Amebic Liver Abscess With Hemobilia
Abraham Koshy, MD, DM, Chandigarh, India Mohd S. Khuroo, MD, DM, Chandigarh, India Sudha Suri, MD, Chandigarh, India Dharam V. Datta, MD, PhD, Chandigarh, India Satish K. Khanna, MS, Chandigarh, India
Hemobilia is an uncommon cause of gastrointestinal bleeding. Trauma to the liver is the most common cause [I], and ascariasis and fascioliasis have been described as parasitic causes [2]. We are reporting a case of hemobilia as a complication of an amebic liver abscess. Case Report A 23 year old woman was admitted to Postgraduate Institute, Chandigarh, in May 1977. Her complaints started 1 month before admission when at full term she suddenly had acute epigastric pain, hematemesis, and melena followed by fever and mild jaundice. Three days after the onset of symptoms she was delivered of a male infant. On her first admission, pulse was 140/min, blood pressure 110/66 mm Hg, and temperature 104°F. The liver was enlarged and palpable 4 cm below the right costal margin. Hemoglobin was 7 g/100 ml, total leukocyte count 13,00O/mm:%, and serum albumin 2.2 g/100 ml. Alkaline phosphatase was 30 King-Armstrong units (normal 3 to 13). Amebic serology was positive (1:2,048) as determined by the indirect hemagglutination antibody test, and the liver scan showed a space-occupying lesion (Figure 1). The results of serum bilirubin, serum glutamic oxaloacetic transaminase, and coagulation studies were normal. Stool was negative for Entameba histolytica. The patient was treated with metronidazole, chloroquine, and 2 units of blood. She had no episodes of bleeding in the hospital, and both radiologic and endoscopic examination of the upper gastrointestinal tract gave normal results. She became afebrile and asymptomatic in 10 days and was discharged from the hospital. One week later the patient was readmitted with upper gastrointestinal bleeding. A barium meal examination and From the Division of Hepatology and Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh-160012, India. Reprint requests should be addressed to Abraham Koshy. MD, Division of Hepatology, Postgraduate Institute of Medical Education & Research, Chandigarh-160012. India.
Volume 138, September 1979
two endoscopic examinations did not reveal the cause. The bleeding was associated with mild jaundice and pain suggestive of biliary colic. The size of the liver decreased by 1 to 2 cm after each bleeding episode. Superselective hepatic arteriography showed extravasation of contrast material from one of the branches of the right hepatic artery (Figure 2). Laparotomy was performed, and a liver abscess was found in the posteroinferior aspect of the right lobe about 3 cm from the surface. Needle aspiration and cholecystostomy were performed. To control the abscess, antiamebic treatment was repeated. The pus was sterile on routine culture and was positive for amebic antigen. One week later because of another episode of hemobilia, she underwent reoperation. The right hepatic artery was ligated distal to the cystic artery and T tube drainage of the common bile duct instituted. Episodes of hemobilia continued as evidenced by blood draining from the T tube
Figure 1. A preoperative right lateral SsmT~ colloid liver scan showing a large deiect in the right lobe of fhe liver. A = anterior; I = inferior: P = posterior; S = superior.
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Koshy et
al
Figure 2. Selective hepatic arteriogram demonstrating extravasation of contrast into a cavity in the right lobe of the liver.
(Figure 3). A repeat hepatic arteriogram showed revascularization of the right lobe from the left hepatic artery (Figure 4). Right hemihepatectomy was performed after the ninth episode of hemobilia. The postoperative course was complicated by elevation of the serum bilirubin to 7.5 mg/lOO ml and a decrease in the prothrombin index to 45 per cent and the serum albumin to 1.5 g/100 ml. The patient also had bile leakage of 25 to 30 ml/day from the right subphrenic space, poor healing of the primary incision, right pleural effusion, and later empyema necessitating intercostal tube drainage. Subsequently, drainage of a small right subhepatic abscess was required. Five weeks after surgery she became afebrile and was discharged 10 days later. After 3 months jaundice developed which lasted 3 weeks; it was presumably viral hepatitis. The patient was perfectly well when seen at follow-up examination 7 months after right hemihepatectomy, at which time a Tc-99m sulfur colloid scan showed that the liver had regenerated up to the right lateral abdominal wall.
