1. health and fitness
2. disease

UNIVERSITAS INDONESIA
EVIDENCE BASED CASE REPORT
COMPARISON: TREATMENT CATHETER DRAINAGE AND
NEEDLE ASPIRATION FOR LIVER ABSCESS
AUTHOR
SOFIAN KURNIA MARSAWIDJAYA, MD
1106024501
DEPARTMENT OF INTERNAL MEDICINE
DIVISON OF HEPATOLOGY
FACULTY OF MEDICINE UNIVERSITY OF INDONESIA
JAKARTA
2014
LETTER OF APPROVAL
Author
NPM
Title
: Sofian Kurnia Marsawidjaya, MD
: 1106024501
: COMPARISON: TREATMENT CATHETER DRAINAGE AND NEEDLE
ASPIRATION FOR LIVER ABSCESS
Has been approved for presentation at
Cipto Mangunkusumo National Reference Hospital
In November 2014
Supervisor
Andri Sanityoso, Dr.Sp.PD-KGEH,FINASIM
Author
Sofian KM, Dr.
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CONTENTS
Contents………………………………………………………………………………...
3
Introduction…………………………………………………………………………….
4
Case Presentation……………………………………………………………………….
4
Formulate Question…………………………………………………………………....
5
Search Evidence………………..………………………………………………...........
5
Intervention……………………………………………………………………………..
6
Outcome………………….…………………………………………………………
10
Conclusion………………………………………………………………………………
11
References……………………………………………………………………………..
12
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INTRODUCTION
A liver abscess is a suppurative cavity in the liver resulting from the invasion and
multiplication of microorganisms, entering directly from an injury through the blood vessels
or by the way of the biliary ductal system. Liver abscesses are most commonly due to
pyogenic, amebic or mixed infections. Less commonly these may be fungal in origin. Liver
abscess has been recognized since Hippocrates (circa 400 B.C.) who speculated that the
prognoses of the patients were related to the type of fluid within the abscess cavity 1
Liver abscess is generally divided into two, there are amoebik liver abscess (ALA)
and pyogenic liver abscess (PLA). ALA is extraintestinal amebiasis which one of the most
common in the tropics or subtropics, including in Indonesia has many areas endemic for
virulent strains of E. histolytica. E. histolytica lives in the human gut commensal, but with
poor nutritional status may become pathogenic and cause high morbidity. Amoebic liver
abscess is the most common inflammatory lesions liver takes up space. Agents cause is
protozoa, Entamoeba Histolyitica. About 10% of the population in the world, there
Entamoeba histolytica in their intestines, which can then develop into invasive. Protozoa
enter the liver through the portal vein. Amebiasis can occur in various organs but the liver is
the organ most commonly for infection of extra-intestinal.2,3,45
Although amebic liver abscess occurs more commonly on a worldwide basis, the
pyogenic liver abscess predominates in the United States. Liver abscess is found more
commonly in men between 20 and 40 years of age, but can occur at any age. Approximately
60% are solitary and mainly located in the right lobe of the liver, as a result of the streaming
of portal blood flow secondary to the fact that the right lobe is predominantly supplied by the
superior mesenteric vein, and because most of the hepatic volume is in the right lobe. When
multiple abscesses are present, pyogenic or mixed is the most probable type. Patients usually
present with a constant dull pain in the right upper quadrant of the abdomen which may be
referred to the scapular region or the right shoulder.
Research in Indonesia shows ratio of men: women ranged 3:1-22. Age of patients
ranged from 20-50 years, especially in young adults, rare in children anak.3,4 About 10%
from all people in the world had this infection, but only 10% became clinically.
