Pyogenic liver abscess differential diagnosis: Difference between revisions

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==Overview==
==Overview==
Pyogenic liver abscess must be differentiated from other diseases with similar presentation such as amoebic liver abscess, fungal liver abscess, echinococcal (hydatid) cyst and malignancy (hepatocelluar carcinoma or metastasis).<ref name="pmid15189463">{{cite journal| author=Lodhi S, Sarwari AR, Muzammil M, Salam A, Smego RA| title=Features distinguishing amoebic from pyogenic liver abscess: a review of 577 adult cases. | journal=Trop Med Int Health | year= 2004 | volume= 9 | issue= 6 | pages= 718-23 | pmid=15189463 | doi=10.1111/j.1365-3156.2004.01246.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15189463  }} </ref><ref name="pmid5054724">{{cite journal| author=Barbour GL, Juniper K| title=A clinical comparison of amebic and pyogenic abscess of the liver in sixty-six patients. | journal=Am J Med | year= 1972 | volume= 53 | issue= 3 | pages= 323-34 | pmid=5054724 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=5054724  }} </ref><ref name="pmid3316923">{{cite journal| author=Barnes PF, De Cock KM, Reynolds TN, Ralls PW| title=A comparison of amebic and pyogenic abscess of the liver. | journal=Medicine (Baltimore) | year= 1987 | volume= 66 | issue= 6 | pages= 472-83 | pmid=3316923 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3316923  }} </ref><ref name="pmid3945889">{{cite journal| author=Conter RL, Pitt HA, Tompkins RK, Longmire WP| title=Differentiation of pyogenic from amebic hepatic abscesses. | journal=Surg Gynecol Obstet | year= 1986 | volume= 162 | issue= 2 | pages= 114-20 | pmid=3945889 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3945889  }} </ref>
[[Pyogenic liver abscess]] must be differentiated from other diseases with similar presentation such as [[amoebic liver abscess]], [[liver|fungal liver abscess]], [[Echinococcosis|echinococcal (hydatid) cyst]] and [[malignancy]] ([[Hepatocellular carcinoma]] or [[metastasis]]).<ref name="pmid15189463">{{cite journal| author=Lodhi S, Sarwari AR, Muzammil M, Salam A, Smego RA| title=Features distinguishing amoebic from pyogenic liver abscess: a review of 577 adult cases. | journal=Trop Med Int Health | year= 2004 | volume= 9 | issue= 6 | pages= 718-23 | pmid=15189463 | doi=10.1111/j.1365-3156.2004.01246.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15189463  }} </ref><ref name="pmid5054724">{{cite journal| author=Barbour GL, Juniper K| title=A clinical comparison of amebic and pyogenic abscess of the liver in sixty-six patients. | journal=Am J Med | year= 1972 | volume= 53 | issue= 3 | pages= 323-34 | pmid=5054724 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=5054724  }} </ref><ref name="pmid3316923">{{cite journal| author=Barnes PF, De Cock KM, Reynolds TN, Ralls PW| title=A comparison of amebic and pyogenic abscess of the liver. | journal=Medicine (Baltimore) | year= 1987 | volume= 66 | issue= 6 | pages= 472-83 | pmid=3316923 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3316923  }} </ref><ref name="pmid3945889">{{cite journal| author=Conter RL, Pitt HA, Tompkins RK, Longmire WP| title=Differentiation of pyogenic from amebic hepatic abscesses. | journal=Surg Gynecol Obstet | year= 1986 | volume= 162 | issue= 2 | pages= 114-20 | pmid=3945889 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3945889  }} </ref>