Figure 3. Cholangiogram taken through a tube in the gallbladder. Dilated biliary tree and muttiple filling defects are caused by blood clots.
The right lobe of the liver removed at surgery showed multiple liver abscesses. There was one cavity which communicated with a branch of the right hepatic artery and one of the large biliary ducts. It could be seen macroscopically but its presence was also confirmed by injection of gentian violet as well as contrast material into the hepaticartery (Figure 5). Histopathologic aspects of the abscess wall were consistent with those of a treated amebic liver abscess. Entameba histolytica was not demonstrated.
Comments
Hemobilia due to an amebic liver abscess is extremelyrare [3]. There are only two other reports of this complication after an amebic liver abscess although it has been recorded after a pyogenic liver
Figure 4, left. Selective hepatic arteriogram after ligation of the right hepatic artery (arrow). Revascularizatfon of the rfght lobe branches has occurred through connections from the left hepatic artery.
Figure 5, right. Hepatic arferiogram of the specimen of the right lobe. There is extravasation of contrast mater/al into the abscess cavity. 6 = lead marker in communicating bile duct; C = lead marker around abscess cavity.
454
The American Journal of Surgery
Liver Abscess and Hemobilia
abscess. One of these patients survived after ligation of the hepatic artery [4]. Our patient required right hemihepatectomy. Amebic liver abscess was diagnosed in our patient on the basis of clinical presentation, positive amebic serology, the finding of an abscess cavity containing sterile pus positive for amebic antigen at the time of the first laparotomy, and histologic confirmation of abscess cavities consistent with a treated amebic liver abscess in the specimen removed at right hemihepatectomy. The clinical triad of upper gastrointestinal bleeding, biliary colic, and jaundice suggested the diagnosis of hemobilia, and this was subsequently confirmed when bleeding was observed from the T tube draining the common bile duct. The communication between the abscess cavity and the bile duct and right hepatic artery demonstrated that the amebic liver abscess was in fact the cause of hemobilia. This was seen in the gross specimen and further confirmed by gentian violet and contrast injections into the right hepatic artery. Histologically the lining of the cavity showed features consistent with those of a healed amebic liver abscess. Selective arteriography remains the most important procedure in the diagnosis and management of hemobilia. Endoscopy was not helpful in our patient because the endoscope could not be passed into the second part of the duodenum. Hemobilia that originates intrahepatically has been treated by intraarterial infusion of vasopressor agents 151, selective arterial embolization, and hepatic artery ligation [6]. Some cases of hemobilia have also required hepatic resection. The mortality is high. According to one review, 4 of 13 patients who had
Volume 138, September 1979
hepatic resection for traumatic hemobilia died [6]. Many complications have been noted after hepatic resection. As in our patient, an increase in the serum bilirubin level and a decrease in the serum albumin and prothrombin time have been noted. Bile leakage and sepsis are also frequent [ 71, Our report emphasizes the need to suspect hemobilia and to establish the diagnosis and site of bleeding by angiography in patients with a liver abscess and upper gastrointestinal bleeding. If simpler procedures are not effective, partial hepatic resection may be curative. Summary
A patient with hemobilia complicating an amebic liver abscess is described. The diagnosis was based on selective arteriography. The hemobilia did not stop with antiamebic treatment or ligation of the right hepatic artery. Successful results followed right hemihepatectomy. References 1. Bismith H: Medical intelligence. Current concepts. Haemobilia. NEnglJMed266: 617, 1973. 2. Sandblom P: Hemobilia, p 1366-1373. Diseases of the Liver (Schiff L, ed). Philadelphia, JB Lippincott, 1975. 3. Adams EB, MacLeod IN: Invasive amebiasis. Il. Amebic liver abscess and its complications. Medicine 56: 325, 1977. 4. Powell SJ, Sutton JB. Lautre G: Haemobilia in amoebic liver abscess. S Aft' Med J 47: 1555, 1973. 5. Lee SP, Tasman JC, Wattie WJ: Traumatic haemobilia: a complication of percutaneous liver biopsy. Gastroenterology 72: 941,1977. 6. Wilkinson GM, Middelsen WP, Benne CJ: The treatment of post-traumatic hemobilia by ligation of the common hepatic artery. Surg C/in North Am 46: 1337, 1966. 7. Donovan AJ, Turrill FL, Facay FLS: Hepatic trauma. Surg C/in Notih Am 46: 1313, 1966.