Ultrasound and computed tomography scans are non-invasive, equally sensitive
imaging modalities for the detection of amoebic liver abscesses 6,7. Amoeboic liver abscess is
handled with chemotherapy using nitromidazole derivate, aspiration or drainage with surgery
4
8
. Metronidazole is the drug of choice for treatment of amoebic liver abscesses followed by a
luminal agent to eradicate the asymptomatic carrier state 6. Positive result with metronidazole
empirically can conclude to diagnose amoebic liver abscess. The treatment of ALA with or
without aspiration in addition to amoebicidal drugs is discussed controversially and therefore
the therapeutic approach differs widely.9 Here in this paper we tried to find out the answer
determine the beneficial and harmful effects of image-guided percutaneous needle aspiration
procedure compared with percutaneus catheter darinage in patients with liver abscess
CASE PRESENTATION
A 30-year-old woman was admitted to our hospital presenting with abdominal pain in
the upper right side which had developed over 3 week. Since one month this patient had been
abdominal pain, she felt likes sharpnes, squeezed and he also had fever but on in off not a
chilled, and also nausea, vomitus, and malaise. She was not frequently ate in place which
low of higiene and sanitation. And also she was not frequently drink a cup of alcohol. She
isn’t transgender of sexual, didn’t have tatoo, and not a drug abuser.
At presentation, she had a heart rate of 108 beats per minute, blood pressure of
120/70 mmHg, respiratory rate of 22, and a body temperature of 36.9˚C. On abdominal
examination, there was found a mass on upper right quadrant, pushpain, Hepar was felt 2
fingers below prosesus xiphoideus and 2 fingers below arcus costae dextra. This patient have
loculated ascites, shifting dullnes (+). Biochemical analysis showed leukocyt (7,94 x103
cells/mm3), normocytic anemia (8,13 g/dL, MCV 82 fL), hypoalbuminemia (2,6 g/dL), AntiHIV: Non reactive, HbsAg and anti HCV: non reactive. Normal ECG. Ultrasound abdominal
get result absess mass in the right lobe diameters : 13,06 cm x 12,7 cm, suspected abscess
hepar. Based on above findings, our patient problems were hepar mass suspect abscess hepar,
normocytic anemia, dyspepsia syndrome and hypoalbuminemia. This patients get treatment
metronidazole 3x500 mg and cefotaxim 3x1 g iv and this patient also had twice ultrasound
guided needle aspiration.
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FORMULATE QUESTION
patient with this case prompted discussion in the practice “are catheter drainage
more effective than needle aspiration in patients with liver abscess ?”
SEARCH THE EVIDENCE
We searched Pubmed because of ease to access, and huge database. We began our
search strategy using key words “Needle aspiration AND “cathether darinage” AND “liver
abscess”. Since our search produced 23 citations, we further limited to RCT and English
language, free charge, resulted in 3 RCT hits for this search. We reviewed the abstracts and
found only three relevant RCT that might answer our question.
INTERVENTION
We did critically appraised three two prospective randomized trials using the method
described by Straus et al.6 Table 1 and 2 details our assessment
Table 1.
Title
Authors
Publication
Sample size
Domain
Sukhjeet Singh et al,
2013
Treatment of liver
abscess: prospective
randomized
comparison of catheter
drainage and needle
aspiration
Onkar Singh, 2009
Zerem, 2007
Comparative study of
catheter drainage and
needle aspiration
in management of large
liver abscesses
Singh S, Chaudhary P,
Saxena N,Khandelwal S,
Poddar D, Biswal U
Ann Gastroenterol 2013;
26 (3): 1-8
Singh O ·Gupta S ·
Moses S · Jain DK
Sonographically
Guided
Percutaneous Catheter
Drainage Versus
Needle
Aspiration in the
Management
of Pyogenic Liver
Abscess
Zerem E, Hadzic A
Indian J Gastroenterol
2009(May–
June):28(3):88–92
AJR 2007; 189:W138–
W142
60 patients
Patient with liver
abscess clinically and
72 patients
patients with liver
abscess (amebic and
60 patients
patients with pyogenic
liver abscess
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radiologically
Determinant
pigtail catheter
drainage (PCD)
Comparison
percutaneous needle
aspiration (PNA)
Hospital stay, succes,
Volume of the largest
cavity, clinical
improvement, time for
50% reduction,time for
resolution, duration of
drainage
Outcome
pyogenic)
percutaneous
catheter drainage
(PCD)
percutaneous needle
aspiration (PNA)
Duration of hospital
stay, duration of iv
antibiotics, clinical
relief attained, succes
rate
Sonographically
Guided
percutaneous
catheter drainage
percutaneous needle
aspiration (PNA)
Total hospital stay,
succesful treatment,
disappearance of
abscess
Table 2.Validity assessment of the prospective studies
Sukhjeet Singh et
al, 2013
Yes
Onkar Singh,
2009
Yes
Zerem, 2007
Was the randomization concealed?
