AMEBIC LIVER ABSCESS

https://doi.org/10.1016/S0891-5520(05)70121-5Get rights and content

Amebiasis is a widespread parasitic disease caused by the protozoan Entamoeba histolytica. Amebiasis most commonly results in asymptomatic colonization of the gastrointestinal tract, but some patients may develop intestinal invasive disease with ulcerative and inflammatory lesions of the colon.4, 42 Amebic liver abscess (ALA) is the most common extraintestinal manifestation of E. histolytica infection. Amebic liver abscess is marked by a significant male preponderance and is a disease seen most commonly in patients who reside in or have emigrated from an endemic area or have a recent travel history to an endemic area. Patients typically present with acute or chronic abdominal pain and associated constitutional symptoms, but rarely have concurrent dysentery or bloody stools.29, 41, 58 Stool examination and stool antigen detection tests are usually unhelpful because most patients with ALA do not have detectable parasites in their stool.58 Serologic testing with enzyme immunoassays (EIA) specific for E. histolytica circulating antibodies may aid in the diagnosis of ALA.32 In most cases, medical management alone is sufficient to treat uncomplicated cases. Metronidazole remains the drug of choice for treatment of ALA followed by a luminal agent to eradicate the asymptomatic carrier state.24, 36

Section snippets

PATHOGENESIS

Amebiasis is caused by ingestion of infective E. histolytica cysts through a fecal-oral route of exposure. Humans are the principal host, and the main source of infection is the cyst-passing chronic patient or asymptomatic carrier.92 The infective cysts reach humans through water and vegetables contaminated with feces, through food contaminated by night soil fertilizers or by hands of infected food handlers, or by direct transmission of cyst.92 A recent outbreak of amebiasis in the Republic of

EPIDEMIOLOGY

Amebiasis remains an important clinical problem in both developing and developed countries with a significant mortality rate even now.95 The disease is most prevalent in tropical and developing countries where sanitation, public health, and personal hygiene are suboptimal.6 Immigration and travel between countries, however, may increase the incidence of disease worldwide. Countries with the highest E. histolytica endemic activity include Mexico, India, East and South Africa, and portions of

Clinical Signs and Symptoms

Approximately 80% of patients with amebic liver abscess present with symptoms that develop over a few days to several weeks but typically less than 2 to 4 weeks in duration.11, 21, 29 The diagnosis of amebic liver abscess is suggested by the typical clinical picture of fever and chills, anorexia, right upper quadrant pain and tenderness, and hepatomegaly.54 The most common clinical signs and symptoms are listed in Table 2 and include fever, chills, nausea, weakness, and malaise, and a constant,

History and Physical Examination

A careful history must include the patient's presenting complaints, duration of illness, medical history, travel history, history of residence in an endemic area, ill contacts, HIV risk factors, evidence of malnutrition or immunosuppression, medications, and history of alcohol use. On physical examination, typical findings include a tired- and ill-appearing febrile patient with abdominal pain and tenderness usually in the right upper quadrant or epigastrium, hepatomegaly with liver span greater

Drug Therapy

Treatment options for uncomplicated amebic liver abscess include amebicidal drugs and, if indicated, percutaneous or open aspiration of the abscess.6 Metronidazole remains the drug of choice for treating amebic liver abscess.6, 24, 48 This drug has been used in clinical practice for over 25 years for the treatment of amebiasis.24, 93 Metronidazole is a nitroimidazole, which enters the parasite by passive diffusion where it is then converted to reactive cytotoxic nitro radicals by reduced

COMPLICATIONS OF AMEBIC LIVER ABSCESS

The most common complications from amebic liver abscess arise from rupture of abscess with extension into the peritoneum, pleural cavity, or pericardium.2, 28, 29, 41, 47 Peritonitis, paralytic ileus, fulminant colitis, colonic perforation, or toxic megacolon can occur as gastrointestinal complications of an amebic liver abscess.3 Depending on the size and location of the abscess, compression of the biliary tree can occur with resultant obstructive jaundice.3 In rare cases, inferior vena caval

