Gallstone with acute cholecystitis is one of the most common diseases in the clinic. If the disease is serious, gallbladder gangrene, perforation, and sepsis may be caused. Gallbladder diseases rarely cause thoracic-related complications, especially pleural fistula, which is very rare in clinical practice.

A 52-year-old male patient was admitted to the emergency department for 1 month with recurrent right middle and upper abdominal pain.

Computed tomography diagnosis: cholecystitis and peri-inflammation, small abscess around the base of the gallbladder, local peritonitis, and bilateral pleural effusion.

After admission, conservative treatment was given. On the 4th day of admission, the symptoms worsened, and an emergency catheter drainage was performed on the right thoracic cavity to extract 900 mL of dark yellow effusion. After the operation, a large amount of bili-like fluid was continuously drained from the thoracic drainage tube. After the iatrogenic biliary fistula caused by thoracic puncture was excluded, cholecystopleural fistula was considered to be cholecystopleural fistula. On the 6th day of admission, endoscopic retrograde cholangiopancreatography (ERCP) + cholecystography + Oddi sphincterotomy + laminating biliary stent was performed in the emergency department, and cholecystopleural fistula was confirmed during the operation.

The patient recovered well after surgery, computed tomography examination on the 20th day after surgery indicated that pleural effusion was significantly reduced, and the patient was cured and discharged. The patient returned to the hospital 8 months after the ERCP operation to pull out the bile duct-covered stent. The patient did not complain of any discomfort after the postoperative follow-up for 3 years, and no recurrence of stones, empyema, and other conditions was found.

Cholecystopleural fistula is one of the serious complications of acute cholecystitis, which is easy to misdiagnose clinically. If the gallbladder inflammation is severe, accompanied by pleural effusion, the pleural effusion is bili-like liquid, or the content of bilirubin is abnormally elevated, the existence of the disease should be considered. Once the diagnosis is clear, active surgical intervention is needed to reduce the occurrence of complications. Endoscopic therapy (ERCP) can be used as both a diagnostic method and an important minimally invasive treatment.

Amebic liver abscess (ALA) is still a common problem in the tropical world, where it affects over three-quarters of patients with liver abscess. It is caused by an anaerobic protozoan Entamoeba hystolytica, which primarily colonises the cecum. It is a non-suppurative infection of the liver consisting primarily of dead hepatocytes and cellular debris. People of the male gender, during their reproductive years, are most prone to ALA, and this appears to be due to a poorly mounted immune response linked to serum testosterone levels. ALA is more common in the right lobe of the liver, is strongly associated with alcohol consumption, and can heal without the need for drainage. While majority of ALA patients have an uncomplicated course, a number of complications have been described, including rupture into abdomino-thoracic structures, biliary fistula, vascular thrombosis, bilio-vascular compression, and secondary bacterial infection. Based on clinico-radiological findings, a classification system for ALA has emerged recently, which can assist clinicians in making treatment decisions. Recent research has revealed the role of venous thrombosis-related ischemia in the severity of ALA. Recent years have seen the development and refinement of newer molecular diagnostic techniques that can greatly aid in overcoming the diagnostic challenge in endemic area where serology-based tests have limited accuracy. Metronidazole has been the drug of choice for ALA patients for many years. However, concerns over the resistance and adverse effects necessitate the creation of new, safe, and potent antiamebic medications. Although the indication of the drainage of uncomplicated ALA has become more clear, high-quality randomised trials are still necessary for robust conclusions. Percutaneous drainage appears to be a viable option for patients with ruptured ALA and diffuse peritonitis, for whom surgery represents a significant risk of mortality. With regard to all of the aforementioned issues, this article intends to present an updated review of ALA.

