Liver abscess is a common condition in India which is associated with high morbidity and mortality. ALA is the most common extra intestinal site of infection but occurs in only less than 1% of E.histolytica infections. The mortality rate has been estimated to be around 0.2–2.0% in adults and up to 26% in children. There are many options in managing amoebic liver abscess such as medical management, percutaneous or open surgical drainage. Until now there have been no studies which have compared the therapeutic efficacy between pigtail drainage and conservative management in medium–sized (5 to 10 cm). Nor is there any prospective study aimed at identifying parameters for instituting medical management versus drainage procedure for abscesses measuring between 5.0 and 10.0 cm. The aim of this paper is to compare the efficacy of conservative medical management to ultrasound–guided pigtail drainage and establish objective criteria for the management of such abscesses. This is a prospective study of 100 cases of amoebic liver abscess (ALA) of medium size (5 to10cm) presenting to the Surgical Emergency and Surgical Outpatient Department of SMIMER Hospital from the period January 2018 to March 2019. All patients included were diagnosed as having an amoebic liver abscess (ALA) based on a history of anorexia, malaise, fever and pain abdomen with or without a preceding history of diarrhea and findings of tender hepatomegaly, intercostal tenderness, leukocytosis amoebic serology (ELISA) and ultrasound evidence of amoebic liver abscess. Patients were randomly allocated into two groups by double–blinded secret envelop method. Group, I patients consisted of 50 patients who were treated with anti–amoebic (metronidazole 750 mg tid/IV 500mg 6 hourly) and antibiotic (ciprofloxacin 500 mg bd) drugs. Group II patients also consisted of 50 patients who were treated by ultrasound–guided indwelling pigtail catheter drainage in addition to anti–amoebic (metronidazole) and antibiotic (ciprofloxacin) drugs. Improvement in pain, fever, anorexia and clinical signs of hepatomegaly, pulse rate, respiratory rate, and USG abdomen within 72 hours of an institution of therapy was considered as criteria for continuing that particular modality of treatment. At three to five days, patients’ outcome was assessed and if they did not respond to the first modality of treatment, the patient was subjected to the second modality of treatment, i.e. conservative converted to pigtail insertion and patients with pigtail insertion for drainage. A comparison was made between clinical signs and investigations to assess the patients. It was found all patients of Study Group II (pigtail drainage) had earlier improvement of all parameters of response to than patients in Study Group I (conservative management) this response was significant. Another significant finding of this study was abscesses of size >10cm should be aspirated or drained. This study showed that the abscesses of size between 6.0 cm to 10.0 cm should be taken up for pigtail catheter drainage at presentation as the time of resolution and improvement in clinical and investigative parameters were more rapid in Group II as compared to Study Group I with almost no complications associated with pigtail insertion. For abscesses >10 cm and in those ALA associated with complications insertion of pigtail was beneficial. Abscesses less than 6.0 cm could be managed with medical treatment alone.