A liver abscess is a pus-filled mass in the liver that typically results from liver injury or the spread of intra-abdominal infections via the portal vein. The majority are classified as either pyogenic, which is polymicrobial, or amoebic, caused by Entamoeba histolytica; fungal abscesses, mostly due to Candida, are the least common¹. The annual incidence is about 2.3 per 100,000 population, with a higher prevalence in males and those aged 40–60 years. In the United States, 80% of liver abscesses are pyogenic, 10% amoebic, and 10% fungal. Pyogenic liver abscesses account for 0.029–1.47% of hospital admissions and 0.3–1.4% of findings in postmortem studies. Taiwan reports a relatively high incidence of 17.6 per 100,000, with pyogenic liver abscesses representing half of all visceral abscesses and 13% of intra-abdominal abscesses².In developing countries, about two-thirds of liver abscess cases are amoebic, while in developed countries, three-fourths are pyogenic. Amoebic liver abscesses, caused by Entamoeba histolytica, are more common in areas with poor sanitation and affect 3–10% of amoebiasis cases. Pyogenic liver abscesses are often linked to biliary diseases (40%) and portal vein infections (20%). These abscesses may also arise from trauma, direct spread, or hematogenous routes. Clinically, liver abscess presents with fever, right upper abdominal pain, jaundice, malaise, and sometimes referred pain to the right shoulder.In liver abscess patients, inflammatory markers such as elevated C-reactive protein³, alkaline phosphatase, leukocytosis (mainly neutrophils), and abnormal liver function tests are commonly observed but are non-specific for differentiating between pyogenic and amoebic abscesses. Blood cultures are positive in about 50% of pyogenic cases, with hyperbilirubinemia seen in fewer than half. Ultrasonography is the first-line imaging tool, while CT scanning, with 97% sensitivity, is more effective in detecting abscesses and assessing their size and location⁴. Amoebic abscesses typically present as solitary lesions in the right lobe, though they can also appear as multiple lesions in the left lobe. Differentiating the type of abscess through imaging alone is often challenging. Treatment for amoebic abscesses relies on anti-amoebic medications, whereas pyogenic or mixed infections require image-guided drainage⁵.For liver abscesses smaller than 5 cm, repeated needle aspiration may suffice, while larger abscesses often require percutaneous drainage with catheter placement for effective management. This study aimed to evaluate the clinical profile and effectiveness of different treatment modalities in resolving liver abscess symptoms, particularly abdominal pain. Pain intensity was measured using the Visual Analogue Scale (VAS), a 100 mm line on which patients marked their pain level. Through this approach, the study contributes additional insights into the comparative efficacy of liver abscess treatments^6,7.

AIM

To study of clinical profile and various treatment modalities in patient of liver abscess at tertiary care center in Rajasthan

This is an observational descriptive hospital-based study with a cross-sectional design conducted in the Department of General Medicine at Mahatma Gandhi Medical College & Hospital, Jaipur. The study is carried out over a period of 18 months, from April 2023 to September 2024. The study population included patients diagnosed with liver abscess who attended the outpatient department or were admitted to the inpatient department during the study period. Inclusion criteria comprised all patients with liver abscess confirmed clinically and through ultrasonography, including cases in evolving, liquefied, or ruptured stages, with or without peritonitis. Patients below 18 years of age, pregnant females, and those unwilling to provide informed consent are excluded from the study. Data collection involved recording clinical presentations, diagnostic findings, treatment modalities employed, and patient-reported pain intensity using the Visual Analogue Scale (VAS) to assess treatment effectiveness.

Table 1 Distribution of study subject according to Age (yrs)

As shown in the table 23,23,19,23 and 12 study subjects belong to the age group 21-30, 31-40, 41-50, 51-60 and 61-70 yrs respectively. The mean age of the study subject was 42.48 + 13.65 yrs

Table 2 Distribution of study subject according to Residence

In this study 66 (66%) had residence in rural area and 34 (34%) had residence in urban area with ration of rural to urban residence being 1.94 : 1. The patient with rural background were about double of that with urban background.

Table 3 Distribution of study subject according to Duration of Symptoms

As shown in the table most of the study subject i.e  37 (37%) had symptoms of liver abscess of 11-15 days and rest 5, 28, 16, and 14 had duration of symptoms of less than 10, 16 to 20, 21 to 25 and more than 25 days respectively. The mean duration of symptoms was 17.45 + 5.63 days.

Table 4 Distribution of study subject according to Size Range (Maximum diameter) of Liver abscess.

