Page 216 - Medicine and Surgery
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                   212 Chapter 5: Hepatic, biliary and pancreatic systems


                   Management                                   Intravenous broad-spectrum antibiotics until bacterial
                   d-penicillamine(acopper-chelatingagent)depletescop-  culture and sensitivities are available.
                   perstores. Patients should avoid foods high in copper
                   (chocolate, nuts and dried fruits). Siblings and children  Prognosis
                   of affected individuals should be screened. If diagnosed  Poor prognostic factors are co-existent biliary tract dis-
                   and treated sufficiently early, there is some improvement  ease, old age and multiple abscesses.
                   in liver function and further deterioration is arrested.
                                                                Amoebic liver abscess
                   Pyogenic liver abscess                       Definition
                                                                Infection of the liver by Entamoeba histolytica.
                   Definition
                   The development of liver abscesses is thought to follow
                                                                Aetiology/pathophysiology
                   bacterial infection elsewhere in the body.
                                                                E.histolyticaisaprotozoanthatinfectsthelargeintestine.
                                                                The infection water is food borne and is most common
                   Aetiology/pathophysiology                    in parts of the world with poor sanitation, e.g. Far East
                   Enteric Gram negative and anaerobic organisms, e.g.  and Africa. Ingestion of the cysts results in the release
                   Strep. milleri.Infection may reach the liver by the portal  of trophozoites in the intestine, which are thought to
                   vein from a focus of infection drained by the portal vein,  invade through the mucosa gaining entry to the portal
                   e.g. diverticulitis, appendicitis, infected haemorrhoids.  blood system and then spread to the liver.
                   Infection may also result from a generalised septicaemia
                   or direct spread from the biliary tree.      Clinical features
                                                                The onset of symptoms may be sudden or insidious.
                   Clinical features                            Symptoms include right upper quadrant pain, anorexia,
                   Symptoms and signs range from mild to severe, often  nausea, weight loss and night sweats. Tender hepatic en-
                   the symptoms are less marked in elderly patients, with  largement without jaundice is usual. Basal pulmonary
                   a mild fever with or without pain and hepatomegaly. In  collapse and pleural effusion may occur.
                   severe cases patients present with upper abdominal pain,
                                                                Complications
                   swinging fever, anorexia, malaise and weight loss.
                                                                Rupture, secondary infection and septicaemia. Meta-
                                                                static brain abscesses have been reported.
                   Macroscopy/microscopy
                   Maybe single or multiple lesions ranging from a few
                                                                Investigations
                   millimetres to several centimetres in size.
                                                                Ultrasound or CT of the abdomen can show the abscess.
                                                                Blood tests include blood culture and serological tests.
                   Investigations
                                                                Guided aspiration and stool ova, cyst and parasite exam-
                   Ultrasound scan is useful for screening, and pus may be
                                                                ination may demonstrate the organism.
                   aspiratedforcultureunderitsguidance.Furtherimaging
                   may include CT or MRI of the abdomen. Blood cultures,  Management
                   liver function tests and inflammatory markers should  Treated with metronidazole. Percutaneous aspiration is
                   be sent. A raised alkaline phosphatase may be the only  used in resistant cases.
                   marker.
                                                                Hydatid disease
                   Management
                   Repeated ultrasound guided aspirations may be re-  Definition
                   quired. Extensive, difficult to approach abscesses are  A tapeworm infection of the liver common in sheep rear-
                   drained by open surgery, with soft pliable drains.  ing areas such as Greece, Australasia and Wales.
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