Amoebic liver abscess is one frequently encountered intra-abdominal infection, caused by Entamoeba histolytica and has various abdominal and thoracic life-threatening complications. Herein, describe a case of a 30-year-old female, who suffered from multiple amoebic liver abscesses and presented with massive right-sided pleural effusion. She was managed with recommended antibiotics and pigtail catheter for liver abscess and an intercostal drainage tube for massive pleural effusion. However, postintercostal drainage, her chest X-ray demonstrated a right mediastinal shadow, which was confirmed as an intrathoracic extension of the hepatic liver abscess on computed tomography. An ultrasound-guided pigtail catheter was manipulated and placed at the site of thoracic communication. This led to clinical and radiological improvement, but unfortunately, she developed ventilator-acquired pneumonia and died due to her illness. The case represents an uncommon complication of amoebic liver abscess, which is rarely described and adds more knowledge on the thoracic complexities of this infectious disease.

Amebic liver abscesses (ALAs) are the most commonly encountered extraintestinal manifestation of human invasive amebiasis, which results from Entamoeba histolytica (E. histolytica) spreading extraintestinally. Amebiasis can be complicated by liver abscess in 9% of cases, and ALAs led to almost 50000 fatalities worldwide in 2010. Although there have been fewer and fewer cases in the past several years, ALAs remain an important public health problem in endemic areas. E. histolytica causes both amebic colitis and liver abscess by breaching the host's innate defenses and invading the intestinal mucosa. Trophozoites often enter the circulatory system, where they are filtered in the liver and produce abscesses, and develop into severe invasive diseases such as ALAs. The clinical presentation can appear to be colitis, including upper-right abdominal pain accompanied by a fever in ALA cases. Proper diagnosis requires nonspecific liver imaging as well as detecting anti-E. histolytica antibodies; however, these antibodies cannot be used to distinguish between a previous infection and an acute infection. Therefore, diagnostics primarily aim to use PCR or enzyme-linked immunosorbent assay to detect E. histolytica. ALAs can be treated medically, and percutaneous catheter drainage is only necessary in approximately 15% of cases. The indicated treatment is to administer an amebicidal drug (such as tinidazole or metronidazole) and paromomycin or other luminal cysticidal agent for clinical disease. Prognosis is good with almost universal recovery. Establishing which diagnostic methods are most efficacious will necessitate further analysis of similar clinical cases.

In its classic form, amebic liver abscess (ALA) is a mild disease, which responds dramatically to antibiotics and rarely requires drainage. However, the two other forms of the disease, i.e., acute aggressive and chronic indolent usually require drainage. These forms of ALA are frequently reported in endemic areas. The acute aggressive disease is particularly associated with serious complications, such as ruptures, secondary infections, and biliary communications. Laboratory parameters are deranged, with signs of organ failure often present. This form of disease is also associated with a high mortality rate, and early drainage is often required to control the disease severity. In the chronic form, the disease is characterized by low-grade symptoms, mainly pain in the right upper quadrant. Ultrasound and computed tomography (CT) play an important role not only in the diagnosis but also in the assessment of disease severity and identification of the associated complications. Recently, it has been shown that CT imaging morphology can be classified into three patterns, which seem to correlate with the clinical subtypes. Each pattern depicts its own set of distinctive imaging features. In this review, we briefly outline the clinical and imaging features of the three distinct forms of ALA, and discuss the role of percutaneous drainage in the management of ALA.

Amebic liver abscess is the most common type of liver abscess on a worldwide basis, with caudate lobe being a relatively uncommon location for its occurrence. Abscess in caudate lobe of liver is often considered a challenging location for image-guided percutaneous drainage due to its difficult-to-access location along with close relationship with major vessels at porta hepatis.

This study aims to demonstrate safety and efficacy of percutaneous drainage for caudate lobe amebic abscess.

In this retrospective study, hospital database was electronically searched for patients having caudate lobe amebic abscess that underwent percutaneous catheter drainage/needle aspiration (PCD/PNA) between January 2016 and January 2021. The etiology, risk factors, microbiology, complications, different approaches for PCD/PNA, and their outcome were studied and reported.

