E-ISSN:2456-3110

Review Article

Liver Abscess

Journal of Ayurveda and Integrated Medical Sciences

2023 Volume 8 Number 3 March
Publisherwww.maharshicharaka.in

A conceptual study on Liver Abscess with reference to Abhyantara Vidradi

Roja S.1*, Shailaja S.2
DOI: http://dx.doi.org/10.21760/jaims.8.3.19

1* SR Roja, Post Graduate Scholar, Department of Shalyatantra, Sri Kalabairaveshwara Swamy Ayurvedic College Hospital and Research Center, Bengaluru, Karnataka, India.

2 SV Shailaja, Professor, Department of Shalyatantra, Sri Kalabairaveshwara Swamy Ayurvedic College Hospital and Research Center, Bengaluru, Karnataka, India.

Vidradhi is a Rakta Dusti Vikara which undergoes rapid suppuration followed by Puya formation. Acharya Sushrutha has explained ten Adhishthanas of Antarvidradhi, among these Yakrit Vidradhi is also mentioned. Acharya Charaka has explained Vidradhi under Raktavaha Sroto Vikara in which Rakta Dushti and Paaka takes place predominantly. In modern concepts, one can precisely correlate abscess with Vidradhi. The extremely deranged and aggravated Vata, Pitta, Kapha resorting to the bone and vitiating Tvaka (skin) Rakta (blood), Mamsa (flesh) and Meda (fat) of person (with their own specific properties) gradually give rise to deep seated, painful, round or extended Shopha (swelling) is called Vidradhi.[1] It is of 6 types: Vataj, Pittaj, Kaphaj, Sannipataj, Kshataj And Raktaj. According to the site it is of two types- Bahya (external) and Antah (internal) Vidradhi.[2]

Keywords: Abhyantara Vidradi, Liver Abscess, Pyogenic Liver Abscess. Amoebic Liver Abscess

Corresponding Author How to Cite this Article To Browse
SR Roja, Post Graduate Scholar, Department of Shalyatantra, Sri Kalabairaveshwara Swamy Ayurvedic College Hospital and Research Center, Bengaluru, Karnataka, India.
Email: 		SR Roja, SV Shailaja, A conceptual study on Liver Abscess with reference to Abhyantara Vidradi. J Ayu Int Med Sci. 2023;8(3):103-107.
Available From
https://jaims.in/jaims/article/view/2342

Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2023-01-28 2023-01-30 2023-02-06 2023-02-13 2023-02-19
Conflict of Interest Funding Ethical Approval Plagiarism X-checker Note
Nil Nil Yes 18%

© 2023by SR Roja, SV Shailajaand Published by Maharshi Charaka Ayurveda Organization. This is an Open Access article licensed under a Creative Commons Attribution 4.0 International License https://creativecommons.org/licenses/by/4.0/ unported [CC BY 4.0].

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Introduction

A liver abscess is a space-occupying suppurative lesion in the liver resulting from the invasion of microorganisms entering directly from an injury, through the blood vessels, or through the bile ducts. Generally, when bacteria or protozoa destroy hepatic tissue, the cavity produced will be filled up with an infective organism, liquefied cells & leucocytes. Liver abscess falls into two categories based on underlying causes: Bacterial infection, parasitic infection. Pyogenic Liver Abscess and Amoebic liver abscess.

Antarvidradhi is a Vridhi Beda which develops in relation with Kosta[3]

Acharya Sushruta has also mentioned Aharaja Nidanas[4] of Abhyantara Vidradi are Guru Anna, Asathmya Anna Ruksha, Atiusna Ahara, Bahu Madya Sevana.

And also Viharaja Nidanas are Ati Maithuna, Vega Sandharana, Ati Bhaara, Ati Shayana and Ati Vyayama. There are 10 Adhistanas[5] of Abhyantara Vidradi mentioned in Sushrutha Samhita, among them Yakrit Vidradi is also one.

Pyogenic Liver Abscess[6]
A Pyogenic liver abscess is a pocket of pus that forms in the liver due to a bacterial infection. It may be solitary, multi locular and multiple.

Materials and Methods

Causative organisms: Escherichia coli, Staphylococcus aureus, Haemolytic Streptococcu, Klebsiella, Proteus, Pseudomonas, Clostridia and Streptococcus species.[7]

Signs and Symptoms: Pain in the right hypochondrium, fever with chills, sweating, nausea, vomiting, anorexia, weight loss, hepatomegaly, liver tenderness, jaundice, chest findings, spleenomegaly, sepsis, ascites.

