Question

A patient presents with fever and abdominal pain. Clinical examination reveals hepatomegaly extending 4 finger-breadths below the costal margin. USG and CT reveal a 4 cm x 5 cm x 4 cm hypoechoic and hypodense lesion 1 cm deep to the liver surface. Tests for hydatid disease are negative. The best course of action is?

• A. Resection of the affected lobe
• B. Multiple percutaneous aspirations and metronidazole injection in the right lobe
• C. Metronidazole therapy only
• D. Surgical drainage of the abscess and metronidazole therapy

Hint:

Hydatid-negative solitary liver abscess is amoebic; uncomplicated ones melt away on drugs alone.

Answer 1

The Correct Option is C

Step 1: Identify the diagnosis. Fever, abdominal pain, tender hepatomegaly and a solitary hypoechoic/hypodense liver lesion, with hydatid serology negative, points to an amoebic liver abscess. This is the commonest cause of a solitary liver abscess in endemic areas.
Step 2: Recall the principle of treatment. Uncomplicated amoebic liver abscess responds dramatically to medical therapy alone; metronidazole is the drug of choice (followed by a luminal amoebicide such as diloxanide furoate to clear intestinal carriage). Most abscesses resolve on drug therapy without any drainage.
Step 3: Decide whether drainage is needed. Drainage (preferably percutaneous aspiration, not open surgery) is reserved for specific indications: no clinical response after 48 to 72 hours of metronidazole, a large abscess (commonly quoted > 5 to 6 cm or in the left lobe with risk of pericardial rupture), threatened or impending rupture, or diagnostic uncertainty. This 4 x 5 x 4 cm lesion is uncomplicated and not threatening rupture, so it does not yet meet drainage criteria.
Step 4: Eliminate the wrong options. Lobar resection is far too aggressive for an abscess. Open surgical drainage is rarely needed and is reserved for rupture or failed aspiration. Repeated percutaneous aspiration is a second-line measure if medical therapy fails. The appropriate initial step here is metronidazole therapy alone.
Answer: C (Metronidazole therapy only).