Postgrad Med J: first published as 10.1136/pgmj.36.420.629 on 1 October 1960. Downloaded from 629 SPONTANEOUS INTRAPERITONEAL RUPTURE OF AN AMOEBIC LIVER ABSCESS Report of a Case KASTURI SARMA, M.B.B.S (Madras) K. C. NAMBIAR, F.R.C.S.(Eng.), F.R.C.S.(Edin.) Department of Surgery, Stanley Medical College, Madras Introduction Case Report of the liver is M.P., a 6o-year-old man, a destitute, was admitted Progression of an amoebic abscess for vague abdominal pain, constipation, and abdominal essentially histiolytic, with minimal inflammatory distension for the last ten days. The pain was not response and fibrosis. These factors should localized to any part of the abdomen, and it was un- encourage the development of peritonitis. How- accompanied by vomiting. He had no fever or cough. ever, this complication is not as common as is Two months before he had had an attack of dysentery and passed about ten motions a day, containing mucus by copyright. generally believed. Craig4 has analysed the litera- but no blood. The condition improved spontaneously ture on the subject, and finds that out of 740 without treatment, and he felt well until a week before cases of amoebic liver abscess, rupture occurred he attended the outpatient department with vague 197 cases %). Most of the abscesses dyspepsia and pain in the upper abdomen. His com- in (26.6 plaints were not considered serious enough to merit opened into the pleura (70 cases), lung (54 cases), special investigation and he was treated sympto- or pericardium (38 cases). The rest ruptured matically. After that he began to feel worse. He had into the colon (6 cases), stomach (8 cases), bile not sustained any injury. The abdominal pain became ducts cases), vena cava (6 cases), kidney more severe, constant and diffuse. It could not be (3 localized, was not relieved by posture, and did not (3 cases), duodenum (i case) and lumbar region radiate. The abdominal distension had increased over (8 cases). None of the abscesses ruptured into the previous few days. the peritoneal cavity. He was very anaemic (Hb., 40%; R.B.C. 2.2 million; http://pmj.bmj.com/ Less than ioo cases of intraperitoneal rupture W.B.C., i i,600, 74% polys.) and had slight oedema of the feet. His tongue was furred. He was ill. (Pulse are on record. In most of the cases injury or an rate, 104/min.; temperature, ioo0F.) His blood unsuccessful attempt at blind drainage have pressure was normal. precipitated the disaster. Spontaneous rupture is The abdomen was uniformly distended. There was very rare and in the majority of cases it would slight rigidity, which was not, however, localized to any particular quadrant. The liver could not be felt, and appear to have ended fatally. there was no liver tenderness. There was no upward The mortality of amoebic liver abscess varies in enlargement of this organ that could be detected by different series and appears to be proportional to percussion. No ascites could be made out clinically. on October 2, 2021 by guest. Protected the number of abscesses, even reaching ioo% Bowel sounds were inaudible. On rectal examination in he had a prolapsed pile mass. There was no tendemess when the abscesses are more than three in the rectum and no faecal matter could be felt. number.9 There was no oedema of the chest wall and the lungs Intestinal amoebiasis may also cause peritonitis. were clinically normal; there was no evidence whatever This may take the form of a localised patch of of congestion of the right base. to a chronic ulcer eroding through A plain X-ray of the abdomen was taken with the peritonitis due patiert in the sitting position. It was normal. He was the muscular coat of the intestinal wall. Occa- givefi t*o enemas in succession; but no flatus or faeces sionally a fulminating lesion may produce pro- were passed. gressive bowel necrosis, or an accidental injury His condition deteriorated over the next six hours a segment of intestine already and the distension increased. Peritonitis was sus- may perforate pected, and it was decided to perform a laparotomy. weakened by ulceration; in either case the resulting The abdomen was opened by a right para-median acute general peritonitis may be severe enough to incision. The peritoneal cavity contained about two prove fatal,4, 7,11 