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Abraham Koshy, MD, DM, Chandigarh, India Mohd S. Khuroo, MD, DM, Chandigarh, India Sudha Suri, MD, Chandigarh, India Dharam V. Datta, MD, PhD, Chandigarh, India Satish K. Khanna, MS, Chandigarh, India
Hemobilia is an uncommon cause of gastrointestinal bleeding. Trauma to the liver is the most common cause [I], and ascariasis and fascioliasis have been described as parasitic causes [2]. We are reporting a case of hemobilia as a complication of an amebic liver abscess. Case Report A 23 year old woman was admitted to Postgraduate Institute, Chandigarh, in May 1977. Her complaints started 1 month before admission when at full term she suddenly had acute epigastric pain, hematemesis, and melena followed by fever and mild jaundice. Three days after the onset of symptoms she was delivered of a male infant. On her first admission, pulse was 140/min, blood pressure 110/66 mm Hg, and temperature 104°F. The liver was enlarged and palpable 4 cm below the right costal margin. Hemoglobin was 7 g/100 ml, total leukocyte count 13,00O/mm:%, and serum albumin 2.2 g/100 ml. Alkaline phosphatase was 30 King-Armstrong units (normal 3 to 13). Amebic serology was positive (1:2,048) as determined by the indirect hemagglutination antibody test, and the liver scan showed a space-occupying lesion (Figure 1). The results of serum bilirubin, serum glutamic oxaloacetic transaminase, and coagulation studies were normal. Stool was negative for Entameba histolytica. The patient was treated with metronidazole, chloroquine, and 2 units of blood. She had no episodes of bleeding in the hospital, and both radiologic and endoscopic examination of the upper gastrointestinal tract gave normal results. She became afebrile and asymptomatic in 10 days and was discharged from the hospital. One week later the patient was readmitted with upper gastrointestinal bleeding. A barium meal examination and From the Division of Hepatology and Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh-160012, India. Reprint requests should be addressed to Abraham Koshy. MD, Division of Hepatology, Postgraduate Institute of Medical Education & Research, Chandigarh-160012. India.
Volume 138, September 1979
two endoscopic examinations did not reveal the cause. The bleeding was associated with mild jaundice and pain suggestive of biliary colic. The size of the liver decreased by 1 to 2 cm after each bleeding episode. Superselective hepatic arteriography showed extravasation of contrast material from one of the branches of the right hepatic artery (Figure 2). Laparotomy was performed, and a liver abscess was found in the posteroinferior aspect of the right lobe about 3 cm from the surface. Needle aspiration and cholecystostomy were performed. To control the abscess, antiamebic treatment was repeated. The pus was sterile on routine culture and was positive for amebic antigen. One week later because of another episode of hemobilia, she underwent reoperation. The right hepatic artery was ligated distal to the cystic artery and T tube drainage of the common bile duct instituted. Episodes of hemobilia continued as evidenced by blood draining from the T tube
Figure 1. A preoperative right lateral SsmT~ colloid liver scan showing a large deiect in the right lobe of fhe liver. A = anterior; I = inferior: P = posterior; S = superior.
453
Koshy et
al
Figure 2. Selective hepatic arteriogram demonstrating extravasation of contrast into a cavity in the right lobe of the liver.
(Figure 3). A repeat hepatic arteriogram showed revascularization of the right lobe from the left hepatic artery (Figure 4). Right hemihepatectomy was performed after the ninth episode of hemobilia. The postoperative course was complicated by elevation of the serum bilirubin to 7.5 mg/lOO ml and a decrease in the prothrombin index to 45 per cent and the serum albumin to 1.5 g/100 ml. The patient also had bile leakage of 25 to 30 ml/day from the right subphrenic space, poor healing of the primary incision, right pleural effusion, and later empyema necessitating intercostal tube drainage. Subsequently, drainage of a small right subhepatic abscess was required. Five weeks after surgery she became afebrile and was discharged 10 days later. After 3 months jaundice developed which lasted 3 weeks; it was presumably viral hepatitis. The patient was perfectly well when seen at follow-up examination 7 months after right hemihepatectomy, at which time a Tc-99m sulfur colloid scan showed that the liver had regenerated up to the right lateral abdominal wall.
Figure 3. Cholangiogram taken through a tube in the gallbladder. Dilated biliary tree and muttiple filling defects are caused by blood clots.
