A case of psoas abscess due to renal pelvic carcinoma complicated with non-ketotic hyperosmolar diabetic coma]

A 85-year-old man was admitted to our hospital because of semicomatous status. Laboratory data on admission showed elevation of blood sugar (823 mg/dl) and serum osmotic pressure (345 mOsm/l), but ketonuria was not detected. Non-ketotic hyperosmolar diabetic coma was diagnosed. The insulin infusion and physiological saline improved the blood sugar level and consciousness within a day. The abdominal ultrasound examination revealed an abscess in the left kidney and right psoas muscle. The same findings were seen by abdominal computed tomography but the possibility of malignant neoplasm of the left kidney could not be ruled out because of a swelling of the left adrenal gland. Pain associated with psoas abscess and low grade fever were observed. Because of his poor general condition, drainage of the abscess was not performed and conservative therapy using antibiotics was administered. Without any improvement of the abscess, he died due to general deterioration four months later. Autopsy findings showed carcinoma of the left renal pelvis and metastasis to the right psoas muscle, left adrenal gland, liver, bilateral lungs and lymph modes. Psoas abscess is a relatively uncommon disease, especially in elderly patients. The etiology of the disease is divided into primary and secondary causes. Most secondary psoas abscess cases are caused by intestinal diseases, and Crohn's disease has been related to the highest incidence. A few cases of psoas abscess caused by colorectal carcinoma have been reported. Ultrasound and computed tomography are useful in diagnosing this disease and drainage of an abscess is necessary for therapy and proving the cause. Cancer metastasis should considered in differential diagnoses, when psoas abscess is seen in elderly patients.     

Comparison of 99m technetium hexamethylpropylene-amine oxime labelled leucocyte with 111-indium tropolonate labelled granulocyte scanning and ultrasound in the diagnosis of intra-abdominal abscess.

Fifty patients with suspected intra-abdominal abscess were investigated prospectively with ultrasound and with 99mTc-hexamethylpropylene-amine oxime (HMPAO) isotope labelled mixed leucocytes, using 111-In tropolonate granulocyte scanning as the reference standard. Twenty five patients had inflammatory bowel disease (three were postoperative): 21 of these had Crohn's disease and four had ulcerative colitis. The remainder comprised nine with postoperative fever and 16 with fever and abdominal pain. An abscess was diagnosed when focal activity on serial 111-In tropolonate and 99m-Tc-HMPOA images at one, three, and 24 hours resulted in activity at least equal to liver activity at 24 hours. Thirteen abscesses were diagnosed using each type of white cell scanning, resulting in 100% sensitivity for 99m-Tc-HMPAO compared with 111-In tropolonate. Bowel inflammation was easily distinguished from abscess on serial images. Eight of these 13 abscesses were detected by ultrasound. Altogether 17 abscesses were found. Ultrasound detected 12, including four liver abscesses which were not purulent and had not been detected by white cell scanning. Ultrasound had a sensitivity of 71% (12 of 17) and a specificity of 87% (33 of 38) using all confirmed abscesses as the reference standard. White cell scanning showed a sensitivity of 76% (13 of 17: as a result of the four non-purulent liver abscesses) and a specificity of 100%. 99m-Tc-HMPAO scanning is as accurate as 111-In tropolonate scanning, and has several advantages including simplicity, availability, superior image quality, and reduced radiation dose. Both methods are more sensitive and specific than ultrasound for intra-abdominal abscess detection but ultrasound is advisable if a neutrophil infiltrate is not suspected.     

Tuberculose pseudotumorale de la vésicule biliaire

Gallblader tuberculosis is uncommon and may mimic a neoplasia. We report a 55-year-old man who presented with fever and abdominal pain compatible with cholecystitis. Abdominal ultrasound and computed tomographic scan showed a tumoral aspect of the bottom of the gallbladder and invasion of adjacent liver. Diagnosis of pseudo-tumoral gallbladder tuberculosis was obtained with the histologic examination of surgical sampling. Disease course was uneventful with appropriate antituberculous therapy.     

