[Amoebic Liver Abscess][Dr. O.P. Kapoor]
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SPLENIC ABSCESS OF THE UPPER POLE — A VERY CLOSE DIFFERENTIAL DIAGNOSIS OF LEFT LOBE SUPERIOR SURFACE AMOEBIC LIVER ABSCESS
( Bulletin of the Jaslok Hospital & Research Centre. Vol.10 No.1: July 1985 pp 42-44 )
. An amoebic liver abscess in the superior surface of the left lobe is the most dangerous one. This is because it produces very few physical signs till it ruptures in the pericardial sac and causes death. In a febrile patient with ache in left hypochondrium, raised left dome of the diaphragm is the first radiological sign, which should draw one's attention. A splenic abscess in the similar location produces similar symptoms and a raised left dome of the diaphragm.

I describe below a case of this problem.

Case report

A 25-year-old fisherman was admitted for fever and pain in left hypochondrium of a week's duration. On examination he was extremely tender in the epigastrium and left hypochondrium. It was difficult to feel a definite lump, but a definite fullness was felt.

X-ray Chest (Fig. 1) showed elevation of left dome of diaphragm. While cell count was 16,500/cmm. Initially a diagnosis of amoebic liver abscess of superior surface of the left lobe was made. But liver scan (Rose Bengal) was normal and I.H.A. test for amoebiasis was negative. Sonography could not be done because of marked tenderness. CT scan (Fig. 2) showed a splenic haematoma and an abscess formation. Splenectomy was done and the diagnosis was confirmed.

Later on the patient admitted of sustaining an injury to the left hypochondrium, a few days back, when he dived at the high seas to catch the fish.

Discussion

The left dome of the diaphragm can be raised in many conditions. U.S.S.L.L.L.A.L.A. Syndrome [2, 3] is the most important condition. If this diagnosis of an amoebic liver abscess in the superior surface of the left lobe is missed, sudden death could occur because of rupture of the abscess into the pericardium.

Therefore the differential diagnosis of this condition gains importance. An abscess of the superior surface of the spleen is the nearest differential diagnosis. [4] In fact, not only the patient has pain in the epigastrium and left hypochondrium, tenderness and a lump with leucocytosis, but the left dome of the diaphragm is also elevated. In 1979, I described that the lump palpable in splenic abscess has a notch on the "inferior" surface, which will differentiate it, clinically from an enlarged left lobe of the liver. In this particular case, the patient has so much tenderness that it was impossible to feel the lump accurately.

The other conditions, which can cause raised left dome of diaphragm with fever, pain and tenderness in the left hypochondrium are subpulmonic effusion, subphrenic abscess (Fig. 3) and hepatoma of the left lobe of the liver. (Fig. 4).

Summary

The nearest differential diagnosis of an amoebic liver abscess of the superior surface of the left lobe of the liver is an abscess. Of the superior surface of spleen. A case of the later is presented. Both conditions cause elevation of the left dome of diaphragm. The other conditions causing this important radiological sign are also mentioned.

Acknowledgment

I am grateful to Dr. N. H. Keswani, Medical Director, Jaslok Hospital & Research Centre, Bombay for allowing me to publish this material.

References

  1. KAPOOR 0. P.: Amoebic Liver Abscess S. S. Publishers, Bombay, Page 85, 1979.
  2. KAPOOR 0. P. and SHAH NEMISH A.: J. Trop Med. Hyg- 75, 7, 1972
  3. KAPOOR 0. P.: Paper read at Xth Annual Conference of Society of Nuclear Medicine of India at Madras in Oct. 1978.
  4. KAPOOR 0. P.: Paper read at XIXth Annual Conference of Indian Society of Gastroenterology of Simla in Nov. 1978.