“THE OUTCOME OF ULTRASOUND GUIDED PERCUTANEOUS DRAINAGE OF LIVER ABSCESS”

Introduction: Pyogenic liver abscess is aa potentially life-threatening disease with significant morbidity and mortality. Patients usually present with non-specfic symptoms initiallymaking diagnosis and treatment delayed and difficulty. Surgical drainage is associated with morbidity and mortality when compared to minimal invasive procedure and hence the study. Aims and objectives-This study was conducted with the aim to evaluate the need and the outcome of percutaneous drainage in treatment of liver abscess and also to assess the parameters during the procedure which will improve the clinical outcome. Methods- prospective observational study conducted in patients with liver abscess who were treated with ultrasound guided percutaneous catheter drainage during the study period. A total of 76 patients were studied. Results- Percutaneous catheter drainage (PCD) had 100% success rate (reduction in abscess volume by atleast 50%) with early clinical improvement and very few complications. Conclusion- Percutaneous catheter drainage of abscess is treatment of choice which is minimally invasive and also has higher success rate with earlier and better clinical and radiological improvement.


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USG in the differentiation of PLA from other liver lesions and is reported to have a sensitivity of approximately 95% 2 . The portal venous phase using intravenous contrast material gives the best differentiation between the liver and the abscess, with the periphery of the PLA having contrast enhancement as opposed to non-enhancement of the central portion. Magnetic resonance imaging (MRI) does not seem to have any advantage over CT or USG 2 .
In recent years, image-guided percutaneous drainage has been increasingly used to treat liver abscesses with reported success rates ranging from 70-100% 3 . Percutaneous placement of an indwelling catheter is the method most widely preferred to drain liver abscesses 4 . There are two main methods in Percutaneous treatment. They are intermittent needle aspiration and continuous catheter drainage. Intermittent needle aspiration is less expensive but has lower success rate than drainage method and it also require repeated aspiration. It has an advantage though those multiple small abscesses can be aspirated through different tracts in the same sitting. Important drawback of aspiration is that repeated needle aspirations may be required in a single patient over a short period of time which is painful and unpleasant for the patients and hence may not be acceptable and larger cavities often reaccumulate. To avoid this unpleasant pain associated with needle aspiration, percutaneous catheter drainage can be used first tool in the management of hepatic abscess and it provides a route for continuous flow of pus and hence the problems of incomplete and repeated evacuations are not a problem.

Methodology:-
This was a prospective observational srudy conducted at our tertiary care centre, Rajendra institute of medical sciences, Ranchi, Jharkhand, for a perioedof 18 months from June 2018 to December 2019. S ample size was duration based i.e., all the patients with liver abscess treated with ultrasound guided percutaneous catheter drainage during this study period.This study was conducted with the aim to evaluate the need and the outcome of percutaneous drainage in treatment of liver abscess and also to assess the parameters during the procedure which will improve the clinical outcome.
Inclusion Criteria-1.Patients of both the sex and all the age group were included in the study. 2.Abscess cavity size more than or equal to 5cm with liquefied content(partial/complete).

Single cavities or unilocular abscess
Exclusion Criteria-1) Suspected malignancy 2) Co existing coagulopathy 3) Ruptured abscess 4) Signs of peritonitis 5) Multiple abscess, multilocular abscess 6) Ascites During our study period, 76 patients met our inclusion and exclusion criteria. After applying inclusion and exclusion criteria, a detailed history and examination findings were noted. Documented diagnosis of liver abscess done by ultrasound. Routine investigations like haemogram, liver function tests and coagulation profile were noted. The antibiotic cover which was given was also noted.

Procedure:-
Pigtail catheter drainage procedure was done under ultrasound guidance with involvement of both radiologist and the treating surgeon. The characteristics of the abscess like number, location, size, loculations, echogenicity, liquified or not etc all these are recorded before procedure. In drainage technique, seldinger technique was used to insert catheter by using guide wire into the abscess cavity. Careful localization of the abscess and proper selection of the entry site were pre-requisite for successful procedure. The best route of access was considered to the route in which catheter has traversed as little amount of liver tissue as possible and avoidingpleura and bowel. The skin was anaesthetized 2% lignocaine infiltration and by using a No. 11 blade a small stab was made at the entry site on the anesthetized skin. Under real time sonographic guidance, pigtail catheter was inserted through the skin incision and guided into the abscess cavity. After confirming the proper position, stylet was withdrawn and by using 10cc syringe, the abscess cavity was aspitated and the position confirmed. Then the guide wire was removed and the 1184 catheter was attached to a collecting bag. Then the catheter was secured by suturing with silk 1-0. Sterile dressing was applied and the pus collected was sent for culture and antibiotic sensitivity.

