Liver  abscess is a collection of necrotic material composed of the dead pathogen, lysed white blood cells, fibrin, and surrounding inflammatory cells or necrotic liver cells depending upon the causative organism and mechanism of abscess formation. [1] Amoebic liver abscess (ALA) and pyogenic liver abscess (PLA) are the two most common types of liver abscesses, ALA is the most common in developing countries, PLA is most common in developed countries, infective organisms invade the  liver from other abdominal areas like the appendix, colon, etc through portal vein, ascending infection from the biliary tree, through blood from distant focus, direct extension from contiguous organs and penetrating trauma. [2,3] ALA caused by Entamoeba histolytica is the most common extraintestinal manifestation of amebiasis and it accounts for two-thirds of cases of liver abscesses in developing countries. [4,5] Historically, liver abscess is a disease that has seen significant changes in demography, etiology, diagnosis, and treatment during the last century, the incidence looks to be increasing.8 Though contemporary diagnostic techniques such as ultrasonography and computed tomography have lowered mortality to between 2% to 12%, there is still a substantial morbidity associated with liver abscess sequelae, particularly amoebic liver abscess.[6,7] The therapy of liver abscess has long presented a challenge for clinician who must determine whether to undertake therapeutic aspiration and when to abstain from it. Recent advances in diagnostic and interventional radiology led to improved management strategies such as minimally invasive percutaneous drainage with reduced duration of hospital stay compared to conservative treatment and favourable outcomes.[8] In addition to the antimicrobial therapy, percutaneous drainage of abscess has become a mainstay of treatment. However, few patients do not respond to percutaneous drainage and deteriorate. It is important to promptly identify such patients for whom open surgical intervention is the definitive treatment. The objective of the present study is to assess the changing trends in clinical patterns, etiological factors, microbiological aetiology and management in patients with liver abscess in a tertiary care hospital. The objective of the present study is to assess the changing trends in clinical patterns, etiological factors, microbiological aetiology and management in patients with liver abscess in a tertiary care hospital.

The present study is hospital based longitudinal study, carried out in tertiary care hospital. A total of 50 patients were enrolled in the study (N=50).

Inclusion criteria

• Patients suspected of having liver abscess on the basis of history and clinical assessment which were then Confirmed by USG and laboratory work up. • Patients more than 18 years.

Exclusion criteria 

• Patients aging less than 18 years. • Abscess associated with malignancy. • Immunocompromised patients. • Ascitis. • Liver abscess which ruptured in peritoneal, pericardial, pleural cavity.

Sample design: 50 patients, admitted with clinical, laboratory and imaging feature of liver abscess.

Study factors: age, gender, occupation, address, socioeconomic status, addiction, comorbidity, complete haemogram, liver function test, USG feature. Culture of aspirated material from liver abscess blood culture treatment modalities, treatment outcome.

Upon admission, comprehensive baseline investigations were conducted, including a thorough history and clinical examination, which were meticulously documented. The investigative panel comprised complete blood count (CBC), renal function tests (RFTs), liver function tests (LFTs), coagulation profile, viral serology, and blood cultures for febrile patients. Aspiration of abscess for cultures was performed when feasible. Ultrasonography findings of the abdomen were noted and documented, along with chest x-ray.  Patients were treated according to respective protocol Patient on conservative line were followed up daily clinically. Repeat LFT and Ultrasound abdomen was done immediately if patient condition did not improve after 3-4 days as a routine prognostic factor. Management strategies were as follows; Injectable intravenous antibiotics alone (in uncomplicated abscess measuring less or equal to 5cm/50 cc of any size), Ultrasound abdomen suggestive of unliquefied abscess.  Sonography guided Percutaneous aspiration with Antibiotic coverage (in non-ruptured abscess measuring >5 cm to <10 cm, approachable on USG) with a 16G spinal needle. The site, depth, direction of aspiration was guided by ultrasonography and pus aspirated was then sent for culture and sensitivity and routine microscopical examination. Antibiotics were started according to sensitivity report. It was done as a day care procedure and was done on the same day of admission as and when possible after thorough blood investigations. Patient was kept indoor next day to look for any post procedure complication. Sonography guided Percutaneous catheter drainage with Antibiotics coverage (in non-ruptured abscess measuring >10 cm and in those requiring repeated aspirations) and catheter was removed 24hrs after drain output was nil and on follow up USG residual liver abscess was found to be less than 5 cm and in non-liquefied state in symptomless patient. Percutaneous catheter drainage was done with a 14Fr pigtail catheter. Surgical drainage being used only in patients who fail to respond to above treatment and in case of diffuse peritonitis due to intraperitoneal rupture and in intrathoracic rupture. All interventions done Ultrasound Abdomen guided were followed by a post aspiration Ultrasound Abdomen to look for residual liver abscess and its liquefaction status and Xray chest PA view to look for iatrogenic complication for example pneumothorax. Results of study were analysed as frequency and percentage.

