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SHORT COMMUNICATION
Year : 2020  |  Volume : 6  |  Issue : 3  |  Page : 225-227

Is There a Difference in Etiology in the Liver Abscesses in South India?: A Clinical and Microbiological Study


1 Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu
2 Department of General Surgery, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India

Date of Submission03-Jul-2020
Date of Decision09-Jul-2020
Date of Acceptance19-Jul-2020
Date of Web Publication16-Dec-2020

Correspondence Address:
Mr. Tusharindra Lal
B-90, Swasthya Vihar, Delhi-110092, New Delhi

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mamcjms.mamcjms_68_20

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  Abstract 


Background: Liver abscesses in India are considered to be amoebic in origin. Studies for determining causative organism of liver abscesses in Southern India are limited in number. The present study was conducted to determine the etiology of these abscesses in the Chennai region. Methods: Twenty-three patients with a diagnosis of liver abscess were prospectively studied with full blood profile. Ultrasound-guided pus was aspirated and sent for culture. Amoebic serology was performed. The abscesses were classified as pyogenic, amoebic and indeterminate. Results: Sixteen patients (69.6%) were diagnosed as pyogenic, three (13%) as amoebic and four (17.4%) as indeterminate. Fifteen (5.2%) abscesses were single and 12 (52.3%) affected the right lobe. Escherichia coli (42.85%) and Staphylococcus aureus (35.71%) remained the most common causative organisms grown on pyogenic culture. Conclusion: In this study of a small group of patients from South India, liver abscesses were found to be predominantly single and pyogenic in origin with an equal propensity of gram-positive and gram-negative organisms.

Keywords: Aetiology, amoebic, liver abscess, multiple, pyogenic, single


How to cite this article:
Lal T, Iyyappan RP, Kaliyappa C. Is There a Difference in Etiology in the Liver Abscesses in South India?: A Clinical and Microbiological Study. MAMC J Med Sci 2020;6:225-7

How to cite this URL:
Lal T, Iyyappan RP, Kaliyappa C. Is There a Difference in Etiology in the Liver Abscesses in South India?: A Clinical and Microbiological Study. MAMC J Med Sci [serial online] 2020 [cited 2021 Apr 13];6:225-7. Available from: https://www.mamcjms.in/text.asp?2020/6/3/225/303594




  Introduction Top


Liver abscesses continue to remain a common cause of acute abdomen in tropical countries. The etiology of a liver abscess may be an amoebic, pyogenic, tubercular or fungal infection. Most of the studies have shown that liver abscesses in India are amoebic.[1] These abscesses may be single or multiple and may further affect various lobes of the liver.[2] Epidemiological studies to look for causative organisms from South India are limited. Patients presenting in the emergency setting are administered broad-spectrum antibiotics on admission based upon the usual aetiology of the abscess in the region. This study was conducted to evaluate the etiology and microbiological profiles of liver abscesses presenting in a tertiary care hospital in Chennai and would enable more judicious usage of antibiotics.


  Methods Top


This prospective study reports the outcome of 23 patients diagnosed with liver abscess who presented to the surgical emergency from May to October 2019. The study was approved by the Ethics Committee and informed consent was obtained from each patient. All patients were evaluated on the basis of a detailed history, clinical examination and radiological imaging. There were 18 males (78.3%) and 5 females (21.7%) with a male: female ratio of 3.6:1. The mean age was 51.16 and 56 years respectively. There were two infants aged 1 month and 12 months.

Abdominal pain (82.6%) and fever (78.26) were the most frequent symptoms. The patients were investigated by haemogram; amoebic serology; ultrasound-guided pus aspiration followed by Gram’s staining in all cases; Ziehl-Neelsen staining for acid-fast bacillus (AFB); microscopy for Entamoeba histolytica; pyogenic culture; and examinations of stools for Entamoeba histolytica on three consecutive days.

Pyogenic abscesses were diagnosed based on a positive pus culture and amoebic liver abscesses were diagnosed based on the positive serology (enzyme-linked immunosorbent assay, ELISA) and the typical ‘anchovy fish sauce’ color of the drained pus. In the absence of a clear diagnosis, the cases were labelled as ‘indeterminate’. Metronidazole was the drug of choice for amoebic liver abscess while cefoperazone, ceftriaxone, piperacillin-tazobactam combination, ciprofloxacin and, meropenem were used according to the sensitivity of the pyogenic organisms grown on culture. The data were analyzed using descriptive statistics, frequency table and the Chi-square test.


  Results Top


A total of twenty-three patients [eighteen males (78.3%) and five females (21.7%)] with a mean age of 51.16 and 56 years respectively were included in the study. The most common complaint was right upper quadrant (RUQ) abdominal pain (82.60%) and fever (78.26%).

The mean leukocyte count was raised in sixteen patients (69.56%). The total bilirubin was elevated in six patients (27.27%). Serum glutamic oxalo-acetic transaminase (SGOT) was increased in seven patients (31.81%) while the serum glutamic pyruvic transaminase (SGPT) was raised in ten patients (45.45%). Seventeen patients (77.27%) had elevated levels of alkaline phosphatase (ALP).