pints of thin, straw-coloured fluid. Flakes of fibrinous Postgrad Med J: first published as 10.1136/pgmj.36.420.629 on 1 October 1960. Downloaded from 630 POSTGRADUATE MEDICAL JOURNAL October I960 exudate were adherent all over the serous coat of the toms like fever or rigors. A precise diagnosis was small intestine. The caecum was hyperaemic and impossible. Peritonitis was suspected but it was thickened. On pulling out a loop of small intestine from the right hypochondrium a small gangrenous area was not possible to determine, before the abdomen found on the inferior surface of the right lobe of the was opened, that it was due to intraperitoneal liver, posterolateral to the gall bladder, through which rupture of an amoebic abscess of the liver. thick pale-pink pus was pouring into the hepatorenal Another unusual feature of the case was the pouch. It was coming from an abscess which was estimated to be about 2 in. by 3 in. in size, in the lower absence of enlargement of the liver. This may part of the right lobe of the liver. The liver was not have been due to the rupture of the abscess enlarged. causing a sudden release of tension, or to the The pus was aspirated; Morrison's pouch was absence of any accompanying hepatitis. Rogers" drained by a Malecot's catheter brought out through a separate stab incision made in the flank. The area was insists on the usual healthy state of the liver unless walled off with greater omentum, and the abdomen was there is bacterial infection with secondary closed in layers. abscesses, cloudy swelling, or other lesions like About two pints of thick pink pus drained into the amyloid change due to a chronic abscess. Rolle- bedside bottle over the first four post-operative days. Trophozoites of E. Histolytica were identified in the pus. ston8 believes that the liver is usually enlarged, The sinus healed in about four weeks' time. and after evacuation of the pus, weighs more than The patient was treated with Chloroquine and normal. received a course of Emetine injections. He made a satisfactory recovery and the bowels moved on the third Summary day. He was discharged from the hospital at the end of six weeks. A case of spontaneous intraperitoneal rupture of an amoebic abscess of the liver is presented. Discussion The case showed certain interesting features which In all the recorded cases of spontaneous rupture are briefly discussed. of an amoebic liver abscess into the peritoneal cavity the difficulty of making a correct diagnosis Acknowledgements and Benedetti Valen- We are grateful to the Dean, Government is emphasised. Both Labry5 by copyright. tinil made a provisional diagnosis of acute appendi- Stanley Medical College, Madras, for permitting citis. The cases reported by Biggam and Ragab2 us to report this case. and Chang and Robertsone were already under REFERENCES treatment for amoebiasis and the condition was I. BENEDETTI VALENTINI, F. (1929), Policlinico, 36, i09S. therefore suspected. Self's case'0 gave a long 2. BIGGAM, A. G., and RAGAB, A. (I930, J. trop. Med. Hyg., history of proved amoebic dysentery, for which 35, 285. 3. CHANG, C., and ROBERTSON, D. S. (I934), Chin. med. J., he had undergone treatment in the Armed 48, 375. 4. CRAIG, C. F. (I949), 'Oxford Medicine', Vol. V, p. 8i6, Forces. Yet the diagnosis was by no means easy. Oxford. In the present case the clinical manifestations S. LABRY (I925), Lyon med., 35, 324. suggested acute intestinal obstruction. This was 6. ROGERS, L. (I921), 'Bowel Diseases in the Tropics', p. 311, London: Oxford University Press. perhaps due to paralytic ileus of the loops lying 7. ROGERS, L., and MEGAW, J. W. D. (i944), 'Tropicalhttp://pmj.bmj.com/ in the right hypochondrium. An unusual feature Diseases', p. 230, London: J. & A. Churchill. 8. ROLLESTON, H. (1949), 'Oxford Medicine', Vol. III, was the absence of vomiting. There was no liver p. 356, Oxford. enlargement, and liver tenderness, oedema of the 9. SAMBUC, E. (1913), Ann. d'hyg. et de med. colon., I6, 48. chest wall, and rigidity of the upper abdomen io. SELF, J. B. (I95S), Postgrad. med. J., 31, 35. ii. SIMON, S. K. (1925), 'Tice's Practice of Medicine', Vol. 4, were absent. The patient had no general symp- p. 270, London: Butterworth. on October 2, 2021 by guest. Protected.