followed up and may require re-aspiration.