In this study 35 study subject had liver abscess of maximum diameter less than 5 cm and 65 subject had liver abscess of maximum diameter more than 5 cm. In cases of multiple liver abscesses the abscess with greatest diameter is considered

Figure 1 and 2: Distribution of study subject according to Type of Liver abscess and Type of Management  of Liver abscess.

 In this study, the majority of subjects (65%) had single large liver abscess, followed by multiple (24%) and single small abscesses (11%). Most patients (65%) were managed with pigtail catheterization, while 24% received conservative treatment and 11% underwent percutaneous aspiration.

Table 5 Type of Liver abscess according to Residence

Single large liver abscess was more common among rural subjects compared to urban, and this difference was statistically significant (p=0.006).

Figure 3: Management of Liver abscess according to Size of Liver Abscess

Cases with abscess diameter >5 cm were primarily managed by pigtail catheterization, showing a statistically significant difference in treatment approach (p=0.000).

Figure 4,5 and 6: Symptoms of Pain on day 7 and symptoms of Fever, Dyspnoea   on 0 and 7th day according to different type of Liver Abscess

On day 7, pain, fever, and dyspnoea showed significant improvement compared to Day 0 in cases with single large and single small liver abscesses compared to multiple abscesses, indicating a better treatment response (p=0.000 for pain and fever, p=0.001 for dyspnoea). Complete resolution of dyspnoea was observed only in single large abscess cases.

Table 6 Laboratory parameters according to different type of Liver Abscess

Significant reduction in TLC and alkaline phosphatase levels was observed across all abscess types by day 7, while serum bilirubin showed mild improvement, especially in single large and single small abscesses.

Figure 7,8 ,9: Symptoms of Pain on 7th day, and Symptoms of Fever, Dyspnoea on 0 and 7th day  according to different type of Management

Pigtail catheterization and percutaneous aspiration showed significantly better outcomes in pain relief, fever resolution, and dyspnoea improvement by day 7 compared to conservative management. The differences in all three parameters were statistically significant (p=0.000 for pain and fever, p=0.001 for dyspnoea).

Table 7 Laboratory parameters according to different type of management

On day 7, the reduction in total leucocyte count, serum bilirubin, and alkaline phosphatase levels among the different management groups was statistically significant, with p-values of 0.000, 0.052, and 0.043 respectively.

Table 8 Mean Difference of VAS for pain perception for all patients at 0 and & 7 Day

Pain perception measured by VAS significantly decreased from 6.04±2.14 on day 0 to 1.31±2.44 on day 7 in all patients, regardless of the type of management (p=0.000).

Table 10 Distribution of study subject showing Response to Treatment according to Type of Liver abscess

In this study, all cases with single large abscess responded to treatment, whereas response rates were lower in multiple (79.2%) and single small abscesses (81.8%), showing a statistically significant difference.

Table 11 Distribution of study subject showing Response to Treatment according to Type of Management of  Liver abscess

In this study, treatment response was seen in 79.2% of conservatively managed cases, 81.8% of those with percutaneous aspiration, and 100% of cases managed by pigtail catheterization.

Table 12 Distribution of study subject showing Response to Treatment according to Residence of study subject

As shown in the table among the study subjects coming from the urban areas 29 (85.3%) responded to treatment and 5 (14.7%) did not responded. Among the study subjects coming from the rural areas 64 (97.0%) responded to treatment and rest 2 (3.0%) did not responded. So response to treatment is better in rural subject and this difference is statistically significant. (p=0.043)

In our study out of 100 study subjects  23 belong to the age group 21-30, 23 belonged to age group 31-40, 19 belonged to age group 41-50, 23 belonged to age group 51-60 and 12 belonged to age group  61-70 yrs respectively. The mean age of the study subject was 42.48 + 13.65 yrs. So distribution was uniform in various age group.According to a similar study by Parihar et all⁸ in 2024 reported mean age of the patients with liver abscess  as 40.28±12.72 years which is similar to our study .

In this study, liver abscess was more common among rural residents (66%) than urban (34%), suggesting a link to lower socioeconomic status and possibly poorer hygiene.   Das et all⁹ also reported in their study that no case of liver abscess was found in Class I and Class II of Modified Kuppuswamy SES scale and majority (68.09%) of liver abscess cases were from low SES group and amoebic liver abscess was predominant (87.5%) in this group.

