Amebiasis is a parasitic infection caused by the protozoan, Entamoeba histolytica; transmitted through fecal-oral route. The infection can manifest ranging from an asymptomatic state to multiple complications associated with liver abscesses. Amebic liver abscess is the most common extraintestinal manifestation of amebiasis. Men between the ages of 18 and 50 are most commonly affected. Approximately 80% of patients with this disease will develop symptoms within 2 to 4 weeks, including fever and right upper quadrant abdominal pain with 10% to 35% of patients experiencing associated gastrointestinal symptoms. The diagnosis is based on the clinical symptoms and relevant epidemiology coupled with radiographic studies and serologic tests. Optimal treatment includes the use of Metronidazole followed by a luminal agent such as Paromomycin. Rarely, therapeutic aspiration is indicated. Sir William Osler diagnosed the first case of liver abscess in the USA.
Epidemiology
Amebic liver abscess is uncommon in children and ten times more common in men than in women, particularly in individuals between the ages of 18 and 50. The reason for such a striking difference is not clear but thought to be due to factors such as hormonal effects and alcohol consumption. In the United States, most cases are found in immigrants from endemic areas and people living in states bordering Mexico. Worldwide, areas with high rates of infection include India, Africa, and Mexico and parts of Central and South America.
Most individuals are infected by ingesting contaminated food or water although other modes of transmission include oral and anal sex, particularly among men who have sex with men. Around 2% to 5% of patients with intestinal amebiasis may end up with liver abscess.
Pathophysiology
The life cycle of Entameba Histolytica was first explained by Clifford Dobell in 1928. The organism has 2 stages of life, the cystic stage which is the infective stage and the trophozoite stage which ends up causing invasive disease. Upon ingestion of contaminated food and water; the infection starts with ingestion of the quadrinucleate cyst of E. histolytica.
Excystation in the small intestinal lumen is followed by production of motile, potentially invasive trophozoites. In most infections, the trophozoites form new cysts and are limited to the intestinal mucin layer. In other cases, the trophozoites adhere to and lyse the colonic epithelium with subsequent invasion of the colon. Neutrophils respond, resulting in further cellular damage at the invasion site. Once the trophozoites invade the colonic epithelium, subsequent spread to extraintestinal sites such as the liver (by hematogenous spread through the portal circulation) and peritoneum can occur. The organism causes hepatic inflammation followed by necrosis which results in an abscess formation.
Clinical features _most infections are asymptomatic and commensal but some may be invasive and give rise to intestinal and extraintestinal disease. Intestinal disease varies from acute or fulminating dysentery with fever, chills, and bloody or mucoid diarrhea (amoebic dysentery), alternating with periods of constipation. Amoebic granuloma (amoeboma) sometimes mistaken for carcinoma may occur in the wall of large intestine in patients with intermittent dysentery or long duration of long duration Dissemination through the blood may produce abscess in the liver or less commonly of the lung or the brain. Painful ulceration of the skin a rare manifestation that can occur anywhere but most commonly in the perianal and genital regions in association with amoebic dysentery. Penile lesions may result from anal intercourse. Amoebae reached the skin either directly or indirectly through haematogenous spread; amoebic colitis is often confused with other inflammatory bowel diseases. Amoebiasis can also mimic other non-infectious diseases. Conversely the presence of amoebae may be misinterpreted as the cause of diarrhea whose primary enteric illness is the result of another conditions.
Diagnosis: By microscopic demonstration of trophozoites or cysts or fresh suitably preserved fecal specimen, smear of aspirates, scrapings obtained by proctoscopy or aspirates of abscess or section of the tissue. The presence of trophozoites containing red blood cells is indicative of invasive amoebisis. Examination should be done on fresh specimen by trained microscopist as the organism must be differentiated from macrophages. In patients with intestinal amoebiasis examination of 3 specimens collected on 3 separate days will increase the yield of the organism, but the yield of organisms from amoebic liver abscess was only 8 to 44 % even with repeated examination.