Of 30 patients having caudate lobe amebic abscess treated with PCD/PNA, solitary caudate lobe abscess was seen in 29, whereas one patient had more than one abscesses in caudate lobe. Contained and free intraperitoneal rupture of the abscess were seen in 9 (30%) and one patient, respectively. Ten (32%) patients had associated vascular thrombosis, while 2 patients were found to have abscess-biliary communication. Twenty-six (86.7%) patients were treated with PCD, while remaining 4 (13.3%) with PNA. On Univariate analysis, factors such as volume, multilocularity, and contained rupture of the abscess were found to be significantly increasing the duration of percutaneous drainage (PCD), while only multilocularity (p value 0.007) continued to show statistical significance on Multivariate analysis. Venous thrombosis and duration of catheter drainage were the two factors found to have significant influence on the length of hospital stay on Univariate as well as Multivariate analysis (p value 0.05 and 0.001, respectively). The rates of catheter manipulation were also significantly higher in patients with abscess showing complex internal configuration (heteroechoic contents and/or multilocularity). Technical and clinical success rates of 100% and 96.7% were achieved through percutaneous interventions (PCD/PNA), despite the complex location of abscesses and associated complications, with no incidence of vascular injury.

Liver abscess in caudate lobe can be accessed by different routes for percutaneous drainage, despite being surrounded by large vessels and its deep location, without major complications. Thus, PCD/PNA may be considered as a first-line therapy for the management of caudate lobe amebic abscesses in adjunct to medical therapy.

Percutaneous catheter drainage (PCD) is the mainstream treatment for pyogenic liver abscess (PLA). However, in some patients with severe coagulopathy, there may increase the risk of bleeding complications related to PCD. Therefore, this study was aimed to evaluate the incidence of bleeding complications of PCD in PLA patients complicated with coagulopathy.

Between January 2011 and September 2019, patients diagnosed with PLA who had undergone PCD were selected retrospectively. Based on the preoperative coagulation parameters, the patients were divided into the coagulopathy group (PLT ≤ 50 × 10⁹/L or INR ≥ 1.5) and the normal coagulation group. The major and minor bleeding complications related to PCD were compared between the two groups. The ICU occupancy and mortality rates in the coagulopathy group were assessed and compared with patients of normal coagulation group.

A total of 583 PLA patients subjected to PCD were selected. 522 patients were finally included in this study: 64 cases (12.26%) in the coagulopathy group and 458 cases (87.74%) in the normal coagulation group. No major bleeding complications related to PCD was observed. Two patients (0.38%) of minor bleeding complications, one patient in each group, showed no statistically significant difference (0.2% vs.1.6%, P > 0.05). The ICU occupancy rate of coagulopathy group was significantly higher than normal coagulation group (6.2% vs. 0.7%, P < 0.05). No significant difference in mortality rate was noted between the two groups (4.7% vs.1.5%, P > 0.05).

The incidence of bleeding complications related to PCD in PLA patients is rare even if complicated with coagulopathy.

To identify different morphological types of amebic liver abscess (ALA) based on CT findings and to assess whether they have different clinical features.

CT images of 112 symptomatic patients with ALA were analyzed to identify the imaging features distinctive of each morphological type. The following CT findings were investigated: the presence of abscess wall, rim enhancement, edge characteristic, septa, intermediate density zone, and peripheral hypodensity. Abscesses from each type were further evaluated for their clinical presentations, laboratory findings and outcomes.

We identified three types of ALAs: type I, II and III. Type I abscesses (66%) were characterized by absent or incomplete walls, ragged edges and peripheral septa; their edges exhibited irregular and interrupted enhancement. Type II (28%) had a complete wall characterized by rim enhancement and peripheral hypodense halo. Type III (6%) demonstrated a wall but without enhancement. Clinically, type I abscesses presented acutely with severe disease. They had significantly deranged laboratory parameters, higher incidence of rupture and higher rate of inpatient or intensive care unit admission. The severity of the disease prompted immediate percutaneous drainage in most type I abscesses (81%). Two of them died from multiple organ failure. The type II or III abscesses, on the other hand, had delayed presentations with mild to moderate disease, with near normal laboratory findings.

