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

Work from the clinical pattern to the diagnosis and then to the management rule. A febrile patient with abdominal pain, an enlarged tender liver and a single hypoechoic, hypodense collection just under the liver capsule, with negative hydatid testing, is the classic description of an amoebic liver abscess. The treatment philosophy for this entity is that it is primarily a medical disease, not a surgical one, because the responsible organism is killed efficiently by drugs. Metronidazole is the first-line agent and produces rapid clinical improvement in the great majority of uncomplicated cases, and it is usually followed by a luminal amoebicide to eradicate intestinal cysts. Drainage is added only when there is a reason to drain, such as failure to improve on drugs after a couple of days, a very large or left-lobe abscess at risk of rupturing into the pericardium, signs of impending rupture, or doubt about the diagnosis; and when drainage is required, image-guided percutaneous aspiration is preferred over open surgery. This abscess measures about 4 by 5 by 4 cm, sits superficially, and shows no features of complication, so none of the drainage or resection options is justified at the outset. Major hepatic resection would be grossly excessive, open surgical drainage is reserved for ruptured or refractory cases, and repeated aspiration is only a fallback if medication fails. The correct first action is therefore metronidazole therapy alone.
\[\boxed{\text{Metronidazole therapy only}}\]