Investigation Findings

  • CBC - Leucocytosis - WBC count >10000/mm3
  • Anaemia
  • Hypoalbuminemia - Albumin <3g/dl
  • LFT - ALP high
  • Gamma glutamyl transpeptidase will be high
  • Bilirubin > 2 gram/dl
  • SGOT will be high
  • ELISA should be performed.
  • Indirect Haemaglutinin Assays (IHA) is most sensitive test.

Chest X Ray
Clues:

a. Right-lower-lobe atelectasis.
b. Right pleural effusion
c. An elevated right hemi-diaphragm
d. Right cardiophrenic angle is obliterated

In plain abdominal films, air can be seen in the abscess cavities.

Ultrasonography

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  • Abscesses as small as 1 cm in diameter can be detected.
  • Can guide needle aspiration of the abscess.
  • US not only diagnoses and it also indicates the position of abscesses.

Computed tomography

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  • Computed tomography (CT) is more sensitive (95-100%) than US in detecting hepatic abscesses.

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  • Lesions are detectable to around 0.5 cm.
  • The "double target sign" is a characteristic imaging feature of hepatic abscess demonstrated on CECT scans, in which a central low attenuation lesion (fluid filled) is surrounded by a high attenuation inner rim and a low attenuation outer ring.
  • The "cluster sign" is a feature of Pyogenic Liver Abscess. It is an aggregation of multiple low attenuation liver lesions in a localized area to form a solitary larger abscess cavity.

Treatment for Pyogenic Liver Abscess

Conservative: Antibiotics (4-6 weeks)

a. Aminoglycoside
b. Clindamycin
c. Either ampicillin or vancomycin.
d. Aminoglycosides
e. Metronidazole
f. Third-generation cephalosporin


Percutaneous drainage

  • US or CT guided aspiration and drainage by pig tail catheter
  • Irrigation of cavity with saline

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Open Surgical method

Laparotomy

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Open Surgical drainage Laproscopic drainage

Amoebic Abscess

  • It’s common in India and other tropical countries.
  • Amoebic abscess (tropical abscess) caused by a parasite Entamoeba histolytica.
  • It’s the commonest extra-intestinal presentation of amoebiasis.

Mode of transmission

  • Large intestine (history of dysentery)
  • Through portal vein

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Signs and Symptoms

Systemic

  • Fever with chills and rigors
  • Loss of appetite
  • Reduced weight
  • Jaundice

Abdominal

  • Intercostal tenderness
  • Right quadrant pain
  • Localized guarding and rigidity
  • Ascites
  • Splenomegaly



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Thoracic

  • Dry cough
  • Chest pain
  • Right shoulder pain
  • Plueral effusion

Due to complications

  • Septicaemia and Liver failure

Investigation findings

  • Increased WBC count, Altered Albumin and Bilirubin Increased alkaline phosphatase, Altered SGOT and SGPT,
  • Stool examination for Ova and cysts of Entamoeba histolytica, Serologic testing - Indirect haemagglutination test will be positive
  • US abdomen - to locate site of abscess, to confirm diagnosis
  • Chest X-ray findings - pleural effusion and soft tissue shadow
  • CT scan - raised diaphragm, presence of effusion, changes in the lungs

Treatment for Amoebic Liver Abscess

Conservative

Antibiotics (4-8 weeks)

  • Metronidazole 750 mg three times a day for 10 to 14 days is the treatment of choice
  • Tinidazole 600 mg BD x 5days
  • IV or oral antibiotics are essential to control secondary infection
  • Other drugs : Chloroquine 250mg BD 10 to 14 days

Inj: Dihydroemetile 1.5mg/kg/day IM for 5 days

Aspiration

  • Indication: Large abscess >10cm, infected, failure of drug therapy, large left lobe abscess
  • US guided needle aspiration
  • Before aspiration BT, CT, DT- Normal.
  • Inj: Vit K 10mg IM given for 3 days.
  • Aspirant fluid CS should be done
  • Aspirant fluid should be sent for trophozoites



Percutaneous drainage

  • Under US guidance, Pig tail catheter is placed into abscess cavity percutaneously to drain the pus
  • Indication: Failure of USG guided needle aspiration, Multiple abscess, ruptured abscess, if abscess cavity fills again after repeated aspiration or drainage, thick pus.