Amebic liver abscess is the most common extra-intestinal manifestation of the protozoan, Entamoeba histolytica. Men younger than 50 who have immigrated from or traveled to an endemically affected area are most commonly affected. It causes fever, right upper quadrant abdominal pain, diarrhea, and weight loss. This activity describes the life cycle, epidemiology, and transmission of the parasite, and illustrates its clinical features. It explains the role of an interprofessional team in the evaluation and management of patients with amebic liver abscess. It also outlines the indications for aspiration or surgical debridement of the abscess and management of its complications.(1)
Many studies were made on amoebic infections in all parts of the countries and teaching hospitals in the past decades and incidence was going down recently and less cases are seen in recently years probably due to improvement in environmental sanitation and improved water supplies
Many hospital-based studies were made in major teaching hospitals for routine compilation of information or preparation of thesis for master degree on microbiology, radiology and medicine and surgery.
For the diagnosis of both intestinal and extraintestinal amoebiasis and pyogenic liver abscess was by microbiological and radiological methods and at the same time the study of prevalence or burden of the disease.
Isolation and serological diagnosis of Entamoeba histolytica in liver abscess
A total of twenty-five liver abscess cases, twenty male and five females were included in the study randomly. The ages ranged from eighty to sixty years. Serum, aspirated fluid and stool specimen of those patients were collected. Antibodies from serum samples are examined by indirect haemagglutination test and indirect immunofluorescent test. Stool specimens were examined microscopically to detect any cyst or trophozoite form. Aspirated fluid was also examined microscopically and cultivated to isolate the organism. Patients of age ranged from forty to forty-nine years age group were observed to be the highest percentage (36%) from twenty to twenty-nine years age group were the lowest percentage (4%). Antibodies detection by IHA and IFA test were shown to be positive in all selected cases. Neither cyst nor trophozoites form of E.histolytica was seen. Positive titers ranged from 1:64 to 1:16384 in IHA test and 1:64 to 1:512 in IIF test. The highest frequency was observed in 1:8192 dilution in IHA test and 1:128 in IIF test. Microscopic examination of aspirated fluid showed no evidence of trophozoites or any other organism. (2)
Incidence of jaundice in hepatic amoebiasis and study of clinical features
For clinical presentation the incidence of jaundice as clinical presentation was studied.
In 209 cases of hepatic amoebiasis, the incidence of latent and overt jaundice was found in 31.5% and those of overt jaundice was 20.7% The incidence of hepatic amoebiasis among admitted cases was 2.6%. The incidence was found to be higher than in other series. More cases were predominant in male than in females. The possible mechanism or pathogenesis of jaundice in hepatic amoebiasis was discussed. Polymorphonuclear leucocytosis was present in 50% of cases and a history of amoebiasis was given in 50 % of hepatic amoebiasis cases(4)
Liver scanning
In Rangoon General Hospital the main indication of scanning of liver scanning has been hepatic amoebic amoebiasis. Out of 69 patients, 33 had amoebic liver abscess, verified by biopsy and therapeutic trial. Author highlighted the usefulness of liver scanning in the diagnosis of hepatic amoebic abscess.(4)
Role of ultrasonography in the diagnosis of liver abscess Ultrasonography confirmation was done in 60 patients who have been diagnosed clinically and ultrasonographically. 82 abscesses were confirmed of which 63 were confirmed both technically adequate sonograph and interventional radiological confirmation. There were 55 males and 5 females ranging from age 17 to 88 years. The main signs and symptoms observed were fever, pain and tenderness in the abdomen with history of dysentery. Present study represented abscess more solidary and more in the right lobe than the left. Common features were peripheral location round or ovoid lesion with well-defined thin walled cavity. Diagnosis was made by aspiration of gross pus from the abscess cavity in all patients. Favourable clinical response showed ultrasound diminution and disappearance of the abscess cavity.
