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Image-guided percutaneous procedure plus metronidazole versus metronidazole alone for uncomplicated amoebic liver abscess

  1. Norberto C Chavez-Tapia*,
  2. Jorge Hernandez-Calleros,
  3. Felix I Tellez-Avila,
  4. Aldo Torre,
  5. Misael Uribe

Editorial Group: Cochrane Hepato-Biliary Group

Published Online: 21 JAN 2009

Assessed as up-to-date: 4 APR 2008

DOI: 10.1002/14651858.CD004886.pub2


How to Cite

Chavez-Tapia NC, Hernandez-Calleros J, Tellez-Avila FI, Torre A, Uribe M. Image-guided percutaneous procedure plus metronidazole versus metronidazole alone for uncomplicated amoebic liver abscess. Cochrane Database of Systematic Reviews 2009, Issue 1. Art. No.: CD004886. DOI: 10.1002/14651858.CD004886.pub2.

Author Information

  1. Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Department of Gastroenterology, Mexico City, Distrito Federal, Mexico

*Norberto C Chavez-Tapia, Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga #5, Mexico City, Distrito Federal, 14000, Mexico. khavez@gmail.com.

Publication History

  1. Publication Status: New
  2. Published Online: 21 JAN 2009

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Abstract

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

Background

Metronidazole is the standard of care for uncomplicated amoebic liver abscesses (considering that complicated liver abscesses are those localized in left lobe, multiple, and/or pyogenic abscesses). However, a subset of patients with amoebic liver abscesses remain symptomatic, with a significant risk of rupture of the abscess into the peritoneum. The role of image-guided percutaneous therapeutic aspiration in these patients remains controversial.

Objectives

To assess the beneficial and harmful effects of image-guided percutaneous procedure plus metronidazole versus metronidazole alone in patients with uncomplicated amoebic liver abscess.

Search methods

We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials in The Cochrane Library (Issue 2, 2007), MEDLINE (1966 to November 2007), EMBASE (1988 to September 2007), and Science Citation Index Expanded (1945 to September 2007).

Selection criteria

Randomised or quasi-randomised trials comparing an image-guided percutaneous procedure plus metronidazole versus metronidazole alone in patients with uncomplicated amoebic liver abscess.

Data collection and analysis

Inclusion criteria, trial quality assessment, and data extraction were done in duplicate. We calculated relative risks (RR) and mean differences, and checked for heterogeneity by visual inspection of forest plots and chi-squared and I2 tests.

Main results

Seven low quality randomised trials were included. All studies included a total of 310 patients, but due to selective outcome reporting bias, less patients could be included in our analyses. Pooled analysis of three homogenous trials showed that needle aspiration did not significantly increase the proportion of patients with fever resolution (RR 0.60, 95% confidence interval (CI) 0.22 to 1.61). Sensitivity analysis according to trial quality preserved these findings. Trials that evaluated resolution of abdominal pain, days to resolution of fever, pain, resolution of abscess cavities, reduction in liver size, and duration of hospitalisation were heterogeneous. The benefits in the number of days to resolution of pain (MD -1.59, 95%CI -2.73 to -0.42), number of days to resolution of abdominal tenderness (MD -1.70, 95%CI -2.86 to -0.54), and duration of hospitalisation (MD -1.31, 95%CI -2.05 to -0.57) were observed in the needle aspiration group only.

Authors' conclusions

Therapeutic aspiration in addition to metronidazole to hasten clinical or radiologic resolution of uncomplicated amoebic liver abscesses cannot be supported or refuted by the present evidence. The trials lack methodological rigour and adequate sample size to conclude on the presence of effectiveness of adjunctive image-guided aspiration plus metronidazole versus metronidazole alone. Further randomised trials are necessary.

 

Plain language summary

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

Percutaneous needle aspiration does not seem to help patients with uncomplicated amoebic liver abscesses

Amoebiasis (disease caused by the protozoan Entameoba histolytica) remains an important clinical problem in countries around the world, with 40 to 50 million people affected. Mortality rates are significant, with 40,000 to 110,000 deaths each year. In fact, amoebiasis mortality is second only to malaria as cause of death from protozoan parasites. The most common complication of amoebiasis is the formation of a pus-filled mass inside the liver (liver abscess). Metronidazole is the drug of choice for treatment of amoebic liver abscesses followed by a luminal agent to eradicate the asymptomatic carrier state. Cure rates are 95% with disappearance of fever, pain, and anorexia within 72 to 96 hours. This review compares the standard treatment with a more invasive alternative, where pus-filled mass is drained by image-guided percutaneous procedure (performed through the skin). Seven low quality randomised trials were included. All the seven studies included a total of 310 patients, but due to selective outcome reporting bias, less patients could be included in our analyses. Pooled analysis of three homogenous trials showed that needle aspiration did not significantly increase the proportion of patients with fever resolution. Benefits could be observed in resolution time of pain and tenderness. No additional benefit has been found with percutaneous needle aspiration plus metronidazole versus metronidazole alone for uncomplicated amoebic liver abscesses in hastening clinical and radiologic resolution. However, this conclusion is based on trials with methodological flaws and with insufficient sample sizes, and requires further confirmation in larger well-designed, randomised trials.