ALAs have three different CT morphological types, with different clinical and laboratory features. Percutaneous drainage is indicated in most of type I abscesses.

Pleuropulmonary amoebiasis caused by complications of amoebic liver abscess (ALA) is rare.

A 23 years old male, presented with shortness of breath, cough with yellowish phlegm, right chest pain, fever, bulging stomach, yellow eyes, and swelling of both legs. Abdominal ultrasound and CT scan thorax and abdomen revealed right fluidopneumothorax and liver abscess. Serological testing leads to Entamoeba histolytica infection, which was treated with metronidazole but no significant improvement on empyema and abscess liver size. Surgery was performed after percutaneous aspiration drainage failed to evacuate the abscess. HE and PAS staining from surgical tissue showed Entamoeba hystolitica infection.

Serological testing and radiological examination will be more useful in the early detection of cases of Entamoeba hystolitica infection. Surgery may be considered when purulent drainage does not show improvement in the patient's condition.

ALA complication that causes pulmonary empyema can be surgically treated if the pus cannot be drained.

Patients with amoebic liver abscess (ALA) may require percutaneous catheter drainage (PCD). Once the PCD output is substantially reduced or has ceased along with clinical recovery, residual collections on radiological evaluation may concern the treating physicians. The prevalence and significance of such collections is unknown, and the subsequent approach how to tackle them is unclear.

Consecutive patients with one or more uncomplicated ALAs requiring drainage were prospectively enrolled from 3 hospitals and managed based on a standard approach. Catheter removal was attempted after the patients fulfilled all 4 of the following criteria: disappearance of abdominal pain, absence of fever for at least 48 h, an improving trend of TLC (documented on 2 consecutive reports), and catheter drain output of < 10 ml/day for at least 2 consecutive days.

A total of 110 patients (mean age 46.6 ± 10.5 years, 93.6% males, 89.1% alcoholics) underwent PCD placement; 69 patients (69/110; 62.7%) met all 4 criteria within 5 days of PCD placement (optimal response) and had an uncomplicated course. Patients with suboptimal responses (41/110; 37.3%) were evaluated for local and systemic complications; the appearance of fresh collections (5/110; 4.5%), abscess rupture (2/110; 1.8%), bile leakage (3/110; 2.7%), cholangitis (2/110; 1.8%), thrombophlebitis (2/110; 1.8%) and hospital-acquired infections (2/110; 1.8%) were diagnosed and treated accordingly. Ultimately, PCD removal (based on the fulfilment of all 4 criteria) was universally successful after a median of 5 days (IQR, 4-9 days). None of the patients had symptom recurrence after PCD removal, although residual collections were still seen in 97.3% of patients at the time of PCD removal and in 92.1% and 84.9% of patients available for follow-up at 1 and 3 months, respectively.

Based on our clinical protocol, PCD removal in ALA can be successfully expedited even in the presence of residual collections. An inability to fulfill all 4 criteria within 5 days of PCD placement warrants further evaluations for local and systemic complications that require additional therapeutic measures.

A man in his 60s visited a clinic with chief complaints of a fever and general malaise. Suspecting a liver abscess in the left lobe with infiltration into the subcutaneous fat tissue under the rectus abdominis muscle based on computed tomography findings, we performed fine-needle aspiration. An amoebic liver abscess was diagnosed. Remission was achieved by the oral administration of metronidazole alone without placement of a drainage tube. The results obtained in this case suggest that the first line of treatment should be a non-invasive approach with oral administration alone. Invasive intervention should then be considered depending on subsequent progress.

To report venous thrombosis and associated perfusion defect in amebic liver abscess (ALA) using MDCT.

MDCT images of 62 patients with ALA were reviewed for venous thrombosis and associated perfusion abnormalities.

