Abstract
Summary
Liver abscess (LA) is a common health problem among children in tropical countries. We conducted a prospective, observational study at a tertiary-care medical college in order to examine the clinico-socio-demographic profile and assess a possible association between certain predictors of a poor outcome in children admitted with LA. Of a total of 53 children, only 24.4% were malnourished. Staphylococcus aureus was the most common organism observed. Amoebic LA was noted in 7.5%. Right-sided pleural effusion was the most common complication recorded (20.7%). The most successful treatment modality was therapeutic percutaneous aspiration with antimicrobials (90.5% success). An elevated alkaline phosphatase and open surgery were associated with a poor outcome (P = 0.04 in each case). The rate of hospital admissions of children with LA remains high and most are of pyogenic origin. Of the different treatment modalities, therapeutic aspiration along with antimicrobials achieved the best results. Raised alkaline phosphatase and open surgery were predictors of a poor outcome.
Introduction
Liver abscess (LA) remains a common health problem worldwide, the burden of which is primarily borne by tropical countries, including India.1–3 However, there is a dearth of data, especially among children from India, regarding the current clinico-socio-demographic profile and outcome of management of this unrelenting clinical condition. Hence, we undertook to study this aspect and also to assess the risk factors of a poor outcome in paediatric LA cases.
Materials and Methods
A prospective observational study was conducted that included all children admitted with an ultrasonographic diagnosis of LA in Kalawati Saran Children's Hospital, Lady Hardinge Medical College, New Delhi, from December 2010 to February 2012. Ethical approval was given by the institutional ethical committee. Details of the patients regarding their socio-demographic and nutritional status, clinical profile, treatment and outcome were recorded. All patients underwent investigations including: complete haemogram, liver and kidney function tests; prothrombin time; partial thromoplastin time; blood culture; ultrasonography; and ultrasound-guided diagnostic aspiration in case of liquefied contents. The patients were started empirically on a third generation cephalosporin, co-amoxyclavulanate and metronidazole.
Patients were diagnosed as having an amoebic LA (ALA) if the test for amoebic serology was positive with negative bacterial culture from blood and pus. Those with a negative amoebic serology, with or without a positive bacterial culture from pus or blood, were labelled as pyogenic LA (PLA).
The outcome was categorized as favourable/good (group A) or unfavourable/poor (group B). An unfavourable outcome was defined for this study as those with any one of the following features: death; complications related to the disease (Table 1); or delayed recovery from fever (>10 days). The socio-demographic, nutritional, laboratory parameters and treatment modalities were compared between group A and group B.
Socio-demographic characteristics, nutritional status, clinical features, laboratory parameters and treatment modalities
Based on Kuppuswamy socioeconomic scale 4
Based on weight for height in World Health Organization growth charts 5
AST, aspartate aminotransferase; ESR, erythrocyte sedimentation rate
A descriptive analysis was done by calculating frequency, mean and standard deviation (SD) for continuous variables and proportions for categorical variables. Risk of association was estimated by odds ratio (OR) with 95% confidence interval using chi-square/Fisher exact test. Differences were considered statistically significant at P < 0.05. SPSS version 17 software (SPSS Inc., Chicago, IL, USA) was used.
Results
A total of 53 children with LA were admitted during the study period. The socio-demographic characteristics, nutritional status, clinical features, laboratory parameters and treatment modalities are shown in Table 1. Two children died from sepsis with peripheral circulatory failure. Time to recovery from pyrexia ranged from 3 to 30 days, with most (79.2%) patients recovering within 10 days.
Twenty-three (43.4%) children had an unfavourable outcome (group B). Among the parameters compared between the groups, a raised alkaline phosphatase (ALP) >350 IU/L and open surgical drainage were significantly associated with a poor outcome (OR, 3.6; P = 0.04, and OR, 22.2; P = 0.04, respectively).
Discussion
This study shows a relatively high number of admissions for patients with LA, compared with hospital-based studies from other tropical countries1,3 as well as from India, 6 which could be attributed to the fact that ours is a tertiary-care children's referral centre in northern India. The demographic pattern and the presenting complaints in our study were comparable to those reported in most other published studies.1,7
Liver abscess in children generally has an association with low socioeconomic status, unhygienic living conditions and malnutrition.1,2,7 However, in our study, 62.2% came from an upper middle socioeconomic background 4 with 75.4% from an urban background. Only a quarter were suffering from malnutrition. This rather contrasting picture suggests that paediatric hepatic abscesses can occur in children with even mild degrees of malnutrition and from any socioeconomic background.
Worldwide, PLA is more prevalent than ALA. 2 However, the proportion of ALA was lower (7.5%) than that reported in other series.1,8 Complications in the form of a rupture of LA and right-sided pleural effusion occur mostly in cases of ALA8,9 but were found to be associated with PLA in our study.
The different treatment modalities applied for our patients were based on clinical features and an ultrasonographic appearance of the LA. Conservative management alone was successful in 28.3%, which is similar to other reported series.7,10 In our study, therapeutic percutaneous needle aspiration was largely effective, with only two failures (9.5%). Other studies have reported failure rates ranging from 18% to 42.8%.6,7,10 The success rate of percutaneous drainage in our study was 83.4%, which is comparable with other studies. 10 Open surgical intervention was required in 20.7% of cases, but this group suffered a higher rate of adverse outcomes. The poor outcome in patients with open surgery could be attributed to the seriousness of the disease and associated postoperative morbidity.
There is a dearth of data in the published literature about the factors associated with a poor outcome in children with LA. The different predictors of a poor outcome identified in adult and some paediatric studies include larger size or loculated abscess, multiple abscesses, increased polymorphonuclear leukocytosis, hypoalbuminaemia, hyperbilirubinaemia, elevated ALP, lactate dehydrogenase and blood urea nitrogen.3,6 Although the effect of these factors was studied by us, none, except an elevated ALP, had any significant influence on outcome.
The shortcoming of this study is the small number of patients; the statistical results, therefore, may not be robust. However, this is, perhaps, one of the very few studies of LA in children from India which assesses the risk factors for adverse outcome – earlier studies have had even smaller sample sizes. 7 Moreover, considering a time frame of only 14 months, a cohort of 53 children with LA appears to be a substantial number and indicates the need to continue such a prospective study for longer periods.
Conclusion
LA continues to be a common health problem in northern India. The prevailing school of thought that LA is commonly associated with malnutrition in tropical countries was not evident in our study as only a quarter of our patients were malnourished. The ratio of PLA to ALA was high. Among the different treatment modalities, therapeutic percutaneous aspiration along with antimicrobials gave the best results. A raised ALP and open surgery were predictors of poor outcome.
Footnotes
None.