Table 1 shows age groups of patients having liver abscess. Table 2 shows symptoms of patients, 60 % had pain and 60 % had anorexia, 56 % had fever, 44 %had vomiting, 18 % jaundice, Table 3 shows lab findings 76 %had leucocytosis, 70 % had raised SGOT, 66 % had raised SGPT, 84 % had raised alkaline phosphatase ALP.

Table 1: Age group of patients

Table 2: Chief complaints of patients

Table 3: Lab parameters in patients

Table 4: Lobe wise distribution of liver abscess based on USG.

Table 4 shows Lobe wise distribution of liver abscess based on USG,in  50 %pateints  had right lobe involved, 22% had left lobe and 28 % had both lobes of liver inloved in liver abscess.

 Table 5: Types of Abscess

70 % patients had Amoebic liver abscess and 30 % had Pyogenic liver abscess.

 Table 6 : Method of Management

52% cases were managed by conservative treatment, 16 % by Percutaneous aspiration and 20 % by Percutaneous drainage , 12 % by Open Laparotomy.

 Table 7 : Complications of Liver Abscess

8 patients developed complications. 4 had rupture, 2 had pleural effusion and 2 had Septicaemia.

Advancements in modern medical science have transformed the diagnosis and treatment of liver abscesses. The traditional approach involving open surgical drainage, associated with high procedural morbidities, has given way to less invasive methods such as percutaneous and endoscopic drainage procedures. Additionally, conservative management with antibiotics has become a viable alternative, reflecting the evolution towards more patient-friendly and minimally invasive interventions. [9,10] In our study, symptoms of patients, 60 % had pain and 60 % had anorexia, 56 % had fever, 44 %had vomiting, 18 % jaundice. In lab findings 76 %had leucocytosis, 70 % had raised SGOT, 66 % had raised SGPT, 84 % had raised alkaline phosphatase ALP,. Lobe wise distribution of liver abscess based on USG shows   50 %pateints  had right lobe involved, 22% had left lobe and 28 % had both lobes of liver inloved in liver abscess. 70 % patients had Amoebic liver abscess and 30 % had Pyogenic liver abscess. 52% cases were managed by conservative treatment, 16 % by Percutaneous aspiration and 20 % by Percutaneous drainage, 12 % by Open Laparotomy. 8 patients developed complications. 4 had rupture, 2 had pleural effusion and 2 had Septicaemia.

For the case of the distribution of symptoms where the percentage of cases been observed to have a fever and abdominal pain, same as of Ghosh et al a study in this line showed a high prevalence of abdominal pain as a sign. Cheema et al, Zafar et al, and Huang et al informed instances with symptoms including fever, stomach discomfort, and vomiting in larger prevalence which was not in conformity with this present study.[11-13] For the cases of a type of abscess where the highest percentage of cases fall under the amoebic category in the present study findings. Shaikh et al, Hayat et al, and Ahsan et al also showed similar study results when the comparison were made. [14-15] Liver abscess is clinically challenging to diagnose due to nonspecific presenting features. Patients presenting with right upper quadrant pain and fever with tender hepatomegaly should raise a clinical suspicion of liver abscess. If left untreated or delayed, the disease leads to fatal course with significant morbidity and mortality. The epidemiology, treatment and mortality rate for liver abscesses have changed remarkably from the initial case descriptions. The reduction in mortality may be due to improved imaging and diagnostic techniques, as well as to increased use of percutaneous drainage. Abdominal ultrasonography is useful not only in diagnosis and intervention but also in the follow‑up of the condition and to assess resolution. Timely usage of percutaneous needle aspiration and catheter drainage under ultrasonography guidance is helpful and cost‑effective for multiple or solitary abscesses along with systemic antibiotics and metronidazole. It is minimally invasive and readily acceptable to most of the patients and easy to perform and without any complications. Patients treated by this technique recover faster and duration of hospital stay is less. In conclusion, this study emphasises the important role of percutaneous drainage as a mainstay of therapy in this potentially grave disease.