==Differential Diagnosis==
==Differential Diagnosis==
Pyogenic liver abscess must be differentiated from:<ref name="pmid15189463">{{cite journal| author=Lodhi S, Sarwari AR, Muzammil M, Salam A, Smego RA| title=Features distinguishing amoebic from pyogenic liver abscess: a review of 577 adult cases. | journal=Trop Med Int Health | year= 2004 | volume= 9 | issue= 6 | pages= 718-23 | pmid=15189463 | doi=10.1111/j.1365-3156.2004.01246.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15189463  }} </ref><ref name="pmid5054724">{{cite journal| author=Barbour GL, Juniper K| title=A clinical comparison of amebic and pyogenic abscess of the liver in sixty-six patients. | journal=Am J Med | year= 1972 | volume= 53 | issue= 3 | pages= 323-34 | pmid=5054724 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=5054724  }} </ref><ref name="pmid3316923">{{cite journal| author=Barnes PF, De Cock KM, Reynolds TN, Ralls PW| title=A comparison of amebic and pyogenic abscess of the liver. | journal=Medicine (Baltimore) | year= 1987 | volume= 66 | issue= 6 | pages= 472-83 | pmid=3316923 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3316923  }} </ref><ref name="pmid3945889">{{cite journal| author=Conter RL, Pitt HA, Tompkins RK, Longmire WP| title=Differentiation of pyogenic from amebic hepatic abscesses. | journal=Surg Gynecol Obstet | year= 1986 | volume= 162 | issue= 2 | pages= 114-20 | pmid=3945889 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3945889  }} </ref>
Pyogenic liver abscess must be differentiated from:<ref name="pmid15189463">{{cite journal| author=Lodhi S, Sarwari AR, Muzammil M, Salam A, Smego RA| title=Features distinguishing amoebic from pyogenic liver abscess: a review of 577 adult cases. | journal=Trop Med Int Health | year= 2004 | volume= 9 | issue= 6 | pages= 718-23 | pmid=15189463 | doi=10.1111/j.1365-3156.2004.01246.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15189463  }} </ref><ref name="pmid5054724">{{cite journal| author=Barbour GL, Juniper K| title=A clinical comparison of amebic and pyogenic abscess of the liver in sixty-six patients. | journal=Am J Med | year= 1972 | volume= 53 | issue= 3 | pages= 323-34 | pmid=5054724 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=5054724  }} </ref><ref name="pmid3316923">{{cite journal| author=Barnes PF, De Cock KM, Reynolds TN, Ralls PW| title=A comparison of amebic and pyogenic abscess of the liver. | journal=Medicine (Baltimore) | year= 1987 | volume= 66 | issue= 6 | pages= 472-83 | pmid=3316923 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3316923  }} </ref><ref name="pmid3945889">{{cite journal| author=Conter RL, Pitt HA, Tompkins RK, Longmire WP| title=Differentiation of pyogenic from amebic hepatic abscesses. | journal=Surg Gynecol Obstet | year= 1986 | volume= 162 | issue= 2 | pages= 114-20 | pmid=3945889 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3945889  }} </ref><ref name="pmid9834333">{{cite journal| author=Lipsett PA, Huang CJ, Lillemoe KD, Cameron JL, Pitt HA| title=Fungal hepatic abscesses: Characterization and management. | journal=J Gastrointest Surg | year= 1997 | volume= 1 | issue= 1 | pages= 78-84 | pmid=9834333 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9834333  }} </ref><ref name="pmid3275982">{{cite journal| author=Pastakia B, Shawker TH, Thaler M, O'Leary T, Pizzo PA| title=Hepatosplenic candidiasis: wheels within wheels. | journal=Radiology | year= 1988 | volume= 166 | issue= 2 | pages= 417-21 | pmid=3275982 | doi=10.1148/radiology.166.2.3275982 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3275982  }} </ref><ref name="pmid11452064">{{cite journal| author=Mortelé KJ, Ros PR| title=Cystic focal liver lesions in the adult: differential CT and MR imaging features. | journal=Radiographics | year= 2001 | volume= 21 | issue= 4 | pages= 895-910 | pmid=11452064 | doi=10.1148/radiographics.21.4.g01jl16895 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11452064  }} </ref><ref name="pmid7668917">{{cite journal| author=Suwan Z| title=Sonographic findings in hydatid disease of the liver: comparison with other imaging methods. | journal=Ann Trop Med Parasitol | year= 1995 | volume= 89 | issue= 3 | pages= 261-9 | pmid=7668917 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7668917  }} </ref><ref name="pmid3047423">{{cite journal| author=Esfahani F, Rooholamini SA, Vessal K| title=Ultrasonography of hepatic hydatid cysts: new diagnostic signs. | journal=J Ultrasound Med | year= 1988 | volume= 7 | issue= 8 | pages= 443-50 | pmid=3047423 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3047423  }} </ref><ref name="pmid7225721">{{cite journal| author=Niron EA, Ozer H| title=Ultrasound appearances of liver hydatid disease. | journal=Br J Radiol | year= 1981 | volume= 54 | issue= 640 | pages= 335-8 | pmid=7225721 | doi=10.1259/0007-1285-54-640-335 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7225721  }} </ref>
</small>
{| class="wikitable"
{| class="wikitable"
! rowspan="3" |Disease
! rowspan="3" |Disease
Line 16: Line 17:
! rowspan="3" |Other Findings
! rowspan="3" |Other Findings
|-
|-
! rowspan="2" | Fever
! rowspan="2" | [[Fever]]
! colspan="2" | Pain
! colspan="2" | [[Pain]]
! rowspan="2" | cough
! rowspan="2" | [[cough]]
! rowspan="2" | Hepatomegaly
! rowspan="2" | [[Hepatomegaly]]
! rowspan="2" | Jaundice
! rowspan="2" | [[Jaundice]]
! rowspan="2" | Weight loss
! rowspan="2" | [[Weight loss]]
! rowspan="2" | Anorexia
! rowspan="2" | [[Anorexia]]
! rowspan="2" | Diarrhoea
! rowspan="2" | [[Diarrhoea]]
or
or Dysentry
Dysentry
! rowspan="2" | [[Nausea]] and  
! rowspan="2" | Nausea and  
[[vomiting]]
vomiting
! rowspan="2" | [[Stool]]
! rowspan="2" | Stool
|-
|-
! Abdominal pain
! [[Abdominal pain]]
(right upper quadrant pain)
(right upper quadrant pain)
! Pleuritic pain
! Pleuritic pain
|-
|-
|Amoebic  
|[[Amoebic liver abscess]]
liver abscess
|[[Entamoeba histolytica]]
|Entamoeba  
| +++
histolytica
| +++
|✔✔✔
| +/-
|✔✔✔
| +
|✔/✘
| ++/-
|✔
| +
|✔/✘
|✔
(late stages)
(late stages)
|✔
| +
(late stages)
(late stages)
|✔
| +
|✔
| +
|✔
| +
|
|
|Hypoalbuminemia
|[[Hypoalbuminemia]]