 

摘要

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

背景

影像引導經皮穿刺抽吸合併metronidazole對照metronidazole單一治療無併發症阿米巴肝膿腫

metronidazole是治療無併發症阿米巴肝膿腫的標準(認為發生在肝左葉的複雜肝腫膿,多發性腫膿和化膿性膿腫)。 但是,少量的阿米巴肝膿腫病人會有症狀,膿腫突然爆裂至腹膜的風險特別高。人們對於影像導航用於經皮穿刺抽吸治療膿腫病人的作用還存有爭議。

目標

評估影像引導經皮穿刺抽吸合併metronidazole對照metronidazole單一治療無併發症阿米巴肝膿腫的利弊。

搜尋策略

我們搜尋Cochrane HepatoBiliary Group Controlled Trials Register, Cochrane Library(第2期, 2007)的Cochrane Central Register of Controlled Trials, MEDLINE (1966 年−2007年9月), EMBASE (1988年−2007年9月)和Science Citation Index Expanded (1945年 2007年9月)。

選擇標準

影像引導經皮穿刺抽吸合併metronidazole對照metronidazole單一治療無併發症阿米巴肝膿腫的隨機或半隨機試驗。

資料收集與分析

文獻回顧者負責收錄標準,試驗品質評估,資料提取,製作成2份。 我們評估相對風險 (relative risks ,RR) 平均差,透過目測森林圖及卡方和I2檢定,我們檢查試驗的異質性。

主要結論

共包括7個品質低的隨機試驗。研究共包括310 位病人,但是由於選擇結果存在偏誤,我們的分析僅包括了較少的病人。合併3個同性質的試驗之後,結果顯示穿刺術沒有顯著增加有發熱緩解的病人比例(RR 0.60, 95%CI 0.22 1.61)。 依據試驗品質、敏感性分析保存這些發現結果。 評估腹痛緩解、發熱緩解天數、膿腫腔緩解、肝臟大小的縮小和住院日的試驗具異質性。只有穿刺抽吸組觀察了在疼痛緩解天數(MD −1.59, 95%CI −2.73  0.42),腹部壓痛緩解天數(MD −1.70, 95%CI −2.86  0.54)和住院日(MD −1.31, 95%CI −2.05  0.57)上的效益。

作者結論

另外,目前證據不能支持或反對抽吸治療合併metronidazole能夠在臨床或應用放射學方面,促進無併發症阿米巴肝膿腫的緩解。試驗缺乏嚴謹方法論和適當的樣本大小 決定輔助影像引導抽吸法合併metronidazole對照metronidazole單一治療的有效性。需要深入的隨機試驗。

翻譯人

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

經皮穿刺抽吸似乎不能幫助無併發症阿米巴肝膿腫的病人: 阿米巴病 (由單細胞阿米巴原蟲引起的疾病) 仍然是世界各個國家一大重要的臨床問題,4百萬−5百萬的人受到該疾病的影響。死亡率顯著,大約每年死亡案例達到40,000 110,000起。實際上,阿米巴病死亡是唯一第2種由於原生寄生蟲致死的瘧疾。阿米巴病引起的最常見併發症是讓肝臟內部充滿了膿腫塊(肝臟膿腫)。metronidazole是使用管腔劑之後治療阿米巴肝膿腫的一種方案消除無症狀載體的狀態。治癒率達到95%,發熱,疼痛和厭食在72 96小時內消失。本次文獻回顧比較標準治療和更激進的替代療法,透過影像引導經皮穿刺抽吸排泄膿腫塊(穿透皮膚實施)。共包括7個品質低的隨機試驗。7個研究共包括310位病人但是由於選擇結果存在偏見,我們的分析包括較少的病人。合併3個同性質的試驗之後, 穿刺抽吸術顯著增加有發熱緩解的病人比例。從疼痛和壓痛緩解時間可以觀察到這種有益療效。發現經皮穿刺抽吸合併metronidazole對照metronidazole單一治療無併發症阿米巴肝膿腫的過程中,在促進臨床和放射緩解方面,沒有顯示額外有益的療效。 但是,這種結論是建立在研究方法有缺陷,樣本大小不足的基礎上得到的,需要在大規模,設計良好的隨機試驗中確認。