Question-185

A 50 year old heavy alcoholic man came with ascitis, enlarged liver 4 cm below costal margin , his abdomen is tender and his temp. is 37.9 c his blood pressure is 100/60 which of the following is best treatment for current problem ?


a. IV metronidazole + amoxicillin
b. IV metronidazole + amoxicillin + gentamicin
c. Paracentesis
d. Oral amox. Clax.
e. IV albumin

It seems to me that patient is suffering pyogenic liver abscess.Some times AB could not be enough to treat the patient.Abdominal drain would be good idea which helps the patient to recover by AB .
So the first choice is C followed by B in this case . The standard AB therapy is using
a penicillin, an aminoglycoside and metronidazole. A third-generation cephalosporin can be considered in the elderly or if renal function is impaired.Howevre, the patient BP is 100/60 and option B is looking more reasonable


•Pyogenic liver abscess: broad spectrum antibiotics should be started before waiting for culture results. Use a penicillin, an aminoglycoside and metronidazole. A third-generation cephalosporin can be considered in the elderly or if renal function is impaired.[10] Antibiotic therapy can be modified once culture results are available. Treatment may be needed for up to 12 weeks and should be guided by the clinical picture and radiological monitoring.
•Amoebic liver abscess: metronidazole is the treatment of choice. 95% of patients with amoebic liver abscess recover with this alone. Most patients show a response to treatment within 72-96 hours.[16] Diloxanide furoate should be prescribed for 10 days to eliminate intestinal amoebae after the abscess has been successfully treated.
•Antifungal agents such as amphotericin B are used if fungal abscess is suspected.
•Drainage:
•Most patients with pyogenic liver abscess and those with very large amoebic abscesses, may not recover with antibiotics alone and need drainage guided by ultrasonography or CT.
•Percutaneous aspiration can be carried out for small abscesses although catheter drainage has become the standard of care. Larger abscesses may also need catheter drainage which is also CT- or ultrasound-guided. Drainage should also be carried out if there is impending rupture.
•Open surgery may be necessary if the abscess has ruptured and there are signs of peritonitis, if the abscess is larger than 5 cm or multiloculated, or if there is a known abdominal pathology such as appendicitis.