A 61-year old man presented with high grade fever for eight days, vomiting for five days associated with right upper abdomen pain, yellowish discoloration of eyes for three days, and swelling of the feet for three days. He was icteric with a pulse rate of 96/min and blood pressure of 126/80 mmHg. There was bilateral pedal edema. On abdominal examination, tender hepatomegaly was present three finger breadth below the costal margin. Ultrasonography revealed multiple abscesses in the liver, the largest one 8×7.2×6.8 cm in the right lobe with mild pleural effusion. Hematological investigations revealed a Hb of 9.4 gm/dL and WBC 29,900/mm3 with predominantly polymorphic leukocytosis. The biochemical investigations showed a raised BUN of 59 mg/dL, serum creatinine of 1.2 mg/dL. Liver function tests showed total bilirubin of 4.9 mg/dL, direct bilirubin of 3.8 mg/dL, ALP of 1,055 IU/ L, AST of 99 IU/L and ALT of 108 IU/L. The patient tested positive for amoebic antibody by ELISA test. MRI with MRCP revealed four abscesses, two in the right lobe, one in the left lobe and one in the caudate lobe (). The largest one was 7.5×7.2×7 cm in size, in the right lobe. The abscess in the caudate lobe was compressing the porta hepatis and IVC (). The flow in IVC was found to be slowed down on color doppler. Catheter drainage was done from the largest abscess and the patient was started on intravenous metronidazole and broad spectrum antibiotics. Total 580 mL of pus was drained before the catheter was removed. After five days of admission the pedal edema reduced markedly and after ten days it subsided completely. Liver function tests returned to normal range with total bilirubin 1.1 mg/dL, direct bilirubin 0.3 mg/dL, ALP 22 IU/L, AST 42 IU/L and ALT 20 IU/L. The patient was discharged in good condition and followed up for three months and repeat ultrasound done at the end of three months showed no residual abscess and IVC was normal in caliber, color fill and flow pattern.
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.