A 21-year old male presented with upper abdominal pain for 15 days accompanied by a gradually increasing abdominal girth and swelling of the feet with low grade fever for one week. On examination, he was normo-tensive and showed pitting pedal edema. There was a tender hepatomegaly extending three fingers below the costal margin in the mid-clavicular line. Shifting dullness was positive. Hematological investigations revealed Hb level of 9 g/dL and WBC of 7,500/mm3. The biochemical investigations showed a raised BUN of 65 mg/dL and serum creatinine of 1.5 mg/dL. Urine analysis revealed slight proteinuria. Liver functions tests showed a total bilirubin of 0.6 mg/dL, serum ALP of 247 IU/L, AST 40 IU/L and ALT 80 IU/L. Ultrasonography of the abdomen showed an abscess in the right lobe of liver on its postero-superior surface measuring 1.4×1×1 cm with internal echoes and moderate ascites. Color doppler scan was done which showed patent hepatic veins with normal hepatofugal flow. Hepatic IVC was seen displaced and compressed by the large abscess cavity but the flow was normal. Infra-hepatic IVC was dilated to 1.7 cm. The Doppler findings were suggestive of IVC obstruction due to the liver abscess with proximal dilatation. A contrast enhanced CT scan confirmed the findings of thrombus in the IVC (). The patient tested positive for amoebic antibody by indirect haemagglutination test. The patient was started on intravenous metronidazole and broad spectrum antibiotics. The liver abscess was aspirated twice under ultrasonic guidance within a period of two days yielding 500 mL and 360 mL of pus. The pus was thick, creamy and brownish in color and did not grow any organisms on culture. The ascites and pedal edema disappeared rapidly after the treatment. Doppler scan repeated four days later showed a decrease in the infra-hepatic IVC dilatation. Hepatic portion of the IVC was normal in caliber and fully patent in subsequent color doppler examination performed twelve days after the aspiration of pus. The biochemical renal parameters improved and two weeks after aspiration of the liver abscess, the BUN was 32 mg/dL and serum creatinine was 1.1 mg/dL. Patient was followed up for three months, and repeat ultrasonography done was essentially normal.
A 6-year-old malnourished boy was referred with a history of fever of 1-month duration, pain in right upper abdomen, loose motions, and vomitings for 14 days. The prior medical history was unremarkable. The physical examination revealed tachycardia and tachypnea. There was hepatomegaly with tenderness and guarding in the upper abdomen with ascites. On chest auscultation, the air entry was diminished on left side. Blood investigations are tabulated in . The chest radiograph showed left pleural effusion. An ultrasound showed a large single abscess of 94 ml in the left lobe of liver closely abutting the intra-hepatic vena cava. An echogenic lesion of 27 mm length extended from abscess to the IVC. Ascites was also noted. Contrast-enhanced computed tomography of abdomen revealed left lobe liver abscess in segments II and III. The thrombus was visible in the middle and left hepatic veins together with a thrombus in the IVC which extended up to the right atrium [].\nTwo-dimensional-echocardiography confirmed the above findings. The patient tested positive for amebic antibody by Enzyme-linked immunosorbent assay (ELISA) test. Broad spectrum antibiotics including metronidazole had been started by the referring institute. The patient was taken up for surgical intervention on an emergency basis. Median sternotomy and vertical pericardiotomy were performed. Cardiopulmonary bypass was established with aortocaval cannulation. After cooling to 20°C, cardioplegic arrest was achieved with root cold blood cardioplegia. Total circulatory arrest was established. Right atrium was opened parallel to the atrio-ventricular groove. Piecemeal extraction of the thrombus was done [].\nThe IVC was thoroughly irrigated with normal saline. The circulation was temporarily restarted to flush any small remnant thrombus in the IVC. The right atrium was closed and circulation was restarted. Trans-esophageal echocardiography confirmed complete removal of thrombus. Cardiopulmonary bypass was weaned off after re-warming. Left pleural cavity was drained with a tube. After reversal of systemic heparinization, the abdomen was opened by a roof top incision and the falciform ligament was divided. The left triangular ligament was divided to mobilize the left lobe. The abscess was palpable in the postero-superior aspect of segment II lying just left of the divided falciform ligament. It was adhered to the diaphragm which was dissected free and then the abscess was de-roofed. About 100 ml of anchovy sauce pus was drained from the abscess cavity. Lavage was performed followed by placement of tube drain in left sub-diaphragmatic space. Pus was sent for examination which failed to reveal any trophozoites on microscopic examination and was negative for pyogenic organisms. The patient was discharged on 10th post-operative day. The patient is on regular follow-up and he is in good health at 6 months from the date of operation.