Follow Up
The daily output was monitored. The catheter was flushed daily with 10 ml of normal saline to prevent its blockage with debris. Alternate day Ultrasound examinations were done to monitor the cavity size and volume and to confirm the position of tip of the catheter. Clinical improvement in the patient 's condition was noted.The catheter was removed on the basis of combination of clinical and radiological criteria-i) The drainage should be less than 10ml per day (excluding the catheter flush volume. ii) Fever and raised leucocyte count associated with abscess should be absent. iii) evaluation of residual cavity size (should be reduced by atleast 50%) and presence or absence of any biliary fistula should be done, because if any fistula noted catheter drainage was continued till the fistula closed. The follow up was continued until the resolution of abscess.

Outcome-
The patients' outcome in terms of clinical improvement, time required for improvement of symptoms, duration of hospital stay, lab parameters improvement, USG monitoring-residual volume, recollection noted. Complications of the procedure like sepsis, peritonitis, bowel injury, failure of drainage, catheter tip malposition, haemorrhage, pneumothorax, hemothoraxwere documented if any.
The data was collected systematically and case proforma was filled for every patient. The Paired student T -test was used to analyse the values collected before and after the procedure from t-score and degree of freedom of difference in mean reduction of abscess size.

Observation:-
During the study period, a total of 76 patients were included in the study and following observations were done.  Mean -520.57 Different investigations are described in table no.2, mean haemoglobin was 9.6g% and total leucocyte count of 13,200. The pus culture showed, 56.58% was ameobic liver abscess, 23.68% was pyogenic, 5.27% had ameobic with secondary infection (positive culture for pyogenic and amebic) and 14.47% had indeterminate report. On ultrasound examination, the abscesses were more common on the right (84.21%) with mean volume of abscess was 520.57cc ranging from 75cc to 800cc. Post procedural outcome is decribed in table no.3. Mean time for clinical improvement was 4.7 days, time for reduction of abscess size (50% and above) was 5.2 days. Duration of drainage required was 8.4 days and total duration of hospital stay was around 11.6 days. Size of abscess was was expressed in terma of means and standard deviation and t score by comparing it with size of previous week size of abscess. P value was calculated which was statistically significant and so does it show that with percutaneous drainage of abscess there was significant reduction in volume of abscess. Among the complications, 93.42% had no complications at all and only 6.58 had catheter related complications like blockage, catheter tip malposition who were managed conservatively and did not need re procedure.

Discussion:-
Our study showed that the maximum incidence of liver abscess was seen in males (85.33%) when compared to females. Amitesh Kumar Jha et al 5 study also showed incidence male at higher incidence (male: Cristina et al 6 study revealed the most common laboratory abnormality was increased C-reactive protein and fibrinogen blood levels, respectively, in 98% and 93.9% of cases. These were followed by abnormal total leucocytic count in 77% patients and elevated ALP in 67% of cases. In Amitesh Kumar Jha et al 5 study the laboratory revealed leukocytosis (75%), raised ESR (82%), and anemia (52%). The most marked LFT abnormality was raised alkaline phosphatase (62% cases). Abnormal prothrombin time was observed in 43% cases. Our study showed mean haemoglobin was 9.6g% and total leucocyte count of 13,200 where as Dulku et al 7 study showed 59.5% had leucocytosis, 57.1% had raised ALP, 28.6% had prolonged prothrombin time. It was observed that 39 of 50 patients (78%) had leukocytosis. Elevation of serum alkaline phosphatase was also observed in 76% of the patients in Batham IK et al 3 study. Anemia, leukocytosis, high erythrocyte sedimentation rate, elevated C-reactive protein level, hypoalbuminemia, and hyperbilirubinemia, as well as elevated alanine aminotransferase (ALAT) and alkaline phosphatase (AP) levels are the most common laboratory findings. None of the blood tests specifically help to diagnose LA; however, they can suggest a liver abnormality that leads to targeted imaging studies 8 .
Cristina et al 6 study showed radiological drainage was the most frequent initial intervention: ultrasound or CTguided needle aspiration of PLA was performed in 13 patients (11%) and percutaneous abscess drainage was performed on 72 patients (67%). Generally, a percutaneous French 7 pigtail catheter was inserted. The removal of the percutaneous drain was based on the patient's clinical and laboratory response. The median of drainage duration was 12.6 ±14 days. Of all 72 cases that underwent radiological drainage, 7 patients required surgical intervention because of failure of resolution and recurrence of the abscess. Endoscopic retrograde cholangiopancreatography (ERCP) was used to treat liver abscess in 6 patients (5.6%), in which there was a lithiasic or neoplastic biliary obstruction. In the study conducted by Amitesh Kumar Jha et al 5 of 110 patients, 15 patients were treated with medical or conservative treatment with a success rate of 70%, 37 patients were treated with percutaneous needle