LONG-TERM OUTCOME

In most cases, rapid clinical improvement is seen with antiamebic drug therapy alone within a few days to a week as measured by disappearance of fever, pain, and anorexia, greater than 50% regression in liver span on percussion, and normal leukocyte count.77, 78 In contrast, although the liver abscess eventually resolves with complete disappearance radiologically, it does not disappear rapidly on imaging studies. On average, time to complete radiologic resolution is 3 to 9 months, with a range

PREVENTION

Amebiasis infection can be prevented by interrupting the fecal-oral spread of infection, primarily by eradicating fecal contamination of food and water.58, 92 Fresh vegetables are the most commonly contaminated food sources and should be washed carefully with a detergent and then soaked in acetic acid or vinegar for 10 to 15 minutes to eradicate the infective cysts.92 Contaminated water is one of the most important sources for acquisition and spread of infection.12, 92 Boiling water before use

References (97)

  • PetriW.A. et al.

    Subunit structure of the galactose and n-acteyl- d-galactosamine-inhibitable adherence lectin of Entamoeba histolytica

    J Biol Chem

    (1989)
  • F.E. Pittman et al.

    Studies of human amebiasis II. Light and electron-microscopic observations of colonic mucosa and exudate in acute amebic colitis

    Gastroenterology

    (1973)
  • B.D. Ragland et al.

    Entamoeba histolytica target cells killed by trophozoites undergo apoptosis which is not blocked by bcl-2

    Exp Parasitol

    (1994)
  • P.W. Ralls

    Focal inflammatory disease of the liver

    Radiol Clin North Am

    (1998)
  • M.D. Abd-Alla et al.

    Differentiation of pathogenic from nonpathogenic Entamoeba histolytica infection by detection of galactose-inhibitable adherence protein antigen in sera and feces

    J Clin Microbiol

    (1993)
  • E.B. Adams et al.

    Invasive amebiasis II: Amebic liver abscess and its complications

    Medicine

    (1977)
  • M. Ahmad et al.

    Fatal amoebic liver abscess: An autopsy study

    J Gastroenterol Hepatol

    (1991)
  • M. Ahmed et al.

    Systemic manifestations of invasive amebiasis

    Clin Infect Dis

    (1992)
  • Y. Akgun et al.

    Amebic liver abscess: Changing trends over 20 years

    World J Surg

    (1999)
  • N.M. Amin

    Amebic liver abscess

    Am Fam Phys

    (1987)
  • J.N. Aucott et al.

    Amebiasis and “nonpathogenic” intestinal protozoa

    Infect Dis Clin North Am

    (1993)
  • S.Y. Baek et al.

    Therapeutic percutaneous aspiration of hepatic abscesses: Effectiveness in 25 patients

    AJR Am J Roentgenol

    (1993)
  • BarnesP.F. et al.

    A comparison of amebic and pyogenic abscess of the liver

    Medicine

    (1987)
  • Barwick RS, Uzicanin A, Lareau S, et al: Outbreak of amebiasis in Tbilisi, Republic of Georgia, 1998 [abstract 200]. In...
  • S. Bhatia et al.

    Randomized double-blind trial of metronidazole versus secnidazole in amebic liver abscess

    Indian Soc Gastroenterol

    (1998)
  • L.L. Braga et al.

    Inhibition of the complement membrane attack complex by the galactose-specific adhesin of Entamoeba histolytica

    J Clin Invest

    (1992)
  • K. Chadee et al.

    The pathology of experimentally induced cecal amebiasis in gerbils (Meriones unguiculatus)

    Am J Trop Med Hyg

    (1985)
  • ChengH.-S. et al.

    Amoebiasis among institutionalized psychiatric patients in Taiwan

    Epidemiol Infect

    (1999)
  • ChuahS.-K. et al.