A clinical study of liver abscess in YGH and new YGH, 1998
78 patients of liver abscess were studied during 9 months period from May 1997 to January 1998. Amoebic liver abscess was 18.5 times more common than pyogenic abscess. Amoebic liver abscess was found to be more common in (30-39 age) group and pyemic liver abscess in (40-49) age group. Male female ratio in amoebic abscess was 7:1 and all pyaemic abscess are male. The peak incidence among admission was found in July for amoebic abscess and May for pyaemic abscess, but both types of abscess were common in rainy season. The main clinical manifestation in amoebic liver abscess were pain in right hypochondrial region, fever, jaundice, history of dysentery, constitutional symptoms, tenderness of liver and intercostal tenderness, downward enlargement of hepatomegaly. The main clinical manifestation in pyaemic liver abscess were pain in right hypochondrial region, fever, jaundice, downward enlargement of liver, intercostal tenderness and tender liver. Leukocytosis is more common in pyaemic liver abscess. Amoeba in stool present in 10.8% of amoebic patient. Amoebic abscess was more common in right lobe (87.83%) and pyaemic abscess commonly seen in both lobes (75%)
Colour of pus is was reddish-brown in amoebic abscess (94.6%) and yellowish in (100%) in pyaemic liver abscess. The chest X-ray and ultrasound were very helpful in getting diagnosis and treatment. Single lobe abscess was common in amoebic liver abscess and multiple lobe involvement were seen in pyaemic liver abscess. Laprotomy was not done for all cases. Ultrasound guided aspiration with medical treatment was needed for all pyaemic abscess and 83.7% of amoebic abscess and all have the abscess cavity size of more than 5 cm. In amoebic liver abscess 16.21% ruptured into only into pleural cavity. In pyaemic abscess all cases ruptured with minimal reaction (75%) into pleural cavity, 25% in peritoneal cavity and 25% into pericardial cavity. No more expired cases in both types of liver abscess.(5)
Surgical manifestations of amoebiasis in Mandalay General Hospital, 1983
The analysis was made of (98) cases admitted to Surgical Wards of Mandalay General Hospital for hepatic amoebiasis in one and a half year from January 1980 to June 1981. Out of (98) cases of hepatic amoebiasis, (52) were amoebic hepatitis and (39) amoebic liver abscess without complications and (7) with complications. Hepatic amoebiasis occurred during adult life with the highest incidence in the third, fourth and fifth decade. In the study 70 % of those cases occurred in these decades, the youngest was (16) years of age and oldest (77) years of age. There is preponderance in male sex (77%), among the patients and (63.2 %) among the cases presented in with acute symptoms. The acute onset was more frequently observed in hepatitis than in abscess. The most common clinical manifestations are pain and tenderness over the hepatic area with hepatomegaly occuring in 100% of cases, followed by weakness and weight loss (75%), fever (50%), nausea and vomiting (50%), jaundice and right shoulder tip pain,(22%) diarrhea as an antecedent or accompanying manifestation occurred in (54%) of cases. Amebae was found in stool in about 8% of cases in that study. The incidence was higher in amoebic hepatitis cases. Roentgenographic findings are positive in 50% in which examination was made. Diagnostic yield of aspiration the abscess cavity was (72%) in the present series. Pus in the amoebic liver abscess whether complicated or uncomplicated was bacteriologically sterile. Amoebae were demonstrable in the pus in (4.8%) of cases in the present study. (52) cases of amoebic hepatitis were treated medically. Closed needle aspiration of amoebic liver abscess was done in 28 cases. The incidence of complication of amoebic liver abscess was (7%). Pleuropulmonary complication in one case, rupture into peritoneal cavity in 6 cases. Aspiration was carried out in one case of pleural complication. In all 6 cases of amoebic liver abscess which ruptured into peritoneal cavity, laparotomy, debridement of abscess cavity and tube drainage was done. The above surgically treated cases were under cover of amoebicidal drugs and systemic antibiotics. There were no deaths among 32 cases of treated amoebic hepatitis cases. There was again no mortality among uncomplicated liver abscess. The complications of liver abscess were few being present in 7 %. In complicated liver abscess the mortality was 14%. The results of treatment assessed during follow-up period revealed that out of (28) uncomplicated liver abscess, treated by aspiration. (5) cases recurred. There was no evidence of infection at the drainage site or no fistula was ever noted. In amoebic liver abscess with pleuropulmonary complication one case recurred after medical treatment and aspiration. In these abscesses which ruptured to peritoneal cavity there was (1) recurrence. From the above study the role of surgeon in amoebic manifestation of liver was deduced or indispensable. (7)