Yes
Yes
Yes
Were the groups similar at the
start of the trial?
Yes
Yes
Yes
Was the follow up of patients
sufficiently long and complete?
Yes
Yes
Yes
Were all patients analyzed in the
groups to which they were
randomized?
Yes
Yes
Yes
Were patients, clinicians, and
study personnel kept blind to
treatment?
No
No
No
Were groups treated equally, apart
from the experimental therapy
Yes
Yes
Yes
Was the assignment of patients to
treatment randomized?
Yes
APPLY THE ANSWER
All of studies reported significant difference in succes rate in treatment PCD group
than PNA. Sukhjeet Singh et al, reported the outcome, Pigtail percutaneous drainage was
7
successful in all the 30 cases. On the other hand, image-guided needle aspiration was
successful only in 23 of 30 patients (P=0.006). Out of these 23 patients successfully treated, 9
patients required only one aspiration, 10 required two aspirations, and 4 required three
aspirations. The 7 patients who did not show clinical improvement and / or decrease in cavity
size despite 3 aspirations were taken as failures. In the PNA group, on comparing the cavity
volumes the mean cavity volume in those who were successfully treated was 201.4 cc which
was significantly less than those failing treatment; the mean volume being 403.6 cc
(P<0.011). The patients in PCD group showed earlier clinical improvement (P=0.039) and
50% decrease in abscess cavity volume (P=0.000) as compared to those who underwent
PNA. However, there was no significant difference between the duration of hospital stay or
the time required for total or near-total resolution of cavity.
Onkar Singh, et al reported that needle aspiration was successful in 31 (86%) out of
the 36 patients, after single aspiration in 10, two aspirations in 18, and three aspirations in 3
patients. PCD was successful in 35 (97%) patients. The median duration of catheter insertion
was 13 days (range 6–34 days, mean 12.8 days). Mean (SD) duration of intravenous
antibiotic (p=0.04) and duration to clinical relief (p=0.02) were shorter in the PCD group.
The success rates in the PNA and PCD groups were 86% and 97%, respectively (p=0.2)
(Table 2). PCD failed in one case, who had diabetes and multiple pyogenic liver abscesses
involving the right liver lobe. He had rupture of abscess during treatment leading to
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peritonitis and sepsis, and underwent exploration with curettage of abscess cavity along with
peritoneal lavage and placement of abdominal drains. The mean (SD) size of abscess at
discharge was 3.0 cm in PCD vs. 4.2 cm in PNA group (p=0.88). At 6 months of follow- up,
more number of patients treated successfully by PCD (29/35, 83%) had complete
sonographic resolution of abscess cavities, compared to patients treated successfully by PNA
(14/31, 45%) (p=0.02). There were four recurrences in aspiration group and two in PCD
group at 6 months of follow-up.
On the other study, Zerem and Hadzic, reported that in the percutaneous needle
aspiration group, the average longest diameter of the abscess collection was significantly
greater in patients with unsuccessful (97 ± 42 mm) than in patients with successful (62 ± 35
mm) needle aspiration (p = 0.02). Although the average volume of frank pus was larger in
patients who underwent unsuccessful percutaneous needle aspiration (178 ± 98 mL) than in
those who underwent successful percutaneous needle aspiration (121 ± 96 mL), the
difference was not significant (p = 0.14). Intermittent needle aspiration was successful for all
patients with abscesses 50 mm in longest diameter or smaller. However, this treatment was
unsuccessful for all five patients with multiloculated abscesses. In the PCD group, all patients
were successfully treated, clinical features and laboratory abnormalities subsiding (Table 4).
In four of six patients with multiloculated ab scesses, catheter drainage was performed twice
because drainage was inadequate with the first attempt. Total duration of catheter drainage
for each patient in the drainage group ranged from 3 to 25 days with a mean of 11.0 ± 6.4
days. At the end of treatment, the abscess cavity had disappeared completely in 25 of 50
successfully treated patients and had decreased more than 50% in the other 25 patients (Table
4). On final control examination 6 months after the beginning of treatment, abscesses were
absent in all successfully treated patients. Hospital stay did not differ significantly between
the groups (Mann-Whitney U test; Z = –0.02; p = 0.98)
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OUTCOME
The evidence obtained was reviewed using method that described by the Evidence
Based Medicine Working Group before applying to the patients. Three questions below were
asked to determine the applicability of the articles.
