Type of Article: Original Research Article

A comparitive study of needle aspiration and pigtail catheter drainage in management of

liver abscess

ABSTRACT

Background: Liver abscess used to be associated with high mortality prior to the availability of
percutaneous drainage techniques. Ultrasound guided per cutaneous drainage of liver abscess in
combination with parenteral antibiotic therapy gained acceptance now a days s and is the
procedure of choice in majority of cases. Patients who failed to respond to per cutaneous
aspiration, and those with poor compliance to therapy are candidates for surgical drainage.

Aim: To compare the therapeutic effectiveness of intermittent needle aspiration and pigtail
catheter drainage in manegment of liver abscess.

Methods: : A comparative study was carried out among 60 subjects attending Department of
Surgery, K.R.Hospital, Mysuru over a period of 12 months. Subjects of either sex with
diagnosed cases of pyogenic and amoebic liver abscess were included in the study. Patients
with poor compliance, ruptured liver abscess, uncertain diagnosis, terminal disease and liver
malignancy were excluded from the study.

Results: The mean age group of the study subjects was 44.6 (range 38-84) years. The gender
distribution showed a higher number of males (53) as compared to females (7). Needle
aspiration procedure showed a better outcome statistically as compared to pigtail drainage.
Two patients in catheter drainage groups required surgery due to persistent sepsis and
inadequate drainage.

Conclusions: Per cutaneous intermittent needle aspiration is easier, simpler and less expensive
preferred method of drainage as compared to pigtail catheter drainage approach for liver abscess.

Keywords: Per cutaneous drainage , Pigtail catheter, Intermittent needle aspiration.

Introduction

Liver Abscess is a common condition in india which is associated with high morbidity and
mortality. It is the disease of tropical regions. The aetiology is broadly classified as
amoebic origin and pyogenic origin. Although liver abscess was historically managed with
surgery; advances in imaging techniques have resulted in the shift to minimally invasive
interventional procedures which can either be per cutaneous needle aspiration or pigtail
1
catheter drainage .

50 Million cases of entamoeba histolytica has been reported by WHO and it is the most
commonest cause of liver abscess in developing countries like India. It affects many people
below poverty line and those living under unsanitary conditions. pyogenic liver abscess is
more common in developing parts of the world .. Ascending infection of the biliary tree
secondary to obstruction is now the most commonly identifiable cause of pyogenic liver
abscess. The aetiology of biliary obstruction in Western countries is due to malignant disease,
while in Asia, gall stone disease and hepatolithiasis are more common aetiologies. Immuno
suppression associated with AIDS, intensive chemotherapy or organ transplantation is also
increasing the number of liver abscesses due to infection with opportunistic organisms in
2
India .

Liver abscess can be potentially fatal without treatment, resulting in mortality rates ranging
from 60-80%. However, the advances in imaging facilities like ultrasonography and CT
scan for diagnoses, together with image guided interventions had resulted in a successful
outcome rate ranging from 75-100% for treatment of liver abscess, These interventions
decreased mortality to 5-30%, where as in past, surgical intervention was associated with
significant morbidity and mortality ranging from 10-47% the surgical intervention has now
3
becoming unnecessary .

Primary prevention by improving sanitation, health education, early diagnosis and prompt
treatment may result in lowering mortality associated with the disease. Primary mode of
treatment of amoebic abscess is medical; however many cases are refractory to medical
therapy. Also secondary bacterial infection may complicate about 20% of amoebic liver
abscess. In such patients and in patients with pyogenic liver abscess either per cutaneous
aspiration of abscess by a needle or per cutaneous drainage by an indwelling pig tail catheter
4
may be required. .

Our Study aims to compare the therapeutic effectiveness of intermittent needle aspiration with
pigtail catheter drainage, in management of liver abscess.

Materials And Methods

After obtaining Institutional ethical committee approval, a prospective, open label,

randomized, comparative, single centered study was conducted among 60 subjects attending
General Surgery OPD, K.R. Hospital, Mysuru. All subjects, meeting the inclusion and
exclusion criteria were included in the study, over a period of 12 months (Jan – Dec 2016) . a
written informed consent using a purposive sampling technique was obtained from all study
subjects..
Subjects of either sex with diagnosed cases of pyogenic and amoebic liver abscess were
included in the study. Patients with poor compliance, ruptured liver abscess, uncertain
diagnosis, terminal disease and liver malignancies were excluded from the study.

Descriptive statistics, Unpaired t-test, Fischer Exact Chi-square test were used to analyse the
results.