✔
(+)
|
|
* [[Ultrasound]] is the [[Gold standard (test)|gold standard]] technique for diagnosing [[amoebic liver abscess]]
|
|
* Respond well to chemotherapy and rarely require drainage
* Respond well to [[chemotherapy]] and rarely require drainage
* Marked male predominance
* Marked male predominance
* More common in developing countries
* [[Seropositive]]
* [[Right lobe of liver|Right lobe]] is more frequently involved
|-
|-
|Pyogenic liver abscess
|[[Pyogenic liver abscess]]
|Bacteria
|[[Bacteria]]
* Gram-positive aerobes
* [[Gram-positive]] [[aerobes]]
* Gram-negative enterics
* [[Gram-negative]] enterics
* Anaerobic organisms
* [[Anaerobic]] organisms
* Acid fast bacilli  
* [[Acid fast bacilli]]
|✔
| +
|✔
| +
|✔✔
| ++
|✔✔
| ++
|
| +/-
|✔✔✔
| +++
|✔
| +
(acute loss)
(acute loss)
|✔
| +
|
|
|✔
| +
|Pale/dark
|Pale/dark
|Hypoalbuminemia
|[[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
* Abnormal pulmonary findings
* Diabetes mellitus increases the risk
* [[Diabetes mellitus]] increases the risk
* Medical-surgical approach is indicated
* Medical-surgical approach is indicated
* More common in developed countries
* Culture positive and [[seronegative]]
* Both lobes are commonly involved
|-
|-
|Fungal liver abscess
|Fungal liver abscess
|Candida species
|''[[Candida|Candida species]]''<br>[[Aspergillus|Aspergillus species]]
|✔
| +
|✔
| +
|
| +/-
|✔
| +
|✔
| +
|✔
| +
|✔
| +
|✔
| +
|✔
| +
|✔
| +
|
|
|
|
|
|[[CT]] and [[Ultrasonography|US]] 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
|[[hydatid cyst|Echinococcal (hydatid) cyst]]
|Echinococcus granulosus
|[[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
* [[Calcification|Calcifications]] seen peripherally
|
|
* Blood or liquid from the ruptured cyst may be coughed up
* Blood or liquid from the ruptured cyst may be coughed up
* [[Pruritis]]
|-
|-
|Malignancy
|Malignancy
(Hepatocellular carcinoma/Metastasis)
(Hepatocellular carcinoma/Metastasis)
|
|
*Hepatitis B and C
*[[Hepatitis B]] and [[hapatitis C|C]]
*Aflatoxins
*[[Aflatoxins]]
*Alcohol
*[[Alcohol]]
*Heamochromatosis
*[[Hemochromatosis]]
*Alpha 1 antitrypsin deficiency
*[[Alpha 1 antitrypsin deficiency]]
*Non alcoholic fatty liver disease
*[[Non alcoholic fatty liver disease]]
|
| +
|✔
| +