Clinical study of Tropical liver abscess
36 patients with liver abscess were studied during a period of one year in NOGH General Hospital. It was found to be common in third and fourth decade of life with male preponderance. Main presenting features are pain in right hypochondrium, fever, swelling in abdomen, enlarged tender liver and pulmonary symptoms and signs with 86.1% of the abscess occurring in in the right lobe of the liver. The complications encountered were rupture of liver abscess, into pleural, pericardial, peritoneal cavities and pleural effusion. The chest X ray and ultrasound were helpful in getting the diagnosis. The patients were treated by amoebicidal drugs and broad-spectrum antibiotics alone or in combination with aspiration, tube drainage and laparotomy. Mortality was 5.6%.
Hepatitis of different microbial aetiology at 2MH and DSGH 1994
Out of 32 clinically diagnosed amoebic hepatitis including liver abscess cases, 13 could be etiologically proven having amoebic origin by IFAT and combination with ultrasound.
Clinical study of liver abscess NOGH, Myanmar
35 patients with liver abscess were studied during a period of one year in NOGH Yangon. All patients are diagnosed and treated as liver abscess clinically supported by either ultrasound and/or evidence of pus by aspiration or laparotomy at medical and surgical wards. It was found that liver abscess constituted 8.5% of all liver pathology. Amoebic abscess was 4.8 times more common than pyogenic liver abscess. In both groups middle age was affected. But males are more affected in amoebic abscess and female in pyogenic liver abscess. The main clinical manifestation in amoebic abscess were pain in right hypochondrial region, fever, enlarged tender liver and intercostal tenderness. History of dysentery in the past, a single abscess, confined to the right lobe were suggestive of amoebic liver abscess. In amoebic liver abscess the complications encountered were rupture of liver abscess into pleural cavity 13.7% and peritoneal cavity 10.3 %. Patients with amoebic liver abscess 24% developed complications more often than pyogenic abscess. Case fatality was greater in pyogenic liver abscess (33.3%). (10)
A clinical study of Liver abscess in Pathein General Hospital, Ayeyarwaddy Division
(32) patients with liver abscess, admitted to the hospital during September to August 1998 were reviewed to determine age and sex distribution, clinical presentations, nature of abscess, their management and outcome. Diagnosis of liver abscess was made and confirmed by ultrasonography and follow-up recheck USG was done. Out of 32 cases, 20 were cases of burst liver abscess treated by laparotomy and drainage. One case presented with mass in epigastrium due to ruptured abscess at bare area with pus accumulation between two leaves of falciform ligament. Smaller abscess was treated by USG-guided aspiration in 7 cases and blind aspiration in 2 cases. One case burst liver abscess of segment required segmental resection. In one-and-a-half-year period half of the cases ruptured with late arrival. Although there was no mortality, prevalence of liver abscess was high and with late referral due to poor environmental sanitation in districts.(11)
Cardiac tamponade with pericardial effusion
65-year-old postmenopausal lady was admitted to NOGH on 27 January 1999 with the chief complaint of precordial pain and dyspnea for 3 days. At that time, she had chest pain, constricting in nature and persistent accompanied by dyspnea. She noticed palpitation. During last six months she had progressive loss of appetite with vomiting which mostly contained a small amount of fluid and gas. She had pain in abdomen off and on and was treated as colitis or hepatitis at GP’s clinics with gelmag and metronidazole. She was a chronic smoker for 20 years. On examination the patient was ill, with signs of shock 70 by zero by palpation. IVP was raised 5 cm above sternal angle. Normal heart sounds were audible. Auscultation of lungs revealed VBS with crepitation. Liver was palpable 2 fingers below the costal margin, slightly tender.
