Barnes P F, De Cock K M, Reynolds T N, Ralls P W
Department of Medicine, LAC-USC Medical Center 90033.
Medicine (Baltimore). 1987 Nov;66(6):472-83. doi: 10.1097/00005792-198711000-00005.
We evaluated the clinical features of 96 cases of amebic liver abscess and 48 of pyogenic hepatic abscess. Most patients with amebic abscess were young Hispanic males. Those with pyogenic abscess were older, without any ethnic predominance. Symptoms tended to be acute and localized to the right upper quadrant in amebic infection. In pyogenic disease, symptoms were often nonspecific and chronic in nature. A marked shift to the left of the leukocyte count occurred more frequently in pyogenic abscess, as did markedly abnormal values of the serum albumin, direct bilirubin, lactic dehydrogenase and aspartate aminotransferase. Sonography detected all cases of amebic abscess and missed the lesions in 2 of 39 patients with pyogenic abscess. Abscess cultures yielded pathogens in 90% of cases of pyogenic disease, while blood cultures were positive in 50%. Five of 20 patients with positive blood cultures had additional organisms isolated from the abscess that would have required adjustment of antibiotics for optimal coverage. We believe that all pyogenic abscesses should be aspirated to guide antibiotic therapy. In amebic abscess, the diagnosis was usually based on clinical and sonographic findings, aspiration being performed in only 14% of cases. Ninety-eight percent of patients were treated with amebicidal agents alone, and all responded to therapy. Therapeutic needle aspiration is rarely necessary. In pyogenic abscess, prolonged fever was common during medical therapy. Even in those eventually cured without surgery, the median time to defervescence was 8 days. Though 19 patients underwent surgical drainage, only 2 clearly did not benefit from medical treatment, having high fevers after more than 2 weeks on a regimen of appropriate antibiotics. Surgery is often performed prematurely because physicians expect fever to resolve quickly, but persistent fever of less than 2 weeks' duration should not constitute an indication for surgical drainage. Seven patients with pyogenic abscess died, 5 as a result of hepatic abscess. In 3 of these cases, the diagnosis was unsuspected till autopsy. Improved awareness of this disease may decrease morbidity and mortality from this treatable condition.
我们评估了96例阿米巴肝脓肿和48例化脓性肝脓肿的临床特征。大多数阿米巴脓肿患者为年轻的西班牙裔男性。化脓性脓肿患者年龄较大，无任何种族优势。阿米巴感染时症状往往急性发作，局限于右上腹。在化脓性疾病中，症状通常是非特异性的，且呈慢性。化脓性脓肿中白细胞计数明显左移以及血清白蛋白、直接胆红素、乳酸脱氢酶和天冬氨酸转氨酶值明显异常的情况更为常见。超声检查发现了所有阿米巴脓肿病例，但在39例化脓性脓肿患者中有2例漏诊。化脓性疾病病例中90%的脓肿培养出病原体，而血培养阳性率为50%。20例血培养阳性患者中有5例从脓肿中分离出其他病原体，这就需要调整抗生素以实现最佳覆盖。我们认为所有化脓性脓肿均应进行穿刺抽吸以指导抗生素治疗。在阿米巴脓肿中，诊断通常基于临床和超声检查结果，仅14%的病例进行了穿刺抽吸。98%的患者仅接受抗阿米巴药物治疗，且所有患者对治疗均有反应。很少需要进行治疗性穿刺抽吸。在化脓性脓肿中，药物治疗期间持续发热很常见。即使是那些最终未经手术治愈的患者，体温恢复正常的中位时间也为8天。尽管有19例患者接受了手术引流，但只有2例显然未从药物治疗中获益，在使用适当抗生素治疗2周以上后仍持续高热。手术往往过早进行，因为医生期望发热能迅速消退，但持续时间不到2周的发热不应成为手术引流的指征。7例化脓性脓肿患者死亡，5例死于肝脓肿。其中3例在尸检前未被怀疑患有该病。提高对这种疾病的认识可能会降低这种可治疗疾病的发病率和死亡率。
