AMEBIC LIVER-ABSCESS - SPARE THE KNIFE BUT SAVE THE CHILD

Background/Purpose: Amebic liver abscess (ALA), the most common extrai ntestinal manifestation of infection with Entameba histolytica, carrie s significant morbidity and mortality in the pediatric age group. The efficacy of metronidazole in the treatment of ALA is well established, but the role of surgical intervention remains controversial. Many inv estigators still advocate aggressive surgical therapy for complicated and ruptured ALA. Reports regarding management of ALA in children are sparse and deal with small numbers of patients. The objective of this study was to assess the effectiveness of parenteral metronidazole comb ined with judicious aspiration of ALA in obviating the need for surgic al intervention. Methods: The medical records of all children admitted with the diagnosis of ALA between 1986 and 1997 to the Aga Khan Unive rsity Hospital were reviewed retrospectively. The diagnosis of ALA was confirmed in 48 patients by an ultrasound scan together with elevated indirect hemagglutination (IHA) titres (> 250). Ages ranged from 3 we eks to 14.5 yea rs. Results: Thirty-seven (75%) children were below th e fifth percentile for height and weight, and 45 (93.7%) presented wit h a hemoglobin level of less than 10.0 g/dL. Comorbid factors included pulmonary tuberculosis (n = 2, chicken pox (n = 1), tetralogy of Fall ot (n = 1), and thalassemia major (n = 2). There was a mean delay of 1 3 days before presentation to the hospital. AII patients were treated with parenteral metronidazole and broad-spectrum antibiotics. The latt er were discontinued on confirmation of the diagnosis. The duration of treatment with metronidazole ranged from 2 to 5 weeks. Percutaneous a spiration of the ALA was performed under ultrasound guidance using sed ation in 28 patients for one or more of the following indications; ALA greater than 7.0 ems (n = 20), left lobe involvement (n = 8), and no response after 48 hours of medical therapy (n = 6). Nine patients requ ired more than one aspiration. One patient with peritoneal ru ptu re o f the ALA additionally underwent percutaneous aspiration of the perito neal cavity under ultrasound guidance. One patient required insertion of a chest tube after rupture of the ALA into the right pleural cavity , and another underwent urgent bronchoscopy after rupture of the absce ss into the tracheobronchial tree. The hepatobronchial fistula closed spontaneously with medical therapy. No patient required open surgical drainage, and all recovered without relapse. The mean duration of hosp italization was 12 days. Conclusion: Our experience suggests that pare nteral metronidazole combined with timely aspiration of the abscess ca n obviate the need for surgical intervention in large and complicated ALA even in malnourished children who present late for treatment. J Pe diatr Surg 33:119-122. Copyright (C) 1998 by W.B. Saunders Company.