The following investigations were done. CP showed neutrophil leukocytosis and mild eosinophilia ESR 100mm per first hour; blood sugar and cholesterol were within normal limit. Chest X ray was done on 28 January 1999 showed hyperinflated lung fields and enlarged heart; ECG was done on 27 January and showed sinus tachycardia with ST elevation in chest leads. The case was diagnosed as acute myocardial infarction with cardiogenic shock and treated medically. After four days of hospital treatment no improvement was made and patient requested to be discharged. On 3 February 1999, she was admitted again for progressive dyspnea with hypotension. Physician saw the patient reviewed the history and appropriate investigations were done. At that time patient’s pulse was feeble and heart sounds were fainted.Thinking of pericardial effusion urgent echocardiogram requested and echo revealed the presence of pericardial fluid. Anchovy colour pus of 1200 ml. was aspirated. Chest X ray recheck was made after aspiration and air was introduced to see the size of the heart. Treatment given was metrocidazole 2 tds for 7 days and ciprofloxacin for 10 days and chloroquine course. Patient had recovery from the day of aspiration. Final diagnosis was amoebic pericardial effusion. Investigation was done to support the diagnosis. Stool for amoebae was examined for 3 consecutive days; only Ascaris ova was found.Ultrasound abdomen revealed slightly enlarged liver with normal echogenicity. IVC and hepatic veins were dilated. The liver was congested. Pus was examined for E.histolytica made and no trophozoies was seen. Pus culture was negative. Gram and ZN stains do not reveal any microorganism. Sputum for AFP was negative. Routine examination of pericardial fluid showed pus and blood and total protein 7000 mg%. Sugar was reduced and globulin positive. Haemagglutination Inhibition test for amoebae was positive.
This is a common disease with rare presentation. The thoracic complications of amoebic pericarditis and pericardial effusion least frequent. The commonest mode of spread is direct spread from the abscess of the left lobe of liver or by haematogenous spread of the trophozoites from lesions of the large intestine or amoebic perforation of the hepatic flexure of the colon with perforation of diaphragm and invasion of the pleural and peritoneal cavities. Clinical features of amoebic pericardial effusion are precordial pain, dyspnea, tachycardia, raised IVP, softened heart sounds, paradoxical pulse and shock. Diagnosis is usually confirmed bay characteristic pus from the pericardium. Complication is constrictive pericarditis. When the distant spread of amoebiasis was found the primary lesion (rupture abscess in the left lobe of liver) has already healed, like this case. Patient can develop amoebic abscess one to three months after apparent cure by successful treatment of colitis with metronidazole. IHA is very sensitive test for amoebic abscess or invasive amoebiasis. Antibody may persist for three years after termination of infection. Serology may negative in the first week after onset; titer reaches a peak by second or third month and then decreases to lower level. (12)
A clinical study of Liver abscess, NOGH
During a period of one year, a total of 38 patients with liver abscess admitted to surgical and medical wards of North Okkalapa General Hospital, Yangon, was reported. Incidence of liver abscess was 3.3 per 1000 admission of which amoebic liver abscess constituted 0.3 per cent and pyogenic liver abscess 0.03 per cent. Amoebic liver abscess was 8.5 times as pyogenic abscess. Amoebic liver abscess was common in 30-39 age bracket. Males are more affected in amoebic liver abscess and female are more affected in pyogenic liver abscess. 8.82% of amoebic liver abscess and (100) percent of pyogenic abscess were multiple. The main characteristic features of amoebic liver abscess pain in right hypochondrium, fever, enlarged tender liver and intercostal tenderness. History of dysentery in the past and a single abscess cavity are findings more frequently seen in amoebic liver abscess. The presence of concurrent infection, jaundice, fever and enlarged liver were associated with pyogenic liver abscess. Multiple abscess involving both lobes were more frequently found in pyogenic abscess. And leukocytosis was more common also. All patients with amoebic liver abscess were successfully treated with antimicrobials agents and drainage procedures. Small size of less than 5 cm responded well to medical treatment alone. Size of larger than 5cm were treated with antimicrobial plus percutaneous aspiration with USG guidance. In pyogenic abscess, all cases were treated without drainage. One patient died of septicemia and remaining three recovered. Rupture into peritoneal cavity was the only complication found in the patient with amoebic liver abscess in this study.(10)
Global burden
Amoebic infections are ubiquitous and still reported from all over the world.
