U.S.S.S.L.L.L.A.L.A. Syndrome
As described earlier, the left lobe is developmentally the lateral left lobe which is further subdivided into superior and inferior segments. Due to its anatomical location, an abscess in the superior segment of the lateral left lobe (Fig. 74) if undetected for sometime, can rupture into left lung, left pleural cavity or pericardial cavity. The last mentioned complication is often fatal. This is likely to occur earlier if the abscess is superficial (Fig. 75), though in the left lobe a deep abscess is also likely to come to the surface much earlier than in the right lobe.
In our experience, the fatal chest complications can be avoided if one makes a timely diagnosis of U.S.S.S.L.L.L.A.L.A. Syndrome. In 1972, we had reported six cases of amoebic pericarditis with a mortality rate of 33.3%.' In the last few years, we have encountered five cases of U.S.S.S.L.L.L.A.L.A. Syndrome.^2,3 Due to timely intervention, we have not lost a single case.
High index of suspicion in areas where amoebic liver abscess is common would help in the early diagnosis of this syndrome. It should be suspected in any patient who complains of fever, pain in the upper abdomen specially in the epigastrium, left hypochondrium and the left shoulder. Left shoulder pain is due to left diaphragmatic irritation. Quite often on examination the enlarged tender left lobe of liver is also palpable in the epigastrium and left hypochondrium. It then becomes a problem to decide whether the abscess is a huge one extending from the superior to the inferior surface of the left lobe. Although the degree of tenderness while palpating the left lobe will help, liver scan, if available, would decide the issue. In my opinion, this enlargement is due to associated congestion or compensatory hypertrophy. X-ray chest would show a raised left dome of the diaphragm (Fig. 76). on fluoroscopic examination, the raised left dome of the diaphragm is immobile.⁴ Unlike other conditions which elevate the left dome of the diaphragm (including an inferior surface abscess of the left lobe as described earlier), in this condition, no gas shadows are seen under the diaphragm. Even the normal gas shadow in the fundus of the stomach is conspicuous by its absence(Fig. 76)

Diagnosis
In endemic areas this syndrome should be thought of if a patient has fever, vague pain in the upper abdomen and left shoulder. On radiological examination, if an immobile elevated left dome with no gas shadow under it is seen, the degree of suspicion is further enhanced. Diagnosis is confirmed easily if liver scan is available. It would show a cold area in the superior part of the left lobe (Figs. 77a,b). Serological tests, if available, are also very helpful in confirming the diagnosis.

Differential diagnosis

1. Splenic abscess-(Fig. 78). it can produce all the symptoms, signs and radiological appearances of U .S.S.S.L.L.L.A.L.A. Syndrome (Fig. 79) . I n my opinion, clinical examination is of greater value. In the case of a lump which is palpable in the epigastrium and left hypochondrium, the presence of a notch is in favour of a splenic abscess (Fig. 80). Diagnostic aspiration could be misguiding because chocolate coloured pus may be aspirated from a splenic abscess as well (Fig. 81). Liver scan would show absence of a cold area in the left lobe of the liver. When ^99mTc sulphur colloid radiopharmaceutical is used, according to my observation, the normal splenic shadow is absent (Fig. 82). in the absence of scan facilities, a barium meal X-ray of the stomach would indicate the diagnosis. A splenic abscess would push the stomach to the right (Fig. 83)
2. Superior surface junctional amoebic liver abscess-This has been discussed elsewhere in the book.
3. Hepatoma of the left lobe of the liver-I have seen a patient in whom right lobe hepatectomy had been done for hepatoma two years earlier. Now he had a recurrence in the left lobe. The patient had a raised left dome of the diaphragm (Fig. 84). Past history, absence of acute pain, fever, tenderness and the presence of an irregular epigastric lump suggested the diagnosis.
4. Subphrenic abscess-X-ray chest may show fluid level under the raised left dome of the diaphragm.

Treatment
All these patients should be tapped as early as possible to avoid rupture of the abscess into the chest. My experience is that the abscess being so located, if the tapping is done from the epigastrium with the needle pointing upwards (Fig. 85), the pus can be drained more easily.

References

1. Kapoor, O P. and Shah Nemish, A, J. Trop Med. Hyg., 1972, 75, 7
2. Kapoor, O P. Paper read at X Annual Conference of Society of Nuclear Medicine of India at Madras in October 1978.
3. Kapoor, O P. Paper read at XIX Annual Conference of Indian Society of Gastroenterology at Simla in November 1978
4. Ramachandran, S. Post Grad Med. J., 1961, 50; 684