Ruptured amoebic liver abscess with perforated amoebic typhlitis: A rare entity

Background: Amoebic liver abscess (ALA) is the most frequent extra intestinal manifestation of Entamoeba histolytica infection. Rupture of ALA is an important cause of morbidity and mortality mainly in developing countries. In invasive amoebiasis, the trophozoites penetrate the intestinal mucosa causing amoebic colitis. Simultaneous amoebic cecal perforation and ALA rupture is a rare complication of invasive amoebiasis with a high rate of mortality which mainly occurs in malnourished patients. We report 4 rare cases of amoebic cecal perforation with ruptured liver abscess. Cases Patients and Methods: 4 unusual cases of ruptured ALA associated with perforated cecum which were operated at Department of Surgery, Maulana Azad Medical College from June 2016 to May 2017 are reported along with relevant review of literature. Results: Three patients were male and 1 was female. The mean age was 35.5 years. All cases had generalized peritonitis. Two patients had a single abscess in the right lobe, 1 had an abscess in both lobes of liver and 1 had multiple abscesses. Liver abscess in all 4 cases were amoebic as amoebic serology of pus was positive in all cases. At presentation, all 4 cases had clinical signs of generalized peritonitis. Ultrasonography for collection in peritoneal cavity showed moderate free fluid in with internal echoes suggestive of pyoperitoneum. Two patients had free air under the diaphragm. All 4 patients underwent resuscitation and then taken up for surgery. Exploratory laparotomy was done which showed pyoperitoneum. One patient had sealed perforation in the cecum, 2 had a perforation in cecum, and 1 had multiple perforations in cecum and ascending colon. Limited resection was done in 3 cases and right hemicolectomy in 1 case who had multiple perforations in cecum and ascending colon, in all 4 cases, exteriorization of bowel was done. Postoperatively, 1 patient died of respiratory failure due to bilateral pneumonia. Conclusion: Ruptured ALA along with perforation of cecum is a rare condition presenting as acute abdomen with high mortality. Surgical intervention is mandatory in all these cases.