A Review of the Global Burden, New Diagnostics, and Current Therapeutics for Amebiasis
Abstract
Amebiasis, due to the pathogenic parasite Entamoeba histolytica, is a leading cause of diarrhea globally and has emerged as an important infection among returning travelers, immigrants, and men who have sex with men residing in developed countries. Severe cases can be associated with high case fatality. Polymerase chain reaction-based diagnosis is increasingly available but remains underutilized. Nitroimidazoles are currently recommended for treatment, but new drug development to treat parasitic agents is a high priority.
Keywords: HIV; MSM; PCR; amebiasis; burden; colitis; diarrhea.(13)
One family of Dutch got infection after returning from Italy and reported in Dutch.
Outbreak of amoebiasis in a Dutch family; tropics unexpectedly nearby.
Abstract
An amoebic liver abscess, amoebic dysentery and asymptomatic cyst passage were diagnosed in a Dutch family who have visited Italy in summer holiday. Strain of Entamoeba histolytica as determined by polymerase chain reaction (PCR)-based DNA typing. PCR analysis of parasite DNA extracted directly from stool samples makes differentiation between the morphologically identical cysts of E. histolytica and the non-pathogenic Entamoeba dispar possible. Serum antibodies to E. histolytica are almost always present in symptomatic patients. Invasive infections with E. histolytica require treatment with a tissue amoebicidal drug, followed by a contact amoebicide to prevent recurrence. Currently, paromomycin is considered to be the first-line luminal amoebicide. (14)
Abstract
Extraintestinal amoebiasis is an uncommon complication of Entamoeba histolytica infection, occurring in about 5-10% of patient. However, diagnosis and management in resource-limited settings is very challenging owing to limited diagnostic tools and nonspecific clinical symptoms.
Case Presentation
A 13-year-old female Cameroonian presented with upper abdominal pain, high fever, and chest pain for one week. After clinical evaluation and basic investigation, she was diagnosed with a giant amoebic liver abscess.
Conclusion
Amoebic liver abscess is a rare complication of Entamoeba histolytica infection with devastating complications. The diagnosis of this disease requires high index of suspicion.(15)
Invasive amebiasis: an update on diagnosis and management
Abstract
In its invasive form, the trophozoite is responsible for clinical syndromes, ranging from classical dysentery to extraintestinal disease with emphasis on hepatic amebiasis. Abdominal pain, tenderness and diarrhea of watery stool, sometimes with blood, are the predominant symptoms of amebic colitis. Besides the microscopic identification of Entamoeba histolytica, diagnosis should be based on the detection of specific antigens in the stool or PCR associated with the occult blood in the stool. Amebic dysentery is treated with metronidazole, followed by a luminal amebicide. The trophozoite reaches the liver causing hepatic amebiasis. Right upper quadrant pain, fever and hepatomegaly are the predominant symptoms. The diagnosis is made by the finding of E. histolytica in the hepatic fluid, or in the necrotic material at the edge of the lesion in a minority of patients, and by detection of antigens or DNA. Ultrasonography is the initial imaging procedure indicated. The local perforation of hepatic lesion leads to important and serious complications.(16)
Conclusions
Amoebic infections are still prevalent and local and international studies are accessed from local reports in journals and thesis in various disciplines, medicine, surgery, radiology and microbiology. The risk factors, epidemiology or disease burden and presentations and complications of amebic liver abscess and pyaemic liver abscess are mentioned.The various invasive and non-invasive diagnostic techniques of amebic liver abscess were outlined as in molecular (PCR technique) epidemiology and ultrasonography and other imaging. Treatment options and therapeutics are mentioned. Past findings and involvement in management of patients demonstrated the interplay among the interprofessional team in diagnosing, treating, and rehabilitation of patients with amebic liver abscess.
