Amoebic Liver Abscess. O P Kapoor (Pp 205; Rs.425) S S Publishers, 1979

Parasitological surveys have shown that about 3% to 5% of the population of the UK are asymptomatic carriers of Entamoeba histolytica, and that about 200 cases of clinical amoebiasis are diagnosed in England and Wales each year. Many cases probably go unrecognized including a few which the reach the necropsy room. Because the disease is comparatively rare in Western Europe, it is often not considered by clinicians in this list of differential diagnoses; likewise, research for the elusive amoeba in stool is made by laboratory staff with little experience of this particular parasite.
Hepatic amoebiasis is one important form of the disease, and Dr. Kapoor’s book is based on his personal experience of 200 cases seen in Bombay. In a historical review he tell us of the officer in 1818 who was cured of his liver abscess when it was opened by a fortuitously well placed shot, and he also makes a case for amoebiasis as the cause of Napoleon’s death. Subsequent chapters discuss the world distribution of the disease, the mechanisms by which the scanty population of amoebae in the liver may cause such extensive damage, and the immunological response to the invader. New understanding has grown from studies of animal models.
The clinical sections of these monographs are particularly clearly presented and illustrated. The cardinal symptoms are upper abdominal pain and fever, but both may be absent and Dr. Kapoor emphasizes the importance of recognizing the rarer pulmonary and cardiac presentations. Most abscesses occur in the right lobe, but those in the left lobe present with a more variable clinical picture and may perforate into the pericardium or general peritoneal cavity, thereby creating an acute surgical emergency. The patient may thus present to one of a number of different specialists. Usually the most prominent physical sign is a tender enlargement of the liver. A focal point of tenderness is a valuable sign and indicates the best sport to aspirate the abscess. A few patients with large of multiple amoebic abscesses may have jaundice or portal systemic encephalopathy.

Special investigations
Hepatic scintiscanning with ^99mTc sulphur colloid is emphasized as an important step in diagnosing and localising the abscess and scanning agents excreted in the biliary tree such as ¹³¹I Rose Bengal - will often help to distinguish an abscess near the gall bladder bed from an empyema. Ultrasound, which has only recently become available to the author in Bombay, receives little mention. In skilled hands this is probably as good as or better than scintiscanning at localizing an abscess and, unlike the latter, it has the advantage of usually being able to differentiate an abscess from a liver tumour - another common cause of fever and hepatic enlargement in tropical areas. Ultrasound will clearly become more widely available in developing countries and portable machines are being made for use in rural areas. The role of abdominal computerised axial tomography is not defined. The various available serological tests are discussed; while they remain positive for some years after an amoebic infection, a negative result is distinctly unusual in a patient with an amoebic liver abscess.

Management
The medical management is well described. The author favours a combination of two drugs - usually dehydroemetine, and either metronidazole or chloroquine. The former is favoured when there is a coexistent dysentery. The most important point in evaluating the clinical response is relief of pain, which should be almost complete in four or five days. Controversy continues about the advisability of aspirating amoebic liver abscesses. Dr. Kapoor recommends aspiration of very large or superficial abscesses, those causing sever pain in rupture may be imminent, and left-lobe abscesses. The procedure is clearly described. Despite the hallowed textbook descriptions, the pus removed is seldom like anchovy sauce but usually more chocolate coloured and, on occasion, it may be creamy yellow. Surgical intervention is rarely necessary unless the abscess develops secondary bacterial infection or rupture occurs.
This is a readable and lavishly illustrated book and, while most the illustration are of high standard the reproduction of the few photomicrographs and some of the radiographs is disappointing. The bibliography is extensive and up to date. The book can be recommended to all doctors who see patients with amoebiasis and, because of increasing air travel, we should all be alert to this diagnostic possibility.

IAIN M MURRAY-LYON

The Lancet, March 29 1980
Amoebic Liver Abscess
O. P. KAPOOR, Grant Medical College, Bombay
Bombay: S. S. Publishers. 1979. Pp. 208. $ 50 Rs 425

HEPATIC amoebic abscess, although a rare clinical problem in the United Kingdom, should always be borne in mind since the diagnosis may well be missed in sporadic cases. This monograph, embodying the author's personal experience of many hundreds of patients with amoebic abscess of the liver, should be a useful reference book The emphasis is clinical, the book consisting largely of descriptions of the syndromes produced by an abscess in different parts of the liver and the special problem of pulmonary amoebic abscess. To allocate a whole chapter to a description of the pus from an amoebic abscess may seem excessive, but it is an example of the author's careful observation that typifies this book. The historical review and chapters on pathogenesis, pathology, and immunology are brief but, as in all the sections, the literature is well reviewed. The investigation of a suspected amoebic abscess is described clearly and includes chapters on the role of serology, radiology, hepatic scintigraphy, ultrasonic imaging, and CAT scanning. The differential diagnosis and atypical presentations are discussed in several short chapters. The sections on medical and surgical treatment of the condition will be useful to those with limited experience in this area; the stages of medical treatment and indications for aspiration and surgical treatment are clearly stated. The outstanding feature of this book is the very high standard of illustrations consisting of two hundred excellent colour photographs and clear reproduction of radiographs. The author has a conversational style of writing which makes the book easy to read. This book should prove a useful reference volume in any medical library.