Were the study patients similar to the patient in my practice?-Yes.
Our patients had liver abscess that similar to the study patients. Patients in this case
obtain antibiotics therapy metronidazole for more ten days, but while the symptoms of fever
and abdominal pains is get improvement, patients still there complaints lump in the upper
right even though has reduced and still pain if he depth of inspiration. In addition, we also
applied inclusion and exclusion criteria and compared demographic baseline of the study to
our patient. In this case patient reported got twice needle aspiration.
Were all patient-important outcomes considered?-Yes.
These studies measured all clinically important outcomes included symptoms relieved
Clinical improvement or response to treatment as follows: succes rate (proportion of patients
10
without reduction in liver size), duration of hospital stay, duration of drainage, duration of
intravenous antibiotics.,
Are the likely treatment benefits worth the potential harm and costs? Yes.
We found evidence that percutaneous catheter drainege (PCD) added benefits in the
management of liver abscess. Percutaneous drainage (either needle aspiration or catheter
drainage) with systemic antibiotics has become the preferred treatment for the management
of pyogenic liver abscesses.This EBCR found that evidence to support or refute aspiration of
the abscess cavity. Accordingly, our findings are conclusive to make a definite
recommendation on the benefit of adjunctive therapeutic catheter drainege (PCD). PCD has
this obvious advantage over PNA, which may have accounted for quicker clinical recovery,
lesser duration of parenteral antibiotics and lesser failure rate among patients treated with
PCD. On the other hand, placing a catheter needs more expertise followed by nursing care.
CONCLUSION
Based on the current evidence, we conclude that this EBCR found evidence to
support or refute catheter drainage of the abscess cavity versus
needle aspiration in
uncomplicated liver abscess. Randomised clinical trials with larger sample sizes and adequate
randomisation (generation of the allocation sequence as well as allocation concealment) and
blinded outcome assessment of out comes important to patients are urgently needed. Such
trials should use uniform measures to assess outcomes. Strict evaluation of adverse events
resulting from different interventions employed in the management of amoebic or pyogenic
liver abscesses should be included in future trials.
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REFERENCE
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catheter drainage and needle aspiration. Annals of Gastroenterology 2013
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Lesmana L, Noer S. Edisi Pertama. Jakarta. Jayabadi, 2007. 487-91
3. Wenas NT, Waleleng BJ. Abses hati pogenik. Dalam: Buku Ajar Ilmu Penyakit
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keempat. Jakarta. Pusat Penerbitan Departemen Ilmu Penyakit Dalam FKUI, 2006.
Hal. 462-63
4. Blessmann J, Binh HD, Hung DM, Tannich E, Burchard G. Treatment of amoebic
liver abscess with metronidazole alone or in combination with ultrasound-guided
needle aspiration: a comparative, prospective and randomized study. Tropical
Medicine and International Health 2003;8(11):1030–4.
5. Bukhari AJ, Abid KJ. Amebic liver abscess: Clinical Presentation and Diagnostic
Difficulties. Kuwait Medical Journal. 2003. p.183-186
6. Friedman SL, Quaid KR, Grendel JH. Infection of the liver, parasitic infection of the
liver. Current, Diagnosis & Treatment in Gastroenterology. 2nd ed. New York:
McGrawHill Companies, toe; 2003.p.586-7.
7. Santoso M, Wijaya. Diagnostik dan penatalaksanaan abses amebiasis hati. Dexa
Medica 2004;4:17-20.
8. Stanley SL. Amoebiasis. Lancet 2003;361:1025–34.
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America 2000;14(3):565–82.
10. Chavez-Tapia NC, Hernandez-Calleros J, Tellez-Avila FI, Torre A, Uribe M Imageguided percutaneous procedure plus metronidazole versus metronidazole alone for
uncomplicated amoebic liver abscess (Review). 2009 The Cochrane Collaboration.
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Chapter 121
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