老年人糖尿病合并细菌性肝脓肿的超声介入治疗

目的 评价超声引导下穿刺抽脓及置管引流治疗老年人糖尿病合并细菌性肝脓肿的临床应用价值。方法 对46例老年糖尿病合并细菌性肝脓肿的患者进行经超声引导下脓汁抽吸、置管引流治疗。结果 46例患者穿刺抽脓及置管引流全部成功，治愈率93．5％（43／46），所有患者均未出现穿刺并发症。随后30、60、180d经门诊随访未见复发。结论 超声引导下介入治疗老年人糖尿病合并细菌性肝脓肿安全、有效，可以明显缩短疗程，可作为首选的治疗方法。     

A case of amoebic liver abscess complicated by a gastric fistula cured with oral medication only

A 26-year-old man was admitted to our hospital because of a high-grade fever and abdominal pain. A blood test showed marked inflammation. Enhanced computed tomography (CT) showed an 8.0×6.0cm cystic lesion in the left hepatic lobe. Esophagogastroduodenoscopy showed a huge egg-yolk-like mass in the gastric submucosa in the lesser curvature of the gastric body from the gastric angle. There were 3 ulcers on the mass, out of which milky pus flowed. Trophozoites of Entamoeba histolytica were detected from cultures of the liver abscess and a biopsy of the gastric ulcers. The amoebic dysentery antibody titer was increased 1600 times. An amoebic liver abscess complicated by a gastric fistula was diagnosed. As therapy, oral metronidazole was administered for 2 weeks without percutaneous drainage. The systemic inflammatory findings improved immediately and the abscess decreased markedly in size.     

A case of gas-forming liver abscess with diabetes mellitus

A 43-year-old man was admitted to our hospital with right hypochondriac and epigastric pain. An abdominal radiograph showed a large niveau in the right subphrenic space. An abdominal CT scan demonstrated a large liver abscess (diameter, 13 cm) with gas formation. Klebsiella pneumoniae cells were isolated from the abscess, and the patient was treated with antibiotics and percutaneous drainage. It is very important to treat gas-forming liver abscess immediately, because subsequent bacteremia and septic shock are frequently noted, and the associated mortality rate is high.     

Splenic abscess and sickle cell disease

This is a report of our experience with 10 cases of splenic abscess in patients with sickle cell disease (SCD). All presented with fever and abdominal pain and were found to have a tender enlarged spleen. Two were found to have a ruptured spleen and five of them were septicemic on presentation. Although both ultrasound and CT-scan of the abdomen were of diagnostic value, we found CT-scan more accurate and reliable in the diagnosis of splenic abscess. Ultrasound and/or CT-scan should be used routinely in the evaluation of SCD patients who present with fever and abdominal pain, especially if they have a tender enlarged spleen. Diagnostic aspiration under CT-scan or ultrasound guidance should be used in doubtful cases to differentiate between splenic abscess and a large splenic infarct. All our patients were managed by peri operative antibiotics and splenectomy with no mortality. Salmonella was the commonest causative organism. Although CT-guided aspiration of splenic abscess is being advocated recently, we feel splenectomy should be the treatment of choice in patients with SCD as there is no point in preserving a non-functioning spleen that is present in the majority of patients. CT-guided aspiration may be employed as a temporary measure for those patients who are at high surgical risk with unilocular abscess. Am. J. Hematol. 58:100–104, 1998. © 1998 Wiley-Liss, Inc.     

A case of tuberculous mesenteric lymphadenitis detected by abdominal symptom after 4 months' antituberculous chemotherapy against pulmonary tuberculosis

We reported a case of tuberculous mesenteric lymphadenitis. A twenty three year old man was admitted to our hospital with pulmonary tuberculosis on May, 1988. Chest X ray findings improved after 4 months' antituberculous chemotherapy, but he complained of right lower abdominal pain and a mass with tenderness. Barium series of gastro-intestinal tract showed evidence of extrinsic compression on the intestine. Abdominal CT showed rim enhancement and a multiloculated appearance, and the ultrasonography showed a hypoechoic mass. But we did not make a definite preoperative diagnosis, therefore exploratory operation was done. An abscess with caseous granuloma was found in the mesenteric lymphnodes removed at laparotomy.     

Ruptured abdominal aortic aneurysm secondary to tuberculous spondylitis.

A 69-year-old man was admitted with low back pain and signs of nerve root compression. A computed tomography (CT) scan showed abscess formation in the left psoas region, spondylodiscitis L3-L4 and a ruptured abdominal aortic aneurysm. The aortic aneurysm was replaced with a bifurcated vascular graft. One week later, laminectomy at the L4-level was done. In a small abscess, Mycobacterium bovis was found. The condition was considered to be a mycobacterial spondylitis secondary to BCG instillations of the urinary bladder for carcinoma. The patient received antituberculous medication for 9 months. Subsequently bone transplantation and internal fixation of the spine became necessary. Three years after surgery he is in good condition and there are no signs of graft infection on CT. Spondylitis and mycotic aortic aneurysm should be kept in mind in patients who have been treated for carcinoma of the bladder with BCG instillations.     