Results

During the 12 months study period, 30 patients underwent needle aspiration and 30 patients
underwent liver abscess treatment by pigtail catheter drainage. The mean age group of the
study subjects was 44.6 (range 24-66) years. The gender distribution showed 55 males
(91.67%) as compared to 5 females (8.33%). Mixed type of liver abscess 48(80%) were
predominant over amoebic 10(16.67%) and intermediate type 2(3.33%). All the pyogenic
abscesses were found in association with amoebic etiology.

Frequency of symptoms include pain abdomen in all the patients 60(100%), fever a more
consistent symptom 58(96.67%), malaise a non specific symptom in 38(63.33%) jaundice
was present in 11(18.33%), respiratory symptoms like cough and dyspnoea were present in
29 (48.33%) and in 26 (43.33%) respectively. 16 (26.66%) of patients had previous history
of liver abscess and 3 (5%) patients with previous history of systemic illness. 47 (78.33%)
cases were known alcoholics and 13 (21.67%) cases were non-alcoholic. Abdominal
tenderness was elicited in right hypochondrium to epigastrium in 60 (100%) of the cases. 51
(85%) cases had hepatomegaly with 7 (11.67%) showed signs of peritonitis.

Klebsiella and E.coli were the most commonest organisms cultured in 14 (18.33%), 7
(11.67%) cases were positive for entoamoeba histolytica,. S.aureus , enterobacter and
acinetobacter were cultured in 5 (8.33%), 3 (5%) and 2 (3.33%) cases respectively. 29 cases
yielded no growth in culture.

Isolated right lobe liver abscess was the most common finding seen in 49 (81.67%) cases.
8(13.33%) cases showed isolated left lobe abscess and 3 (5%) cases had abscess in both the
lobes. 14 (23.33%) cases had single abscess cavity and 46 (76.67%) cases had multiple
abscesses.

Per cutaneous needle aspiration was successful in all 30 patients. The mean cavity volume in
percutaneous needle aspiration was found to be 236+/- 94ml (p 0.003). Pigtail catheter
drainage was successful only in 28 patients. Patients who underwent per cutaneous needle
aspiration showed early clinical improvement in 5.6 +/- 1.4 days. Repeated aspirations were
possible to approach multiple abscess cavities There was 50% decrease in abscess cavity
volume in 6.1+/- 1.6 days. Two patients in catheter drainage groups required surgery due to
persistent sepsis and inadequate drainage. Duration of hospital stay or time required for near
total resolution of cavity was same in both the groups.(TABLE 1)

Discussion

The liver abscess is mainly classified into amoebic and pyogenic. Pyogenic liver abscess
which used to be mainly encountered in tropical regions, is now more common due to
increased biliary interventions, stenting, cholecystitis, cholangitis etc. Liver abscess is 3 to 10
4
times more common in men . Per cutaneous drainage (either needle aspiration or catheter
drainage) with systemic antibiotic therapy has become the preferred treatment for the
5
management of pyogenic liver abscesses . In contrast, for amebic abscesses, the primary
mode of treatment is medical; however, as many as 15%of these may be refractory to medical
therapy, while 20% may be complicated by secondary bacterial infection. Such amoebic
abscesses and those involving left lobe, or those with impending rupture also need to be
drained. Open Surgical drainage is now undertaken only in cases which fail to respond to
6
percutaneous drainage .

Although, Pigtail drinage is a preferred method most widely used to drain liver abscesses,
recent studies have shown percutenous needle aspiration to be simpler, less costly, and
equally effective. Usually needle aspiration is preferred for smaller abscesses and catheter
drainage is done in larger ones. But no clear cut guidelines are available to guide the choice
7
of the technique. .

Several previous prospective randomized studies have compared percutaneous needle

aspiration with pigtail catheter. There are many reports with reasonably good results in
8
percutaneous needle aspiration along with systemic antibiotics . Giorgio et al performed on
an average 2.2 aspirations in 115 patients and reported resolution of symptoms and hepatic
lesions in 98% of the patients. In our study we treated 30 patients with per cutaneous needle
aspiration incombination with systemic antibiotics. Of these 30 patients, all were successfully
treated, 6 required only one aspiration, 14 required a second aspiration and 10 patients
required a third aspiration as well. Thus, 30 patients who were successfully treated with
aspiration required an average of 2.2 aspirations. The mean duration of time taken for clinical
improvement was 5.6+/- 1.4 days (p 0.0021) in the percutaneous aspiration group.. Rajak et
9
al reported a success rate of 60% with needle aspiration. However, in their study only two
attempts of aspiration were made and failure to attain clinical, hematological and radiological
improvement was taken as failure of therapy. The success rate of PNA in the literature varies
from 79-100%. The success rate in our study after single aspiration was 20%, after second
aspiration 66.67% and after third aspiration it was 100%.