The study found 43 (69%) patients with venous thrombosis: portal vein thrombosis (PVT) occurred in 39, hepatic vein thrombosis (HVT) in 37 and inferior vena cava (IVC) thrombosis in 4. Combined PVT and HVT occurred in 33 (77%) patients. The portal vein thrombi remained localized in subsegmental branches in 25 patients and extended to segmental branches in 14. The hepatic vein thrombi were confined to peripheral branches in 18 patients; they progressed to the main trunk in 19 and to the IVC in 4. A wedge-shaped hypoattenuating zone suggesting ischemia was identified in 33 (77%) patients in portal phase: 31 had combined PVT and HVT, 2 had HVT alone, but none had PVT alone. It occurred significantly more often with combined PVT and HVT than HVT alone (p = 0.05). Arterial phase enhancement occurred in 2 of 13 patients with multiphasic CT. All patients were symptomatic despite medical therapy and therefore required percutaneous drainage. About half of the patients were identified with ruptured abscesses. Segmental atrophy was observed in seven of nine patients who underwent follow-up CT.

Combined PVT and HVT commonly occur with ALA and often manifests as segmental hypoperfusion in portal venous phase, indicating ischemia. The detection of such events by CT may be indicative of severe disease that requires aggressive management involving percutaneous drainage.

To report venous thrombosis and associated perfusion defect in amebic liver abscess (ALA) using MDCT.

MDCT images of 62 patients with ALA were reviewed for venous thrombosis and associated perfusion abnormalities.

The study found 43 (69%) patients with venous thrombosis: portal vein thrombosis (PVT) occurred in 39, hepatic vein thrombosis (HVT) in 37 and inferior vena cava (IVC) thrombosis in 4. Combined PVT and HVT occurred in 33 (77%) patients. The portal vein thrombi remained localized in subsegmental branches in 25 patients and extended to segmental branches in 14. The hepatic vein thrombi were confined to peripheral branches in 18 patients; they progressed to the main trunk in 19 and to the IVC in 4. A wedge-shaped hypoattenuating zone suggesting ischemia was identified in 33 (77%) patients in portal phase: 31 had combined PVT and HVT, 2 had HVT alone, but none had PVT alone. It occurred significantly more often with combined PVT and HVT than HVT alone (p = 0.05). Arterial phase enhancement occurred in 2 of 13 patients with multiphasic CT. All patients were symptomatic despite medical therapy and therefore required percutaneous drainage. About half of the patients were identified with ruptured abscesses. Segmental atrophy was observed in seven of nine patients who underwent follow-up CT.

Combined PVT and HVT commonly occur with ALA and often manifests as segmental hypoperfusion in portal venous phase, indicating ischemia. The detection of such events by CT may be indicative of severe disease that requires aggressive management involving percutaneous drainage.

Liver abscesses are mainly caused by parasitic or bacterial infection and are an important cause of hospitalization in low-middle income countries (LMIC). The pathophysiology of abscesses is different depending on the etiology and requires different strategies for diagnosis and management. This paper discusses pathophysiology and epidemiology, the current diagnostic approach and its limitations and management of liver abscess in low resource settings.

We searched PubMed for relevant reviews by typing the following keywords: 'amoebic liver abscess' and 'pyogenic liver abscess'.

Amoebic liver abscess can be treated medically while pyogenic liver abscess usually needs to be percutaneously drained and treated with effective antibiotics.

In an LMIC setting, where misuse of antibiotics is a recognized issue, liver abscesses are a therapeutic conundrum, leaving little choices for treatment for physicians in low capacity settings.

As antimicrobial resistance awareness and antibiotic stewardship programs are put into place, liver abscess management will likely improve in LMICs provided that systematic adapted guidelines are established and practiced.

The lack of a quick and reliable diagnostic strategy in the majority of LMIC makes selection of appropriate treatment challenging.