CASE REPORT: Gallbladder Vasculitis Associated with Type-1 Cryoglobulinemia

A patient with type I cryoglobulinemia and monoclonal gammopathy of uncertain significance was found to have acute gallbladder vasculitis. The most prominent manifestation was upper abdominal pain in the setting of normal liver tests. An abdominal ultrasound demonstrated a thickened gallbladder wall, along with gallstones. HIDA scanning showed a nonfunctioning gallbladder with an edematous and thickened wall. There was characteristic leukocytoclastic vasculitis affecting the gallbladder. The patient recovered uneventfully subsequent to cholecystectomy. Gallbladder vasculitis should be considered in patients with unexplained upper abdominal pain and systemic vasculitis.     

Diagnosis of Chilaiditi's syndrome with abdominal ultrasound.

Chilaiditi's sign is a radiographic term used when the hepatic flexure of the colon is seen interposed between the liver and right hemidiaphragm. When symptomatic, this is Chilaiditi's syndrome. We report a case of a 70-year-old man who presented with abdominal pain, vomiting, singultus and constipation. Ultrasound was initially performed which showed an intestinal loop between the anterior surface of the right liver lobe and the diaphragm. The chest X-ray revealed colon gas under the right diaphragma and the abdominal CT-scan confirmed the hepatodiaphragmatic interposition of the colon. Colonic elongation and laxity of colonic and hepatic suspensory ligaments are the principal predisposing factors. The advantages of the abdominal ultrasound in the diagnosis and follow-up as well as possible complications and forms of therapy with this syndrome are discussed.     

Liver abscess caused by periodontal bacterial infection with Fusobacterium necrophorum

Liver abscess is recognized as a life‐threatening disease. However, even in recent years, approximately 50% of liver abscess cases are considered to be cryptogenic. Here, we report a case of liver abscess associated with periodontal bacterial infection by Fusobacterium necrophorum, which is commonly found in the oropharyngeal flora. A 36‐year‐old man presented with fever and contrast‐enhanced abdominal computed tomography revealed multiple liver abscesses. F.necrophorum was isolated from oral smears, liver aspirates and blood samples. Liver abscesses caused by periodontal bacterial infection are rare, however, the incidence is expected to increase in the future, as periodontitis is extremely common and is on the rise as one of the most common chronic infections in the world. A systemic survey including periodontitis may be required for the exact diagnosis of the source of infection.     

A case of primary neuroendocrine carcinoma of liver presenting with liver abscess]

Primary hepatic neuroendocrine cell carcinoma is a very rare tumor. We experienced a 75-year-old woman with primary hepatic neuroendocrine carcinoma presenting with pyogenic liver abscess. Abdominal CT scan revealed a multiseptated liver abscess and an enlarged lymph node in portocaval portion. We performed percutaneous drainage of the liver abscess, but the amount of drained pus did not decrease after 20 days. The follow-up abdominal CT scan showed that the cystic portion of liver abscess had been replaced by the solid tumor. Microscopic examination of the tumor tissue showed nests of epithelial cells with uniform round hyperchromatic nuclei and high nuclear to cytoplasmic ratio. Immunohistochemical staining was strongly positive for synaptophysin and chromogranin A.     

échographie dans les abcès hépatiques à germes pyogènes chez les diabétiques

Ojectives

Evaluate different echographic aspects pyogenic liver abscess in diabetic patients, and compare them with those described in the literature in non-diabetic.

Materials and Methods

A retrospective study over a period of 10 years of the records of diabetic patients with pyogenic liver abscess who underwent an abdominal ultrasound study.

Results

The mean age of patients was 57±16.7 years old with a male predominance. All patients had type 2 diabetes. The clinical signs were mainly the right upper quadrant pain, hepatomegaly, impaired general condition and fever. The right liver was the most affected. The ultrasound appearances were polymorphic, mostly anechoic and heterogeneous. Rupture of abscesses into the abdominal cavity was noted in two patients, which requiring surgical treatement. Treatement consisted in insulinotherapy and antibiotherapy. The evolution was favorable in all cases.

Conclusion

The ultrasound appearances of hepatic abscesses in diabetics are polymorphic and depend on the evolutionary stage. They do not differ from those reported in the literature in non-diabetics.     

