Ten years back, I wrote a monograph on this subject. I drew the attention of my medical colleagues that there are so many facets to this disease that a thesis could be written on each one of them. Since then nothing has changed in the literature on this subject and old references continue to be cited.

On page 45 in this issue of the journal, Varadhacharv et al have done well on this subject. A lot of new work however remains to be done.

Is it not time already that a new clinical picture of amoebic liver abscess should be painted?

During the last decade:

1. More and more imaging modalities have appeared making early diagnosis easier.
2. Multiple serological tests have appeared in the market, making the specific aetiological diagnosis very easy.
3. Tall claims have been made of cure of amoebic liver abscess by a single dose treatment with tinidazole or rnetronidazole.
4. The evacuation of the abscess is being done under the guidance of sonography instead of blind tapping.
5. Drugs like metronidazole and tinidazole are being very widely used for treatment of intestinal arnoebiasis, giardiasis, leucorrhoea, campylobacter (Helicobacterpylori) induced peptic ulcer, all sorts of anaerobic infections of intestines, stomatitis etc. These are the drugs prescribed sometime or the other by some doctor to nearly every patient of irritable colon patients, which affects nearly 20 percent or more of our population.
6. Laparoscope is being used to aspirate some of the abscesses under "actual' vision (not indirect sonographic vision).

Then how is it possible that the clinical picture and the life history of this disease should remain the same? When the period of hospital stay for the most dangerous medical emergency, viz. myocardial infarction has been reduced from six weeks to less than six days, how is it that the hospital stay for amoebic liver abscess has not been reduced to any extent?

Recently a patient was admitted in a private hospital in the lowest subsidized class and was discharged after ten days still 'ill' but the hospital bill had already mounted to six thousand rupees! He was given I.V. metronidazole for one week, but no tapping was done!

With the availability of efficient modern oral amoebicidal drugs, is hospitalization really necessary? And who has shown that I.V. use of metronidazole is better than oral? (Surgeons use I.V. drugs more frequently because their patients are on "nil by mouth"). In fact, metronidazole after being swallowed is taken up by the liver in such large amounts that not enough reaches the intestines if the patient is given a small dose! Therefore while a liver abscess patient can be treated by a small dose of 400 mg tds, patients having amoebic colitis need a dose of 600 to &00 mg tds! With all the modern gadgets, can we not identify patients who need aspiration? They can be admitted only for a day or two and sent home for the rest of the medical treatment. Why not aspirate on the first or second day rather than observe? Nowadays, invasiveness is the keyword in the management of myocardial infarction, pneumothorax, haematemesis, epistaxis, pulmonary oedema and many other serious medical illnesses. Similarly, let more abscesses be aspirated if the healing can be hastened. Don't we need dozens of controlled and double blind trials to prove this point? Whatever few studies have been reported have little statistical value.

Why can't a general practitioner do the same study in his practice? Today, all over the world, daytime nursing homes and clinics have sprung up where such patients go in the morning and after tapping, come home in the evening. In Bombay alone, a few centres have started. Like invasive cardiologists are doing coronary angioplasty, surgeons or invasive radiologists will not mind doing abscess tapping as an outdoor procedure as it is no more a "blind" procedure but can be done under sonography guidance.

Isn't it embarrassing to note that when I wrote ten years back that the entity of "amoebic hepatitis" does not exist and five years later proved the point again with the help of CT scanning, this entity continues to be mentioned in many medical text books!

Should the young physicians and gastroenterologists not wake up and start working on the subject and write something new, rather than tell the old story all over again.

Though the incidence of this illness has reduced, I am seeing more cases of "relapse" (after a year or two or more) and chronic residual amoebic liver abscesses. Unusual complications like amoebic osteomyelitis have been observed by me and reported. In the past I had observed dozens of patients in the autopsy room who had died in spite of having received a full course of metronidazole! I continue seeing scores of patients who have been referred to me after a full course of metronidazole for unsatisfactory recovery! And yet slogans like "Flagyl Conquers Amoebiasis" continue to be inserted in the advertisements.

How can gastroenterologists do work on this subject when:

1. Many inferior surface abscesses continue to be presented to the surgeon as acute abdomen.
2. Abscesses of the superior surface of the left lobe continue to be seen by the cardiologists as pericardial amoebiasis.
3. Many chest shadows are being attended by pulmonologists who are not so much aware of the entity of complicated amoebic liver abscess.
4. Many patients having a small liver abscess recover with the standard treatment given by a GP and never reach the specialist to be included in their statistics.

Yes - problems are many. But they can be tackled. Let the old monotonous method of writing articles and reviewing amoebic liver abscess be altered. Let it not become a mockery of a M.D. thesis written overnight in a closed room of students' hostel.

Let the physicians, general practitioners, surgeons, cardiologists, pulmonologists and gastroenterologists work and discuss together and decide many issues. Should not everybody start aspirating with a thick 13 number needle (amoebic pus at times is very thick) to get homogenous results rather than saying -"No pus could be aspirated?"