Amoebic liver abscess differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Yamuna Kondapally, M.B.B.S[2]

Overview

Amoebic liver abscess must be differentiated from other diseases that cause fever, abdominal pain, cough, jaundice, hepatomegaly, anorexia, nausea, vomiting, and pale or dark stools such as pyogenic liver abscess, fungal liver abscess, echinococcal cyst, and hepatocellular carcinoma.

Differential Diagnosis

Amoebic liver abscess must be differentiated from:

Disease	Causes	Signs and Symptoms											Laboratory Findings	Imaging Findings	Other Findings
		Fever	Pain		cough	Hepatomegaly	Jaundice	Weight loss	Anorexia	Diarrhoea or Dysentry	Nausea and vomiting	Stool
			Abdominal pain (right upper quadrant pain)	Pleuritic pain
Amoebic liver abscess	Entamoeba histolytica	+++	+++	+/-	+	++/-	+ (late stages)	+ (late stages)	+	+	+		Hypoalbuminemia (+)	Ultrasound is the gold standard technique for diagnosing amoebic liver abscess	Responds well to chemotherapy and rarely require drainage Marked male predominance More common in developing countries Sero-positive Right lobe is more frequently involved
Pyogenic liver abscess	Bacteria Gram-positive aerobes Gram-negative enterics Anaerobic organisms Acid-fast bacilli	+	+	++	++	+/-	+++	+ (acute loss)	+		+	Pale/dark	Hypoalbuminemia (+++)	Cluster sign CT scan shows cluster sign Aggregation of multiple low attenuation liver lesions in a localized area to form a solitary larger abscess cavity	Abnormal pulmonary findings Diabetes mellitus increases the risk Medical-surgical approach is indicated More common in developed countries Culture positive and seronegative Both lobes are commonly involved
Fungal liver abscess	Candida species Aspergillus species	+	+	+-	+	+	+	+	+	+	+			CT and USG findings with four patterns of presentation: Wheel-within-a-wheel pattern Bull’s-eye configuration pattern Uniformly hypoechoic nodule Echogenic foci with variable degrees of posterior acoustic shadowing	Less common Pure fungal abscess or associated with pyogenic abscess Candida and Aspergillus are commonly found in the culture of aspirated pus Associated with underlying malignancy or DM
Echinococcal (hydatid) cyst	Echinococcus granulosus		+		+		+ (Obstructive jaundice)	+	+				Histology: Hydatid cyst with three layers a.The outer pericyst, which corresponds with compressed and fibrosed liver tissue b.The endocyst, an inner germinal layer c.The ectocyst, a thin, translucent interleaved membrane	Ultrasound: Cystic to solid-appearing pseudotumors Water lily sign Calcifications seen peripherally	Blood or liquid from the ruptured cyst may be coughed up Pruritis
Malignancy (Hepatocellular carcinoma/Metastasis)	Hepatitis B and C Aflatoxins Alcohol Hemochromatosis Alpha 1 antitrypsin deficiency Nonalcoholic fatty liver disease	+	+ (uncommon)			+	+	++			++	Pale/Chalky	High levels of AFP in serum Abnormal liver function tests	Liver biopsy	Other symptoms: Splenomegaly Variceal bleeding Ascites Spider nevi Asterixis