肝结核5例诊治分析

[目的]分析肝结核的临床表现、影像学特点及治疗措施,提出诊治对策,提高诊断能力.[方法]回顾性 分析5例肝结核患者的病历资料,以期提高对肝结核的诊断及认识.[结果]5例中,以脐周痛、发热为主要表现1例,以右上腹痛表现1例,以右下胸痛为主要表现1例,以肝功能损害为主要表现1例,以腹胀、多浆膜腔积液为主要表现1例；其中3例经病理及影像学检查确诊,另2例为临床诊断考虑肝结核,给予抗结核治疗有效.[结论]肝结核可表现为腹痛、腹胀,也可无明显腹部症状,或仅有肝功能损害及表现为多浆膜病变；腹部CT表现为肝脏结节,增强后可强化,或有钙化表现；病理活检是金标准,表现为肉芽肿性炎.对于有肺结核病史,近期出现发热、纳差、腹痛、肝脏肿大伴触痛、血沉增高、肝功能异常尤其是γ-GT增高、贫血、甲胎蛋白正常,结合腹部CT及B超表现需考虑肝结核的可能.     

胆囊周围脓肿的超声表现

目的探讨超声影像技术在胆囊周围脓肿（简称囊周脓肿）诊断中的价值。方法使用彩色多普勒超声诊断仪,对经临床证实的囊周脓肿的63例行各种切面扫查。详细观察胆囊炎性改变情况,囊周脓肿的大小、形态、范围及回声情况,脓肿与毗邻组织脏器间的关系等,将异常所见摄片记录。结果 63例中接受手术治疗45例,术中发现与囊周组织均有不同程度的粘连。囊周脓肿术前超声诊断与手术所见基本符合率100%（34/34）,脓肿对囊周组织器官的炎性粘连、包裹,超声判定与术后诊断基本符合率为82.35%（28/34）。结论超声对囊周脓肿具有较高诊断价值。     

Isolated tubercular liver abscess in children treated with percutaneous isoniazid infusion

Isolated Tubercular liver abscess is mainly reported in adult patients. We report two cases of isolated tubercular liver abscess in paediatric patients. Diagnosis was made by clinical and ultrasound guided aspiration of pus showing acid fast bacilli in one case. In second case, biopsy of the abscess wall was confirmatory. In both cases percutaneous drainage of pus and transcatheter infusion of Isoniazid was given. After two weeks of infusion no acid fast bacilli was detected and cavity size decreased. Direct infusion of anti-tubercular drugs is more efficient than systemic therapy alone. This is first of its kind in treating isolated tubercular abscess in paediatric patients. So, percutaneous infusion of anti-tubercular agents can be considered in the treatment of tubercular liver abscess.     

Endoscopic removal of chicken bone that caused gastric perforation and liver abscess.

A 40-yr-old gentleman presented with abdominal pain, nausea and vomiting since 3 weeks. CT scan of the abdomen showed a liver abscess but also a bone penetrating the left lobe of the liver. A 5-cm-long chicken bone was removed endoscopically. He was discharged on day 8 and was asymptomatic 12 months later. Endoscopic retrieval of an extraluminal foreign body causing liver abscess has not been reported previously.     

腹部手术后腹腔脓肿处理的临床观察

目的 :观察腹腔脓肿患者的诊断和治疗结果。方法 :回顾性分析 1992～ 2 0 0 1年诊治的 4 3例腹腔脓肿患者的临床资料。结果 :腹部手术后腹腔脓肿 4 3例 ,经 B超及 CT检查确诊后 ,根据脓肿部位及大小分别药物治疗 14例 ,脓肿穿刺抽脓 12例 ,脓肿置管引流 7例 ,手术引流 10例 ,均治愈。结论 :腹腔脓肿是腹部手术后常见的并发症 ,应注意预防、早期诊断和及时有效引流     

Clinical and histological recovery from “life-threatening” severe acute alcoholic hepatic failure with complete hepatofugal portal blood flow

A 25-year-old man who was a heavy alcohol drinker was admitted to our hospital after presenting with general malaise, dyspnea, abdominal distension, systemic edema and jaundice. His liver function tests showed hyperbilirubinemia and prolonged prothrombin time, and a computed tomography scan and ultrasound showed liver atrophy and massive ascites. Furthermore, Doppler ultrasound revealed complete hepatofugal portal blood flow in the portal trunk and intrahepatic portal branches. Causes other than alcohol were excluded, and he was diagnosed as having severe acute alcoholic hepatic failure (Maddrey’s discriminant function score 43.3, MELD score 21), although not clinically typical. He was treated with anti-coagulation therapy according to the precise evaluation of portal blood flow by Doppler ultrasound, and marked clinical, biochemical and hemodynamic improvements were observed. Liver biopsy performed 2 months after onset showed submassive necrosis with pericellular fibrosis. Liver biopsy performed three years after onset showed mild portal fibrosis with a marked improvement. Doppler ultrasound is an indispensable tool for evaluating patients with severe acute hepatitis.