Based upon pus culture and amoebic serology of the twenty-three patients, sixteen (69.6%) were diagnosed as pyogenic, three (13%) as amoebic and the remaining four (17.4%) were labelled as ‘indeterminate’. There were fifteen (65.2%) single abscesses and eight (34.8%) multiple abscesses. The average size of the abscesses was 6.5 cm (range: 4.5–12 cm). The abscesses were predominantly in the right lobe (12/23, 52.2%), 6/23 (26.1%) affected both right and left lobes, 4/23 (17.4%) affected the left lobe and 1/23 (4.3%) affected the caudate lobe of the liver [Table 1].
Table 1 Types of abscess, single or multiple and lobe affected

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Positive cultures were obtained in fourteen out of sixteen patients.  Escherichia More Details coli remained the most common organism (42.85%) grown on pus culture amongst single and multiple pyogenic abscesses. Staphylococcus aureus Scientific Name Search  was the second commonest organism causing pyogenic abscess isolated in 35.71% cases [Table 2].
Table 2 Organisms isolated from pus culture

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The remaining two patients were treated empirically as pyogenic abscess. All patients recovered and were discharged after resolution of symptoms with advice to continue oral antibiotics for a total period of three weeks.


  Discussion Top


Liver abscess is a common presentation to the surgical emergency requiring prompt treatment with antibiotics or surgical drainage. It is generally believed that most liver abscesses in tropical countries are amoebic in origin,[3] however, the present study showed that nearly 70% of the liver abscesses in the adult population were pyogenic in origin, which is usually more often in the pediatric age group.[4] In fact, amoebic liver abscesses were confirmed in only 13% of cases. The present study shows that it cannot be assumed that aetiologies of liver abscesses in all regions of tropical countries would be predominantly amoebic. Clearly, amoebiasis does not seem to be endemic in Southern India especially in the Chennai region. It is not uncommon to be unable to reach a diagnosis every time in liver abscess patients due to inability to sample pus or grow an organism on culture. Four cases were labelled as ‘indeterminate’ which is similar to the study reported from North India and responded to a combination of antibacterial and anti-amoebic treatment and therefore could not be classified into any one type.[5] Abdominal pain and fever were the most common presenting symptoms. In patients with pyogenic liver abscess, haemoglobin was low and serum bilirubin was raised in six patients, SGPT was elevated in 10/16 (62.5%), SGOT was raised in 7 and ALP was consistently increased in all the patients. This is in line with the general observation that liver function tests are more often altered in pyogenic liver abscesses.[1]

It is commonly believed that pyogenic liver abscesses are multiple[6] as they are hematogenous in origin and amoebic are solitary and confined to the right lobe.[7] However, in our study, 10/16 (62.5%) patients with a pyogenic liver abscess had a solitary abscess with 7 (70%) affecting the right lobe while the remaining were multiple. The number of abscesses and their location cannot be used to determine the aetiology. Thus, the findings from our study contradict traditional teaching. Escherichia coli, possibly from portal circulation and Staphylococcus aureus possibly from a septic focus in the body were the predominant organisms responsible for 68.75% of the pyogenic infections.


  Conclusion Top


In this study of a small group of patients from South India, liver abscesses were found to be predominantly single and pyogenic in origin. Escherichia coli and Staphylococcus aureus were the commonest causative organisms with equal propensity. Fewer cases of amoebic abscesses suggest that amoebiasis is not endemic in Southern India.

This research was undertaken towards the award of Indian Council of Medical Research, Short Term Studentship (ICMR STS-2019) for undergraduate medical students.

Financial support and sponsorship

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.Conflicts of interest

The authors declare that they have no competing interests.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The study was approved by the Institutional Ethical Committee of Sri Ramachandra University, Chennai.



 
  References Top

1.
Mohan S, Talwar N, Chaudhary A, Andley M, Ravi B, Kumar A. Liver abscess: a clinicopathological analysis of 82 cases. International Surgery 2006;91:228-33.  Back to cited text no. 1
    
2.
Ochsner A, DeBakey M, Murray S. Pyogenic abscess of the liver: II. An analysis of forty-seven cases with review of the literature. The American Journal of Surgery 1938;40:292-319.  Back to cited text no. 2
    
3.
Jha AK, Das A, Chowdhury F, Biswas MR, Prasad SK, Chattopadhyay S. Clinicopathological study and management of liver abscess in a tertiary care center. Journal of Natural Science, Biology, and Medicine 2015;6:71  Back to cited text no. 3
    
4.
Waghmare M, Shah H, Tiwari C, Khedkar K, Gandhi S. Management of liver abscess in children: our experience. Euroasian Journal of Hepato-gastroenterology 2017;7:23.  Back to cited text no. 4
    
5.
Tayal A, Lal P, Uppal B. Single and multiple liver abscesses in adults in Delhi are amoebic in origin: a clinical and microbiological study. Tropical Doctor 2013;43:77-9.  Back to cited text no. 5
    
6.
Lodhi S, Sarwari AR, Muzammil M et al. Features distinguishing amoebic from pyogenic liver abscess: a review of 577 adult cases. Trop Med Int Health 2004;9:718-23.  Back to cited text no. 6
    
7.
Sharma N, Sharma A, Varma S, Lal A, Singh V. Amoebic liver abscess in the medical emergency of a North Indian hospital. BMC Res Notes 2010;3:1-4.  Back to cited text no. 7
    



 
 
    Tables

  [Table 1], [Table 2]



 

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