(uncommon)
(uncommon)
|
|
|
|
|✔
| +
|✔
| +
|
| ++
|
|
|
|
|
|
| ++
|Pale/Chalky
|
|
* High levels of [[alpha-fetoprotein|AFP]] in serum
* Abnormal [[liver function test]]s
|
|
* [[Liver biopsy]]
|Other symptoms:
|Other symptoms:
* Splenomegaly
* [[Splenomegaly]]
* Variceal bleeding
* [[Variceal bleeding]]
* Ascites
* [[Ascites]]
* Spider nevi
* [[Spider nevi]]
* Asterixis
* [[Asterixis]]
|}
|}
</small>


==References==
==References==
{{reflist|2}}
{{reflist|2}}
[[Category:Emergency mdicine]]
[[Category:Disease]]
[[Category:Up-To-Date]]
[[Category:Infectious disease]]
[[Category:Gastroenterology]]
[[Category:Hepatology]]

Latest revision as of 23:55, 29 July 2020

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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

Pyogenic liver abscess must be differentiated from other diseases with similar presentation such as amoebic liver abscess, fungal liver abscess, echinococcal (hydatid) cyst and malignancy (Hepatocellular carcinoma or metastasis).[1][2][3][4]

Differential Diagnosis

Pyogenic liver abscess must be differentiated from:[1][2][3][4][5][6][7][8][9][10]

Disease Causes symptoms Lab 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

(+)

Pyogenic liver abscess Bacteria + + ++ ++ +/- +++ +

(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 US 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
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)

+ +

(uncommon)

+ + ++ ++ Pale/Chalky Other symptoms:

References

  1. ↑ 1.0 1.1 Lodhi S, Sarwari AR, Muzammil M, Salam A, Smego RA (2004). "Features distinguishing amoebic from pyogenic liver abscess: a review of 577 adult cases". Trop Med Int Health. 9 (6): 718–23. doi:10.1111/j.1365-3156.2004.01246.x. PMID 15189463.
  2. ↑ 2.0 2.1 Barbour GL, Juniper K (1972). "A clinical comparison of amebic and pyogenic abscess of the liver in sixty-six patients". Am J Med. 53 (3): 323–34. PMID 5054724.
  3. ↑ 3.0 3.1 Barnes PF, De Cock KM, Reynolds TN, Ralls PW (1987). "A comparison of amebic and pyogenic abscess of the liver". Medicine (Baltimore). 66 (6): 472–83. PMID 3316923.
  4. ↑ 4.0 4.1 Conter RL, Pitt HA, Tompkins RK, Longmire WP (1986). "Differentiation of pyogenic from amebic hepatic abscesses". Surg Gynecol Obstet. 162 (2): 114–20. PMID 3945889.
  5. ↑ Lipsett PA, Huang CJ, Lillemoe KD, Cameron JL, Pitt HA (1997). "Fungal hepatic abscesses: Characterization and management". J Gastrointest Surg. 1 (1): 78–84. PMID 9834333.
  6. ↑ Pastakia B, Shawker TH, Thaler M, O'Leary T, Pizzo PA (1988). "Hepatosplenic candidiasis: wheels within wheels". Radiology. 166 (2): 417–21. doi:10.1148/radiology.166.2.3275982. PMID 3275982.
  7. ↑ Mortelé KJ, Ros PR (2001). "Cystic focal liver lesions in the adult: differential CT and MR imaging features". Radiographics. 21 (4): 895–910. doi:10.1148/radiographics.21.4.g01jl16895. PMID 11452064.
  8. ↑ Suwan Z (1995). "Sonographic findings in hydatid disease of the liver: comparison with other imaging methods". Ann Trop Med Parasitol. 89 (3): 261–9. PMID 7668917.
  9. ↑ Esfahani F, Rooholamini SA, Vessal K (1988). "Ultrasonography of hepatic hydatid cysts: new diagnostic signs". J Ultrasound Med. 7 (8): 443–50. PMID 3047423.
  10. ↑ Niron EA, Ozer H (1981). "Ultrasound appearances of liver hydatid disease". Br J Radiol. 54 (640): 335–8. doi:10.1259/0007-1285-54-640-335. PMID 7225721.
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