The right lobe of the liver removed at surgery showed multiple liver abscesses. There was one cavity which communicated with a branch of the right hepatic artery and one of the large biliary ducts. It could be seen macroscopically but its presence was also confirmed by injection of gentian violet as well as contrast material into the hepaticartery (Figure 5). Histopathologic aspects of the abscess wall were consistent with those of a treated amebic liver abscess. Entameba histolytica was not demonstrated.
Comments
Hemobilia due to an amebic liver abscess is extremelyrare [3]. There are only two other reports of this complication after an amebic liver abscess although it has been recorded after a pyogenic liver
Figure 4, left. Selective hepatic arteriogram after ligation of the right hepatic artery (arrow). Revascularizatfon of the rfght lobe branches has occurred through connections from the left hepatic artery.
Figure 5, right. Hepatic arferiogram of the specimen of the right lobe. There is extravasation of contrast mater/al into the abscess cavity. 6 = lead marker in communicating bile duct; C = lead marker around abscess cavity.
454
The American Journal of Surgery
Liver Abscess and Hemobilia
abscess. One of these patients survived after ligation of the hepatic artery [4]. Our patient required right hemihepatectomy. Amebic liver abscess was diagnosed in our patient on the basis of clinical presentation, positive amebic serology, the finding of an abscess cavity containing sterile pus positive for amebic antigen at the time of the first laparotomy, and histologic confirmation of abscess cavities consistent with a treated amebic liver abscess in the specimen removed at right hemihepatectomy. The clinical triad of upper gastrointestinal bleeding, biliary colic, and jaundice suggested the diagnosis of hemobilia, and this was subsequently confirmed when bleeding was observed from the T tube draining the common bile duct. The communication between the abscess cavity and the bile duct and right hepatic artery demonstrated that the amebic liver abscess was in fact the cause of hemobilia. This was seen in the gross specimen and further confirmed by gentian violet and contrast injections into the right hepatic artery. Histologically the lining of the cavity showed features consistent with those of a healed amebic liver abscess. Selective arteriography remains the most important procedure in the diagnosis and management of hemobilia. Endoscopy was not helpful in our patient because the endoscope could not be passed into the second part of the duodenum. Hemobilia that originates intrahepatically has been treated by intraarterial infusion of vasopressor agents 151, selective arterial embolization, and hepatic artery ligation [6]. Some cases of hemobilia have also required hepatic resection. The mortality is high. According to one review, 4 of 13 patients who had
Volume 138, September 1979
hepatic resection for traumatic hemobilia died [6]. Many complications have been noted after hepatic resection. As in our patient, an increase in the serum bilirubin level and a decrease in the serum albumin and prothrombin time have been noted. Bile leakage and sepsis are also frequent [ 71, Our report emphasizes the need to suspect hemobilia and to establish the diagnosis and site of bleeding by angiography in patients with a liver abscess and upper gastrointestinal bleeding. If simpler procedures are not effective, partial hepatic resection may be curative. Summary
A patient with hemobilia complicating an amebic liver abscess is described. The diagnosis was based on selective arteriography. The hemobilia did not stop with antiamebic treatment or ligation of the right hepatic artery. Successful results followed right hemihepatectomy. References 1. Bismith H: Medical intelligence. Current concepts. Haemobilia. NEnglJMed266: 617, 1973. 2. Sandblom P: Hemobilia, p 1366-1373. Diseases of the Liver (Schiff L, ed). Philadelphia, JB Lippincott, 1975. 3. Adams EB, MacLeod IN: Invasive amebiasis. Il. Amebic liver abscess and its complications. Medicine 56: 325, 1977. 4. Powell SJ, Sutton JB. Lautre G: Haemobilia in amoebic liver abscess. S Aft' Med J 47: 1555, 1973. 5. Lee SP, Tasman JC, Wattie WJ: Traumatic haemobilia: a complication of percutaneous liver biopsy. Gastroenterology 72: 941,1977. 6. Wilkinson GM, Middelsen WP, Benne CJ: The treatment of post-traumatic hemobilia by ligation of the common hepatic artery. Surg C/in North Am 46: 1337, 1966. 7. Donovan AJ, Turrill FL, Facay FLS: Hepatic trauma. Surg C/in Notih Am 46: 1313, 1966.
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