In our study  most of the study subject i.e  37 (37%) had symptoms of liver abscess of 11-15 days and rest 5, 28, 16, and 14 had duration of symptoms of less than 10, 16 to 20, 21 to 25 and more than 25 days respectively. The mean duration of symptoms was 17.45 + 5.63 days. Jotsna et all¹⁰compared the efficacy of conservative management and ultrasound guided Pigtail catheter drainage of uncomplicated amoebic liver abscess and divided 40 patients  under 2 groups(Conservative management  as group I and Ultrasound-guided pigtail drainage as group II ). The mean duration of symptoms in group-I (n=20) was 13.45 days and in group II (n=20) it  was 17.20 days with maximum duration in group I was 6-10 days in 10(50%) subjects and in group II it was more than 21 days 8 (40%) subjects.

In this study most of the study subject i.e 65 (65%) had single large liver abscess, 24 (24%) had multiple liver abscesses and rest 11 (11%) had single small liver abscess . So majority of the type of liver abscess were solitary and large abscess. Similar finding was there in study by  Ghosh et all¹¹ who   reported solitary liver abscess to be present in in 65%, few (<3) liver abscess in 11% and multiple (>3) in 25.3%.

In this study, all single large abscesses were managed by pigtail catheterization, all multiple abscesses by conservative management, and all single small abscesses by percutaneous aspiration. Notably, all cases with abscess diameter >5 cm underwent pigtail catheterization, indicating a statistically significant association with abscess size (p=0.000).Choudhary et all¹² in their  similar study reported that 72% of patients of liver abscess were subjected to percutaneous aspiration in abscess >100 ml or >3 cm. So over all larger abscesses were managed by percutaneous aspiration or drainage along with antibiotic.

In our study, all cases with single large and single small abscess became afebrile by day 7, whereas 20.8% of multiple abscess cases remained febrile, showing a significantly better response in the former groups (p=0.000). Additionally, dyspnoea was completely resolved by day 7 in all single large abscess cases, while it persisted in multiple and single small abscess groups. This indicates that single large abscess cases showed a significantly better clinical recovery in terms of fever and dyspnoea compared to others (p=0.001).Choudhary et all¹² reported abdominal pain (98%) as  the most common symptom. So overall nearly most of the studies  found fever and pain in the abdomen as the most common symptoms.

The reduction in total leucocyte count and alkaline phosphatase by day 7 was significantly greater in cases managed with pigtail catheter drainage compared to other modalities (p < 0.05). Although serum bilirubin also decreased more with pigtail drainage, the difference was not statistically significant. Ghosh et all¹¹ reported in their study that the mean TLC was  19,100 ± 9104/μL, mean bilirubin was 1.55 ± 2.18 mg/dL and mean alkaline Phosphatase was 622 ± 446 IU/L. Volume of abscess was found to be directly proportional to the levels of serum alkaline phosphatase (P = 0.041) . Parihar et all   134 found   leukocytosis in 121 (80.7%), elevated liver enzymes (95 (63.3%) AST and 80 (53.3%) ALT), elevated ALP in 133 (88.7%), and low albumin levels (138 (92%)) in a significant proportion of patients. Serum albumin level (p<0.001) and ALP (p<0.001) were significantly low and high, respectively, in patients with hospital stays ≥10 days.                 

Among  the study subjects coming from the urban areas 29 (85.3%) responded to treatment and 5 (14.7%) did not responded. Among the study subjects coming from the rural areas 64 (97.0%) responded to treatment and rest 2 (3.0%) did not responded. So response to treatment is better in rural subject and this difference is statistically significant. (p=0.043).

The pain perception of all patients in form of VAS changed from 6.04+2.14 on day 0 to 1.31+2.44 on day 7 with mean difference 4.73+2.08 which was statistically significant .(p=0.000)  It means the pain decreased significantly in all patients after treatment irrespective of type of management which again means all types of treatment were effective in reducing the pain in the abdomen.

In this study, all cases of single large abscess managed with pigtail catheterization responded to treatment (100%), whereas response was lower in multiple abscesses managed conservatively (79.2%) and single small abscesses managed by percutaneous aspiration (81.8%), with the difference being statistically significant (p=0.001). Thus, single large abscesses showed the best response, while multiple abscesses responded least, though no mortality was reported.Kumar et all¹³ reported that pleural effusion in 24% of cases  and intraperitoneal rupture in 4% of cases.

Liver abscess cases predominantly presented with fever and abdominal pain, with larger abscesses (>5 cm) showing more severe symptoms and laboratory derangements. Pigtail catheter drainage in single large abscesses and percutaneous aspiration in single small abscesses led to significantly better clinical and biochemical recovery by day 7. Conservative management in multiple abscesses showed comparatively poorer response due to limited pus evacuation.

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