The abscess corresponds to a neoformed cavity created by the necrosis of the hepatic parenchyma induced by the pathogenic agent  . Liver abscesses can be divided according to the infectious agent involved (bacteria, parasites, fungi)  . In Southeast Asia: Amebiasis disease occurs in 15% of healthy carriers and is responsible for 25% of liver abscess    . It is an import pathology because of immigration and tourism    . According to the WHO, 10% of the population is infected, which corresponds to about 500 million people    . In Mali in 2012, 50 cases of liver abscess were diagnosed and treated in the General Surgery Department at CHU Gabriel  . The incidence of non-parasitic abscesses has doubled in the last two decades because of HIV/AIDS. The diagnosis is clinical in front of the Fontan triad, confirmed by ultrasound  . Medical treatment depends on the size of the abscess and the absence of complications  . These complications are: the rupture of the abscess in a hollow organ or in the peritoneal cavity, the extension of close by  . The prognosis depends on early diagnosis and appropriate management  . Lack of study in the service on this pathology motivated us to do this work.
2. Method and Material
This is a 24-month prospective study (January 2016-December 2017) performed in the General Surgery Department at the Kati Reference Health Center (Mali). Have been included all patients admitted for liver abscess and taken care of in the service. During this period 30 patients were hospitalized and treated for liver abscess. Patients on admission received a complete clinical examination, additional examinations. The analysis of these data was done using the SPSS software and the CHI2 test was used with a significance level P < 0.05.
we recorded 30 cases of liver abscess, a hospital frequency of 0.081%. There were 21 men and 9 women, the sex ratio was 2.3 (Figure 1), the average age was 35 years. The most found favoring factors were a history of intestinal amoebiasis 43.3%, chronic alcoholism in 16.7%, toxic products in 3.3%. The most common clinical signs were fever 17 (56.3%), hepatitis 22 (73.3%), hepatomegaly 16 (53.3%) and anorexia 3 (10%), vomiting 2 (6.7%), cough with chest pain 3 (10%).
The physical signs are summarized in Table 1. On abdominal ultrasound the abscess collection was localized in the right lobe in 70%, unique in 62%. The blood count performed made it possible to recover leukocytosis in 23 patients (76.7%) and hyper lymphocytosis in 2 patients, i.e. 6.6%. The average abscess size was 47.1 mm. Amoebic serology performed in all our patients was positive in 80% of cases, i.e. 24 patients. All patients were seronegative for HIV testing. The cytobacteriological study of pus in 13 patients identified Escherichia coli in 6 cases. The chest X-ray performed in 14 patients allowed to observe the
Figure 1. Sex.
Table 1. Physical signs.
elevation of the right diaphragmatic dome in 4 cases. The true complications were the abscesses of abscesses in the peritoneal cavity requiring surgical treatment in 3 patients (10%). Echo-guided puncture in 10 patients (33.3%) and medical treatment alone was effective in 56.7% of cases. The average duration of treatment was 5 days and the patients were followed for 6 months, the evolution was favorable. We did not register any deaths.
The abscess of the liver is very often the consequence of the amebiasis that plagues the underprivileged population and it remains relevant in surgical practice in Mali.
Our frequency of 0.081% does not differ from that of Diaby G.S  and that found in intertropical Africa (1% to 2%). It is rare in industrialized countries  . The abscess of the liver is seen at any age. The mean age of 35.4 years of our study does not differ from that of the literature    . The most affected were men with a sex ratio of 2.3. This male predominance has been found by other authors   . Clinically the liver abscess is in the form of painful and febrile hepatomegaly (Fontan triad). This functional and physical triad has been found by other authors    .
Table 2 contains all the functional signs.
Table 2. Functional signs and authors.
The assessment of hepatomegaly depends on the volume of the abscess and the experience of the examiner. The frequency of 26.7% hepatomegaly in our study differs from that found by the American author   .
Abdominal ultrasound by its ease of realization, its effectiveness and its moderate cost is the examination of choice in the diagnosis and the follow-up of the disease    . It was performed in all our patients upon admission or during hospitalization with 100% sensitivity, specifying the topography, the number and the size of the hepatic collections.
In our study the right lobe was the seat of the abscess in 70% of cases. This localization has been observed by all the authors of the literature    . This is due to the fact that it constitutes a larger tissue mass than that of the left lobe, as well as the relative importance of its vascularization and imperfect mixing in the portal vein of mesenteric and splenic vein flows   . The abscess was unique in 62%, this result does not differ from those of the literature    . The detection of serum antibodies confirms the amoebic origin of the liver abscess   . This examination performed in all our patients was negative in 6 cases.
The cytobacteriological examination of pus makes it possible to distinguish an amoebic abscess from a bacterial abscess   .
Escherichia coli was detected in 20% of the 13 patients who performed this test. Other studies have shown that the detection of amoeba on examination of pus is inconsistent   . Retroviral serology was negative in all our patients. Other authors have found an emergence of liver abscess with the AIDS pandemic    . Imaging techniques have significantly modified the diagnostic and therapeutic aspects of liver abscesses   . These therapeutic techniques differ according to the literature, we have as a method: medical treatment (antiamibien, antibacterial), echo-guided evacuation puncture, percutaneous drainage and conventional surgery    .
Table 3. Evolution and authors.
The medical treatment with nitro-5-imidazoles and/or aminoglycosides associated with third-generation cephalosporins, combined with an echo-guided evacuation puncture is a reference according to the authors    .
Medical treatment was more common in our study, 56.7%. This result does not differ from those of Djossou in France  and Donikian in New Caledonia  .
Echo-guided evacuation puncture is a very popular therapeutic method today   . Our frequency of 33.3% echo-guided puncture does not differ from that of Donikian  .
The indication of this echo-guided puncture differs according to the authors. For some, the size of the abscess > 10 cm and the location at the left lobe are indications   . For others, the indication of the puncture was rather based on clinical criteria including the persistence or aggravation of fever and/or hepatitis 48 to 72 hours after the institution of medical treatment   .
This was also the case in our study.
Surgical treatment of liver abscess is considerably reduced nowadays   . These surgical means are reserved for the only complications namely the rupture of the abscess in the peritoneal cavity, pleural, pericardial, the fistulization of the abscess to the skin, in a hollow viscera and finally the failure of the medical treatment.
In our study this treatment was performed in 3 patients (10%) following rupture of the abscess in the peritoneal cavity.
The evolution of treatment according to the authors is summarized in Table 3.
Hospital stay was 5 days on average.
The abscess of the liver is a topical pathology in surgical practice in our country. Medical treatment is curative apart from complications. Echo-guided puncture is a very common therapeutic method nowadays that makes it possible to reduce the length of hospital stay. This surgical treatment is reserved for complications.