Pyogenic liver abscess:An audit of 10 years’experience

AIM:To describe our own experience with pyogenic liver abscesses over the past 10 years and investigate the risk factors associated with failure of initial percutaneous therapy.METHODS:A retrospective study of records of 63 PLA patients presenting between 1998 and 2008 to Australian tertiary referral centre,were reviewed.Amoebic and hydatid abscesses were excluded.Demographic,clinical,radiological,and microbiological characteristics,as well as surgical/radiological interventions,were recorded.RESULTS:Sixty-...     

Pyogenic liver abscess：An audit of 10 years’experience

AIM: To describe our own experience with pyogenic liver abscesses over the past 10 years and investigate the risk factors associated with failure of initial percutaneous therapy.METHODS: A retrospective study of records of 63 PLA patients presenting between 1998 and 2008 to Australian tertiary referral centre, were reviewed. Amoebic and hydatid abscesses were excluded. Demographic, clinical, radiological, and microbiological characteristics, as well as surgical/radiological interventions, were recorded.RESULTS: Sixty-three patients (42 males, 21 females) aged 65 (± 14) years [mean ± (SD)] had prodromal symptoms for a median (interquartile range; IQR) of 7 (5-14) d. Only 59% of patients were febrile at presentation; however, the serum C-reactive protein was elevated in all 47 in whom it was measured. Liver function tests were non-specifically abnormal. 67% of patients had a solitary abscess, while 32% had > 3 abscesses with a median (IQR) diameter of 6.3 (4-9) cm. Causative organisms were: Streptococcus milleri 25%, Klebsiella pneumoniae 21%, and Escherichia coli 16%. A presumptive cryptogenic cause was most common (34%). Four patients died in this series: one from sepsis, two from advanced cancer, and one from acute myocardial infarction. The initial procedure was radiological aspiration ± drainage in 54 and surgery in two patients. 17% underwent surgical management during their hospitalization. Serum hypoalbuminaemia [mean (95% CI): 32 (29-35) g/L vs 28 (25-31) g/L, P = 0.045] on presentation was found to be the only factor related to failure of initial percutaneous therapy on univariate analysis.CONCLUSION: PLA is a diagnostic challenge, because the presentation of this condition is non-specific. Intravenous antibiotics and radiological drainage in the first instance allows resolution of most PLAs; However, a small proportion of patients still require surgical drainage.     

Inflammatory pseudo-tumor of the liver: is pre-operative diagnosis possible?

Inflammatory pseudo-tumors of the liver are rare and difficult to diagnose, mimicking malignant tumors. OBJECTIVES: To specify the circumstances of detection and the clinical, biological, radiological and pathological features of inflammatory pseudo-tumors, in order to improve preoperative diagnosis. METHODS: Diagnosis of inflammatory pseudo-tumors of the liver was performed on surgical specimens in 8 patients from January 1987 to January 2001. We retrospectively analyzed the clinical, biological, radiological and pathological features of these 8 inflammatory pseudo-tumors. RESULTS: All the patients (5 females and 3 males) presented a chronic infectious syndrome and/or previous history of chronic inflammatory disease. The correlation between biological, radiological and pathological aspects showed two distinctive types of inflammatory pseudo-tumors: a type revealed by a biological inflammatory syndrome, with a non encapsulated, heterogeneous and hypervascular lesion at imaging, and a dense fibroblastic inflammatory pseudo-tumor with portal endophlebitis on histology (n=5), and a type without inflammatory syndrome, with an encapsulated, homogeneous, hypovascular lesion at imaging and abundant necrosis on histology (n=3). CONCLUSION: The analysis of previous history, of clinical, biological and radiological presentations, specially MRI, could predict the diagnosis of inflammatory lesion which must be confirmed by trans-parietal biopsy to avoid inappropriate radical hepatectomy.     

Salmonella Paratyphi A liver abscess—Secondary infection of an amoebic liver abscess?

Liver abscess is a rare complication of both enteric fever and non-enteric salmonella infection. We present an unusual case of Salmonella Paratyphi A liver abscess, where secondary bacterial infection of an amoebic liver abscess was suspected.     

Colorectal carcinoma: is screening possible?

Colorectal cancer (CRC) is a major health problem in western countries. It is the most frequently diagnosed cancer in EU countries with about 220,000 new cases per year; the number of CRC deaths approaches 112,000. Most cancer arises from adenomatous polyps through the adenoma-carcinoma sequence; the natural history of the disease is long: the risk of invasive cancer in adenoma is about 2% per year. Given the natural history of CRC, early diagnosis represents the most appropriate tool to reduce the disease-related mortality. Several tests are available to screen healthy subjects at average risk for CRC: faecal occult blood tests, flexible sigmoidoscopy, combined faecal occult blood tests and flexible sigmoidoscopy, total colonoscopy and double contrast barium enema. Issues related to the introduction on a large scale of population-based screening programmes for CRC are discussed.     

Anti-tissue transglutaminase antibodies in patients with abnormal liver tests: is it always coeliac disease?