Abhyanthara Vidradhi Chikitsa

  • In case of Abhyanthara Vidradhi, Varunaadi Kashaya added with Ushakadigana should be given.
  • In Abhyanthara Vidradhi & Parsvasula[8] (pain in flanks ) Siravyadha should be done in between the axilla & breast on the left flank.
  • Role of Paniya Kshara is mentioned in Abhyantara Vidhradhi[9]

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Discussion

Antarvidradhi is a Darunatara Roga which needs an early diagnosis and management. Sushruta while explaining the Samprapti of Vidradhi mentioned about the vitiation of Doshas in Twak, Mamsa, Rakta, Medas, Asthi whereas the same pathology i.e., haematogenous spread is the main source of infection in liver abscess.

Sushruta mentioned that the symptoms of Abhyanthara Vidradhi should be understood as similar with those of Bahya Vidradhi, by means of their Apakva & Pakva Avasthasa and few necessary investigations has to be incorporated for accurate diagnosis.

Acharya Sushruta has laid importance to Raktha Mokshana, Kshara Prayoga in Amavastha and Bhedana Karma in Pakwavastha of Antharvidradhi. In order to save the life of the patient this shows the importance of Shalya Chikitsa as Pradhanatama.


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Advanced technology for diagnosis of liver abscess like USG, X-ray, MRI, CBC, stool examination, etc. is practiced. With the help of these tools diagnosis of Yakrit Vidradhi can be made precisely on the evidence based investigations which may be helpful to correlate with liver abscess.

Conclusion

Yakrit Vidradhi is life threatening condition which needs an early and précised diagnosis and treatment. Stages of liver abscess is a diagnostic challenge for both physician and surgeons based on physical examination alone, therefore relevant investigations are highly suggested to prevent delayed diagnosis which may lead to higher morbidity and mortality. Paneeya Kshara plays an important role in the management of Abhyanthara Vidradi since Kshara has properties like Agni Deepana, Tridoshagna, Dosha Pachana and Ropana. Yakrit Vidradhi is one among Abhyanthara Vidradhi & it can be managed with Shastra Karma where Vyadhana and Visravana are indicated in the management of Vidradhi. The main stay of treatment is adequate drainage and antibiotic regimen.

Reference

1. Ambika Dutt Shastri, Ayurveda-Tattva Sandipika-Hindi commentary on Sushrut Samhita, Chaukhambha Sanskrit Samsathan, Varanasi, Reprint Edition Nidana sthana, 2007; 9/4.

2. Ambika Dutt Shastri, Ayurveda-Tattva Sandipika-Hindi commentary on Sushrut Samhita, Chaukhambha Sanskrit Samsathan, Varanasi, Reprint Edition Nidana sthana, 2007; 9/6, 263, 9/18, 264.

3. Ambika Dutt Shastri, Ayurveda-Tattva Sandipika-Hindi commentary on Sushrut Samhita, Chaukhambha Sanskrit Samsathan, Varansi, Reprint Edition Nidana sthana, 2007; 9/27.

4. Ambika Dutt Shastri, Ayurveda-Tattva Sandipika-Hindi commentary on Sushrut Samhita, Chaukhambha Sanskrit Samsathan, Varansi, Reprint Edition Nidana sthana, 2007; 9/14.

5. Ambika Dutt Shastri, Ayurveda-Tattva Sandipika-Hindi commentary on Sushrut Samhita, Chaukhambha Sanskrit Samsathan, Varansi, Reprint Edition Nidana sthana, 2007; 9/20-22.

6. S Das. A manual of clinical Surgery, 6th edition, editor Soman Das, Calcutta, 2004 june.

7. Bailey and love short practice of surgery, International student edition, 26th edition.

8. Ambika Dutt Shastri, Ayurveda-Tattva Sandipika-Hindi commentary on Sushrut Samhita, Chaukhambha Sanskrit Samsathan, Varansi, Reprint Edition Nidana sthana, 2007; 8/17.

9. Ambika Dutt Shastri, Ayurveda-Tattva Sandipika-Hindi commentary on Sushrut Samhita, Chaukhambha Sanskrit Samsathan, Varanasi, Reprint Edition Nidana sthana, 2007; 11/12.


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