The average size of abscess in our study was 322+/- 106 ml and 236+/- 94 ml for the pigtail
drainage and percutaneous needle aspiration group respectively, comparable to the study
9
reported by Rajak et al (335 mL and 221 mL respectively) . The success rate achieved by
9
Rajak et al was 60%, comparable to 66.67% success rate after the second aspiration in our
study. Subsequent aspirations seem to improve the success rate of therapy.
 10
Singh and Kashyap , 1989 reported a 15% incidence of secondary bacterial contamination
11 8
after repeated needle aspirations; however, others (Baek SY et al , Giorgio et al , Rajak et
9
al ) have not encountered this problem. Although secondary bacterial infection remains a
possibility with indwelling drainage catheters this complication has been rarely reported in
liver abscess. Complications such as hemorrhage, pleural effusion/empyema, persistent bile
drainage, catheter displacement, sepsis etc., have been reported with both PNA (4% in series
11 12 11
of Baek SY et al ) and PCD (12% in the series of Lambiase et al ). Baek SY et al and
8
Giorgio et al described the much lower incidence of complications with PNA than with PCD
as one of the major advantages of needle aspiration over catheter drainage. However, in our
9 13
study and some recent studies (Rajak et al 1998, Yu et al 2004), both the procedures were
found to be safe if performed properly with minimal complications. There was no mortality
in either of the study groups.

However there were few limitations in our study which include; small sample size, open
label, hospital based and single center study. Further studies to evaluate , and to overcome
the above limitations is highly recommended.

Conclusion

Percutaneous intermittent needle aspiration is easier, simpler and less expensive preferred
method of drainage as compared to pigtail catheter drainage for liver abscess.

Funding

No funding sources.

Conflict of interest

Not declared.

Ethical approval

The study was approved by institutional ethical committee.

References

1. Sherlock S, Dooley J. 9th ed. Oxford: Blackwell Sci Pub; 1993. Diseases of the liver
and billiary system; pp. 471–502.
2. David A, Pawlosky ZS.: Amoebiasis and its control. A WHO meeting. Bulletin of
WHO. 1985 Dec; 63(6): 417-426.

3. Seeto RK, Rockey DC. Pyogenic liver abscess. Changes in etiology, management,
and outcome. Medicine (Baltimore) 1996;75:99–113.

4. Gerzof SG, Johnson WC, Robbins AH, Nabseth DC. Intrahepatic pyogenic abscesses:
treatment by percutaneous drainage. Am J Surg. 1985;149:487–494.

5. Sepulveda B, Manzo NTG. Clinical manifestations and diagnosis of amebiasis. In:

Martinez-Palomo A, editor. Amebiasis: Human Parasitic Diseases. No. 2. Amsterdam:
Elsevier; 1986. pp. 169–187.

6. Petri A, Hohn J, Hodi Z, Wolfard A, Balogh A. Pyogenic liver – 20 years' experience.

Comparison of results of treatment in two periods. Langenbecks Arch Surg.
2002;1:27–31. doi:10.1007/s00423-002-0279-9.

7. Rahimian J, Wilson T, Oram V, Holzman RS. Pyogenic liver abscess: recent trends in
etiology and mortality. Clin Infect Dis. 2004;11:1654–9.

8. Giorgio A, Tarantino L, Mariniello N, et al. Pyogenic liver abscesses: 13 years of

experience in percutaneous needle aspiration with US guidance. Radiology.
1995;195:122–124.

9. Rajak CL, Gupta S, Jain S, Chawla Y, Gulati M, Suri S. Percutaneous treatment of

liver abscesses: needle aspiration versus catheter drainage. AJR. 1998;170:1035–
1039.

10. Singh JP, Kashyap A. A comparative evaluation of percutaneous catheter drainage for
resistant amebic liver abscesses. Am J Surg. 1989;158:58–62.

11. Baek SY, Lee MG, Cho KS, Lee SC, Sung KB, Auh YH. Therapeutic percutaneous
aspiration of hepatic abscesses: effectiveness in 25 patients. AJR. 1993;160:799–802.

12. Do H, Lambiase RE, Deyoe L, Cronan JJ, Dorfman GS. Percutaneous drainage of
hepatic abscesses: comparison of results in abscesses with and without intrahepatic
biliary communication. AJR. 1991;157:1209–1212.

13. Yu SCH, Ho SSM, Lau WY, et al. Treatment of pyogenic liver abscess: prospective
randomized comparison of catheter drainage and needle aspiration. Hepatology.
2004;39:932–938.