    The prognostic factors of severe amebic liver abscess: A retrospective study of 125 cases

    Am J Trop Med Hyg

    (1992)
  • R.L. Conter et al.

    Differentiation of pyogenic from amebic hepatic abscesses

    Surg Gynecol Obstet

    (1986)
  • L.S. Diamond et al.

    A redescription of Entamoeba histolytica Shaudin 1903 (amended Walker 1911) separating it from Entamoeba dispar (Brumpt 1925)

    J Eukaryot Microbiol

    (1993)
  • C.D. Freeman et al.

    Metronidazole: A therapeutic review and update

    Drugs

    (1997)
  • B.M. Ghandi et al.

    Enzyme-linked protein A: An ELISA for detection of amoebic antibody

    Trans R Soc Trop Med

    (1985)
  • J.C. Gillis et al.

    Secnidazole: A review of its antimicrobial activity, pharmacokinetic properties and therapeutic use in the management of protozoal infections and bacterial vaginosis

    Drugs

    (1996)
  • A. Giorgio et al.

    Pyogenic liver abscesses: 13 years of experience in percutaneous needle aspiration with US guidance

    Radiology

    (1995)
  • G.C. Greaney et al.

    Ruptured amebic liver abscess

    Arch Surg

    (1985)
  • A.J. Greenstein et al.

    Amebic liver abscess: A study of 11 cases compared with a series of 38 patients with pyogenic abscess

    Am J Gastroenterol

    (1985)
  • A.A. Hai et al.

    Amoebic liver abscess. Review of 220 cases

    Int Surg

    (1991)
  • R. Haque et al.

    Prevalence and immune response to Entamoeba histolytica infection in preschool children in Bangladesh

    Am J Trop Med Hyg

    (1999)
  • R. Haque et al.

    Rapid diagnosis of Entamoeba infection by using Entamoeba and Entamoeba histolytica stool antigen detection kits

    J Clin Microbiol

    (1995)
  • D.C. Harker et al.

    Characteristics of ribosomes during differentiation from trophozoites to cyst in axenic Entamoeba sp

    Cell Differ

    (1972)
  • Huston CD, Hahn CS, Petri WA Jr: Role of host cell caspase 3 in apoptotic killing by Entamoeba histolytica [abstract...
  • M.F. Irusen et al.

    Asymptomatic intestinal colonization by pathogenic Entamoeba histolytica in amebic liver abscess: Prevalence, response to therapy, and pathogenic potential

    J Infect Dis

    (1992)
  • K.N. Jalan et al.

    Amebiasis in the developing world

  • M.P. Joyce et al.

    Pathology of human amebiasis

  • JuniperK. et al.

    Serologic diagnosis of amebiasis

    Am J Trop Med Hyg

    (1972)
  • D. Katzenstein et al.

    New concepts of amebic liver abscess derived from hepatic imaging, serodiagnosis, and hepatic enzymes in 67 consecutive cases in San Diego

    Medicine

    (1982)
  • J. Knobloch et al.

    Development and persistence of antibodies to Entamoeba histolytica in patients with amebic liver abscess

    Am J Trop Med Hyg

    (1983)
  • Cited by (109)

    • Entamoeba

      2023, Molecular Medical Microbiology, Third Edition
    • Entamoeba stage conversion: progress and new insights

      2020, Current Opinion in Microbiology
    • Infections of the Hepatobiliary System

      2020, Seminars in Ultrasound, CT and MRI
    View all citing articles on Scopus

    Address reprint requests to Molly A. Hughes, MD, PhD, University of Virginia Health Sciences Center, Division of Infectious Diseases, MR4 Bldg., Box 2115, 300 Park Place, Charlottesville, VA 22908, e-mail: [email protected]

    This work was supported by the National Institutes of Health, grant no. AI-43596.

    *

    Division of Infectious Diseases, Department of Medicine, University of Virginia Health Sciences Center, Charlottesville, Virginia

    View full text