In the present era of modern medical science, diagnosis of liver abscesses has become easy through radiological and serological tests, and treatment modalities from minimally invasive to conservative have proved successful in the treatment of liver abscesses. Antibiotics remain the primary course of treatment for both amoebic liver abscess (ALA) and pyogenic liver abscess (PLA), unless there is persistent fever, a substantial abscess cavity, or complications that require surgical intervention. In our study 70 % patients had Amoebic liver abscess and 30 % had Pyogenic liver abscess. 52% cases were managed by conservative treatment, 16 % by Percutaneous aspiration and 20 % by Percutaneous drainage, 12 % by Open Laparotomy. 8 patients developed complications. 4 had rupture, 2 had pleural effusion and 2 had Septicaemia.

1. Khim G, Em S, Mo S, Townell N. Liver abscess: diagnostic and management issues found in the low resource setting. Br Med Bull. 2019;132(1):45-52.
2. Trillos-Almanza MC, Restrepo Gutierrez JC. How to manage: liver abscess. Frontline Gastroenterol. 2020;12(3):225-31.
3. Ochsner A, DeBakey M, Murray S. Pyogenic abscess of the liver: II. An analysis of forty-seven cases with review of the literature. Am J Surg. 1938;40(1):292-319.
4. Ghosh S, Sharma S, Gadpayle AK, Gupta HK, Mahajan RK, Sahoo R, et al. Clinical, laboratory, and management profile in patients of liver abscess from northern India. J Trop Med. 2014;2014:142382.
5. Gulshan JI, Manzoor SF. Study of epidemiology and management of liver abscess in Jammu region. Int J Res Med Sci 2024;12:782-8.

6      Ribaudo JM, Ochsner A. Intrahepatic abscesses: amebic and pyogenic. Am J Surg.   1973;125(5):570-4.

7. Barnes S, Lillemoe K. Liver abscess and hydatid cyst disease. In: Zinner M, Schwartz S, Ellis H, Ashley S, McFadden D, eds. Maingot's Abdominal Operations, 10th ed. Stamford, CT: Appleton & Lange; 1997: 1513-45.
8. Yu SC, Ho SS, Lau WY, Yeung DT, Yuen EH, Lee PS, et al. Treatment of pyogenic liver abscess: Prospective randomized comparison of catheter drainage and needle aspiration. Hepatology 2004;39:932‑8.
9. Ghosh S, Sharma S, Gadpayle AK, Gupta HK, Mahajan RK, Sahoo R, et al. Clinical, laboratory, and management profile in patients of liver abscess from northern India. J Trop Med. 2014;2014:142382.
10. Mandel SR, Boyd D, Jaques PF, Mandell V, Staab EV. Drainage of hepatic, intraabdominal, and mediastinal abscesses guided by computerized axial tomography. Successful alternative to open drainage. Am J Surg. 1983;145(1):120-5.
11. Ghosh S, Sharma S, Gadpayle AK, Gupta HK, Mahajan RK, Sahoo R, et al. Clinical, laboratory, and management profile in patients of liver abscess from Northen India. J Trop Med. 2014;2014:142382. 12. Cheema HA, Saaed A. Etiology, presentation and management of liver abscess at Children’s Hospital Lahore. Annals King Edward Med Uninv. 2008;14(4):148-50.
12. Zafar A, Ahmed S. Amoebic liver abscess: a comparative study of needle aspiration vs conservative treatment. J Ayub Med Coll Abbottabad. 2002;14(1):10-2.
13. Hayat Z, Mahmood S, Ali M, Nishtar N, Sartaj N, Neaem F, et al. Liver abscess not an uncommon disease. J Postgard Med Inst. 1995;9(1):56-61.
14. Ahsan T, Jehangir MU, Mahmood T, Ahmed N, Saleem M, Shahid M, et al. Amoebic vs pyogenic liver abscess. J Pak Med Assoc. 2002;52(11):497-501.