BACKGROUND: Coeliac disease (CD) is found in 5-10% of patients with chronically abnormal liver tests and no obvious cause of liver disease. In this population the efficacy of screening for CD by anti-tissue transglutaminase (anti-tTG) may be impaired by the high rate of positive anti-tTG found in chronic liver disease. AIMS: To evaluate the prevalence of coeliac disease and the role of anti-tTG in patients with non-viral, non-autoimmune chronic and no obvious cause of liver damage. METHODS: Out of 2,512 consecutive patients with abnormal liver tests, 168 (118 men, 50 women; mean age 40.7 +/- 12.6 years) were defined, on the basis of clinical data and liver biopsy, as NAFLD or cryptogenic chronic hepatitis. All were tested by recombinant IgA and IgG anti-tissue transglutaminase. Patients with a positive serology underwent endoscopy with duodenal biopsies. RESULTS: NAFLD was diagnosed in 121 patients, in 6 associated with cirrhosis, while 47 patients were considered as cryptogenic hepatitis in the absence of steatosis. Anti-tTG were positive in 20/168 patients (3 IgA alone; 11 IgG alone; 6 both IgA and IgG). Coeliac disease was found at endoscopy and confirmed by histopathology only in the 6 patients (3.6%) with both IgA and IgG anti-tTG positivity. Four of the patients with CD had NAFLD (3.3%), in 2 of them associated with cirrhosis; while 2 of those with cryptogenic hepatitis (4.2%) had CD. CONCLUSIONS: The prevalence of CD in patients with chronically abnormal liver tests of unexplained etiology is 4%, with no relation with the degree of liver steatosis. Screening should be done by testing for IgA and IgG antibodies and then evaluating by endoscopy and biopsy only patients positive for both.     

Mediastinal cystic lymphangioma: is resection always necessary?

Mediastinal cystic lymphangiomas are rare tumours. Usually asymptomatic, they can be complicated by a chylopericardium or/and chylothorax. We report a case of a left lesion infiltrating through the supra-aortic vessels complicated with a iatrogenic left chylothorax managed by bilateral video-assisted thoracoscopy at the same time. First, on the right, the chylous inflow was stopped by suturing the thoracic duct; then, on the left, a fenestration was done to confirm the diagnosis and treat the lesion while preserving the adjacent structures.     

Kallmann's syndrome: is it always for life?

OBJECTIVE: Kallmann's syndrome (KS) is defined by the association of olfactory deficit with irreversible, congenital gonadotrophin deficiency (IHH). We present evidence for the existence of a variant form of KS, in which endogenous gonadotrophin secretion recovers spontaneously in later life. DESIGN: Longitudinal clinical study. PATIENTS: Five men with anosmia or severe hyposmia, who originally presented in their late teens or early twenties as a result of severe pubertal delay and were thus presumed to have KS. RESULTS: Spontaneous onset of endogenous gonadotrophin secretion, evidenced by progressive normalization of testicular volume and of serum testosterone concentration, occurred in these men over a period of years following the initial diagnosis. CONCLUSIONS: This variant form of Kallman's syndrome is not well recognized and may well be under-diagnosed. Once full virilization has been induced, males with congenital gonadotrophin deficiency whose testes have significantly increased in size should be reassessed, off androgen replacement therapy, to identify those who no longer require treatment.     

Early repolarization syndrome: is it always benign?

Early repolarization syndrome is a well-recognized idiopathic electrocardiographic phenomenon characterized by prominent J wave and ST-segment elevation predominantly in left precordial leads. The syndrome shares remarkable cellular, ionic, and electrocardiographic similarities with the Brugada syndrome and idiopathic ventricular fibrillation (a variant of the Brugada syndrome with ST-segment elevation in inferior leads). Although early repolarization syndrome is considered a benign entity, its arrhythmogenic potential still remains unknown. We report the case of a 39-year-old male with a family history of sudden death and an electrocardiogram consistent with early repolarization syndrome. Diagnostic dilemmas are discussed.     

Does pilonidal abscess heal quicker with off-midline incision and drainage?

Background  

No clinical trials have been done to guide the surgeon in the optimal technique of draining a pilonidal abscess. The aim of our study was to investigate whether the location of the incision influences wound healing.     

MELD-based liver allocation: who is underserved?

Deceased-donor livers are a scarce, lifesaving resource. For patients whose lives depend upon liver transplantation, policies for prioritizing allograft allocation are of ultimate importance. In the current paradigm, donor livers are allocated on the basis of medical urgency. Thus, the onus is on the transplant community to refine the allocation system continuously so that livers are targeted to patients who need them most. The current model for end-stage liver disease (MELD)-based allocation system works well, accurately predicting short-term mortality for the majority (83 to 87%) of waitlisted candidates. However, there are patients with liver diseases whose survival is dependent upon factors other than the severity of the liver disease and who may not manifest derangements in their MELD parameters. Such patients may be underserved by current MELD policies. This article reviews the development of MELD and the MELD-based liver allocation system and addresses issues relevant to whether this system may be improved.