PLEA FOR RE-ORIENTATION OF THE CONCEPT OF AMOEBIC LIVER ABSCESS

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There is need for a new look at ‘amoebic liver abscess’. Until now most of our knowledge (of amoebic liver abscess) was based on information, gathered before investigations like visualisation of the liver (liver scan) and specific serological tests for amoebiasis, were available. In fact, it is perhaps one of the few illnesses in medicine on which so much work has been published without the workers having had the benefit of these two very valuable aids to diagnosis. If the mortality due to amoebic liver abscess is to be brought down, an early diagnosis must be made. This is one illness for which there are so many effective drugs and so much surgical help available that once diagnosed, on patient should be allowed to die. Unfortunately, in practice, the diagnosis is quite often delayed. A common example is that of a chest specialist, who does not think of amoebic liver abscess, because in a patient having a shadow at the base of the right lung, liver is not enlarged and tender. Little does he realise that the liver need not enlarge downwards and that a superficial abscess on the superior surface an rupture straight away and cause a chest disease. Similarly, a cardiologist seeing a case of pericarditis with effusion does not think of a rupture of left lobe abscess as long as he does not see any obvious lump and tenderness in the left lobe of the liver. He, too, does not appreciate the fact that an abscess on the superior surface may expand upwards, causing minimal signs in the abdomen. Therefore, the concept of an amoebic liver abscess should be divided into many clinical syndromes so that a chest specialist, a cardiologist or even a general surgeon should be able to think of and diagnose this disease as the cause of the illness. It will not be out of place to compare amoebic liver abscess to ‘Tables Dorsalis’. Although a neurologist is supposed to diagnose this disease, the publicity it has received in medical literature and text books has been so wide that today even a general surgeon, who sees a patient with retention of urine, or a skin specialist seeing a patient with a trophic ulcer, looks for a torch-light to elicit the pupillary reflex, and subsequently refers the case to a neurologist as ‘Tabes Dorsalis’. Most authors in the past have including pleuropulmonary amoebiasis and acute amoebic abdomen along with the other rare complications of amoebic liver abscess such as rupture of the abscess into the inferior vena cava, common bile duct, stomach, colon, kidney, etc. Actually most of these latter complications occur late in this history of amoebic liver abscess, when the diagnosis have been missed for weeks or moths at a stretch. As against that, superficial abscesses in the superior or inferior surface of the right or left lobe may rupture into the thoracic or abdominal cavity during early course of the illness. In case of an acute abdomen, a general surgeon is quite aware that a perforated duodenal ulcer or appendicitis are such common causes of this emergency that if there is no typical history of duodenal ulcer, a silent ulcer is though of and the patient is coaxed to volunteer a past history of minimal upper abdominal pain. Similarly, in countries where amoebic liver abscess is common, in every case of acute abdomen, the surgeon must consider the possibility of an underlying amoebic liver abscess which even be ‘silent’. This is because even a small amoebic liver abscess if ‘superficial’, can rupture into the peritoneal cavity much before it is clinically evident. Many authorities have made important contributions to our knowledge of the clinical picture of amoebic liver abscess, amongst them: Sir Leonard Rogers (1922), Manson-Bahr (1931), Ochsner and DeBakey (1943), Craig (1944), DeBakey and Ochsner (1951), Anderson (1953), Lamont and Pooler (1958), Paul (1960), Wilmot (19623), Viranuvatti (1971) and Ramachandran et al (1976). The account that follows in the next few chapters is based on many such reports and on a personal experience of hundreds of cases seen in Bombay at the J. J. Hospital during the last twenty years and the Jaslok Hospital and Research Centre during the last five years.