The role of metronidazole alone, percutaneous aspiration (PA), and percutaneous catheter drainage (PCD) in the treatment of uncomplicated amebic liver abscess (ALA) is still unclear. This systematic review and meta-analysis evaluated the available evidences with regard to treatment modalities in such patients.

The database was searched for relevant randomized controlled trials (RCTs) published until May 2019. All studies were assessed for risk of bias. The relevant data were pooled in a random or fixed-effect model to calculate the mean difference (MD) or relative risks.

After the detailed screening, 570 patients from 10 RCTs comparing metronidazole alone with metronidazole + PA were included. Most studies had uncertain risk of biases. Days to resolution of abdominal pain (MD - 1.59, 95% confidence interval [CI] - 2.77, - 0.42, I2 = 89%) and tenderness (MD - 1.76, 95% CI - 2.93, - 0.58, I2 = 72%) were significantly shorter in the metronidazole + PA group. There was no significant difference in relation to the resolution of fever, abscess size, and hospital stay. The beneficial effects of PA were seen with medium-to-large (> 5 cm) ALA and not with small (< 5 cm) ALA. Addition of PCD to metronidazole therapy was better than metronidazole alone in one low-quality RCT. Two RCTs found PCD to be better than PA for large ALA.

Percutaneous aspiration as compared with metronidazole alone results in the early resolution of pain and tenderness in patients with medium-to-large ALA. Percutaneous catheter drainage is better for larger ALA. However, discrepancies in RCTs create therapeutic dilemmas necessitating further efforts to generate more reliable data.

Amoebic liver abscess (ALA) is a common clinical problem in tropical countries related to poor sanitation. The epidemiology and clinical presentation of ALA in Fiji has not been previously described. It is unclear whether percutaneous aspiration (PA) or percutaneous catheter drainage (PCD) has better outcomes.

The aims were to describe the epidemiology and clinical presentation of ALA in Fiji and to compare the outcomes of PA and PCD for treatment of ALA.

A retrospective case note review of patients treated with either PA or PCD between 2010 and 2015 was performed. Indications for intervention were ALA > 5 cm, ALA in the left lateral lobe, risk of imminent rupture and failure to respond to medical treatment.

There were 262 patients, 90% were male, 92.9% I-Taukei ethnicity and 86.2% regular recreational kava drinkers. Most presented with upper abdominal pain and fevers. The majority (90.3%) had a single abscess with 87.8% being in the right lobe. 174 (66.4%) had LA and 88 (33.6%) had PCD. There was an unintended selection bias for PA in abscess with a volume of <1 litre. PA was associated with a more rapid resolution of fever and shorter hospital stay, more rapid resolution of the cavity and no morbidity. PCD had five complications, one bleed and four bile leaks. There was no mortality in either group.

ALA in Fiji occurs in I-Taukei males who drink kava. PA appears to offer equivalent if not better outcomes for treatment of ALA.

Intrahepatic pseudoaneurysm (IHPA) is generally iatrogenic, and it warrants urgent management because of its reportedly significant risk of rupture leading to considerable mortality. Intrahepatic pseudoaneurysm caused by amebic liver abscess (ALA) is exceedingly rare with fewer than seven published reports. All reported symptomatic cases have been treated with hepatic artery embolization; therefore, little is known about its natural course and effect of abscess drainage on its outcome. We report the first case of symptomatic intracavitary IHPA caused by ALA in which ultrasound-guided percutaneous catheter drainage of the abscess resulted in the spontaneous resolution of the IHPA.

Amoebic peritonitis secondary to rupture of amoebic liver abscess (ALA) has been reported to occur in 2.4 to 13% of cases with a high fatality rate. There is still no consensus as to how a ruptured ALA associated with diffuse amoebic peritonitis be optimally managed. The mortality rates following surgical therapy in patients with ruptured ALA freely into the peritoneum have ranged from 20%- to 50%. The introduction of percutaneous catheter drainage (PCD) has opened a new therapeutic possibility for this group of patients and emerging data suggest that PCD should be the preferred option in such group of patients.