References
- Control of Communicable Diseases Manual, published by American Public Health Association, 20th edition
- Isolation and serological diagnosis of Entamoeba histolytica in liver abscess
Khin Nyein Wan thesis M.Med.Sc(Microbiology) IM 2. 2000. - HlaMyint, Pe Than Myint, Aye Aye Yi, Majiid A.A, Burma Medical Journal, 1968 (4), pp. 205-210. Incidence of jaundice in hepatic amoebiasis and study of clinical features.
- Hoschl R and SoeMyint. Liver scanning in hepatic amoebiasis, Burma Medical Journal 1968 April, 16 pp 109-119
- Hla Win: A clinical study of liver abscess in YGH and new YGH, Thesis, MSc Surgery IM1, 1998
- KhinMaung Kyi and Ye Myint, Twelfth Surgeon Conference: Yangon, 11-14 November 1998 p. 25. A clinical study of Liver abscess in Pathein General Hospital, Ayeyaraddy Division
- KhinMaungGyi: Thesis Institute of Medicine, Mandalay, 1983. Surgical manifestations of amoebiasis in Mandalay General Hospital Thesis, IMM, 1983
- HtunOo, Clinical study of Tropical liver abscess. Thesis M.Med.Sc (Radiology), Institute of Medicine 1, 1990
- Kaythi Phone Naing, 1995, IM1,M.Med.Sc (Mircobiology). Hepatitis of different microbial etiology 2MH. DSGH 1994
- Win Yee and Ye Myint, Journal of Surgery, September 1998, 9.pp 15-26. Clinical study of liver abscess, NOGH, Myanmar
- Khin Maung Kyi and Ye Myint, Twelfth Surgeon Conference: Yangon, 11-14 November 1998 p. 25. A clinical study of Liver abscess in Pathein General Hospital, Ayeyaraddy Division
- An old lady with cardiogenic shock, Dr.Nu Nu Maw, Consultant Lecturer, Medical ward NOGH, Kyaw Zin Tun: Thesis. IM 2 M.Med.Sc, (Surger), 2001 A clinical study of Liver abscess
- A Review of the Global Burden, New Diagnostics, and Current Therapeutics for Amebiasis. Debbie-Ann T Shirley 1, Laura Farr 2, Koji Watanabe 3, Shannon Moonah 2
- Outbreak of amoebiasis in a Dutch family; tropics unexpectedly nearby] [Article in Dutch] W M Edeling 1, J J Verweij, C IjPonsioen, L G Visser
- Giant Amoebic Liver Abscess: A Rare Diagnosis in a Rural Setting of Sub-Saharan Africa Cyril JabeaEkabe 1 2 3, Jules Kehbila 1 4, NjinjuAsaba Clinton
- Invasive amebiasis: an update on diagnosis and management. José Maria Salles 1, Mauro José Salles, Luiz Alberto Moraes, Mônica Cristina Silva
Comments
Prof Tha Hla Shwe
The above article constitutes the reminiscences of the author while working as a medical officer in the districts many years ago as well as reviews of published articles in Myanmar during those times and up to date. As such the procedures described may not be the procedures practiced at present and the reported data will only reflect the existing situations of those times. They may however present some insight into the prevailing conditions of previous times from which the present health care systems were evolved.
Author Information
Ye Hla
Director (Retired),
(Department of Medical Research, Central Myanmar)
