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Difficulty: MediumGastroenterology and Hepatology

A 35-year-old man is evaluated in the clinic for right upper quadrant abdominal pain and subjective fevers over the past two weeks. He immigrated to the United States from Central America two months ago. His temperature is 38.4∘C38.4^\circ\text{C} (101.1∘F101.1^\circ\text{F}), blood pressure is 118/76 mmHg118/76\text{ mmHg}, and heart rate is 94/min94\text{/min}. Physical examination reveals an enlarged liver with marked tenderness to palpation in the right upper quadrant. Laboratory studies show a leukocyte count of 14,000/μL14,000/\mu\text{L} and mildly elevated alkaline phosphatase. An abdominal ultrasound demonstrates a single 7-cm7\text{-cm} hypoechoic, fluid-filled lesion in the right lobe of the liver. *Entamoeba histolytica* serology is positive. Which of the following is the most appropriate next step in management?

  1. A
    Ultrasound-guided percutaneous aspiration
  2. B
    Intravenous piperacillin-tazobactam
  3. Oral metronidazole and paromomycinAnswer
  4. D
    Intravenous ceftriaxone and metronidazole
  5. E
    Oral albendazole

Answer

Oral metronidazole and paromomycin
The patient has an amebic liver abscess, caused by *Entamoeba histolytica*, indicated by his recent travel history, right upper quadrant pain, fever, a solitary right-lobe cystic lesion on ultrasound, and positive serology. The cornerstone of therapy for an uncomplicated amebic liver abscess is medical management with a tissue amebicide, such as metronidazole or tinidazole. This must be followed by a luminal amebicide, such as paromomycin or iodoquinol, to eradicate intestinal colonization and prevent relapse.

Step-by-Step Solution

1
Identify the primary pathology based on presentation, imaging, and labs.
The patient has a right-lobe cystic liver lesion, fever, right upper quadrant pain, recent travel history to an endemic area, and positive serology for E. histolytica, confirming an amebic liver abscess.
Accurate diagnosis is required to select the specific therapeutic intervention.
2
Determine the standard treatment for an uncomplicated amebic liver abscess.
Medical management with a tissue amebicide (metronidazole) followed by a luminal amebicide (paromomycin) is the gold standard.
Unlike pyogenic abscesses, amebic abscesses respond excellently to medical therapy and rarely require drainage unless they are large, at high risk of rupture, or non-responsive.

Key Concept

The primary treatment for an uncomplicated amebic liver abscess is medical management with a tissue amebicide (e.g., metronidazole) and a luminal agent (e.g., paromomycin), without the need for routine percutaneous drainage.
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Topics

Gastroenterology and Hepatology

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