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The Gastroenterology Training Handbook
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OESOPHAGUS
•Gastro Oesophageal Reflux Disease
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MISCELLANEOUS
•Bleeding
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Liver -
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Abscesses
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Written by Dr Sebastian Zeki
MCQs for this page
What the Curriculum Says
Knowledge
Recognises the importance of sepsis as a complication
Aware of the differential diagnosis and management of sepsis and its
possible sequelae
Knows the appropriate use of the appropriate antibiotics and their
complications Aware of prevention of nosocomial infection
Skills
Understands the principles and practice of diagnosis and treatment of
sepsis
Behaviours
Prepared to involve and liaise with specialist sepsis support
Also....
Knowledge
Knows the importance of clinical nutrition and its disturbances in
patients with acute and chronic liver disease
Appreciates indications for enteral or parenteral support and
understanding of limitations of these interventions
Skills
Shows ability to make careful nutritional assessment
Behaviours
Can liaise with nutritional support team where appropriate
Also...
Knowledge
Understands prognostic scoring systems including Child - Pugh
MELD UKELD Maddrey and disease-specific scoring systems where
they exist
Skills
Builds the use of accredited quantitative scoring systems into routine
clinical liver practice clinical colleagues and junior staff
Behaviours
Shows consistent application of evidence-based in the
evaluation of liver disease and the determination of prognosis
Abscesses
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Solitary + 1 lobe
Emboli
Pyogenic abscesses
CBD CA
Ampullary Ca(15% of cause)
Cholangitis Cholecystitis Panc CA
SOURCE
Written by Dr Sebastian Zeki
CXR-
Elevated right hemidiaphragm
Right basilar infiltrate
Right-sided pleural effusion
MRI and WC scan are less useful for
distinguishing abscess from other
causes of liver mass.
Amoebic abscesses features:
RUQ pain + fever-in 85%.
Leukocytosis (>10,000/mm3) without eosinophilia.
Elevated alkaline phosphatase occurs in 80%.
Hepatic transaminases may also be raised.
Faecal microscopy is +ve in 18%.
Colonic ulcers occur in 55%.
Dysentery can occur at the same time-uncommon.
On USS lesions are solitary and large (right lobe) in 80%.
Serology very sensitive.
Treatment of Amoebic Abscesses:
Antibiotics- metronidazole.
Drainage by open surgery-if no response in 24 hours.
Amoebic Abscess Complications:
Brain abscess.
Cardiac infection.
Pleuropulmonary infection.
Less than 20% aspirate yield
2% die
Via infection
from PV
Solitary +
right lobe
Small and multiple in both lobes
Microbial cultures
Gram stain and MC&S (both aerobic and anaerobic) should be done
Blood cultures positive in 50%.
Cultures obtained from existing drains are NOT useful as usually
contaminated.
Contiguous
(15%)
Colonic
(30%)
Biliary (35%)
Antibiotics (usually 4-6 weeks)
Eg.
amoxicillin-clavulanate alone or a fluoroqu
-
nolone + metronidazole.
+
ERCP can be a useful tool for drainage of liver abscesses in patients with
previous biliary procedures whose infection communicates with the biliary tree.
50% may need
repeat needle
aspiration
Indications for Surgery:
-Multiple abscesses.
-Loculated abscesses.
-Abscesses with viscous contents obstructing the
drainage catheter.
-Underlying disease requiring primary surgical
management.
-Inadequate response to percutaneous drainage
within seven days.
If percutaneous treatment,
catheter drainage is preferred
over needle aspiration
Percutaneous catheter drainage
or needle aspiration.
Drainage catheters should
remain in place until drainage is
minimal (usually up to 7d).
>5cm
<5cm
Liver Abscesses Treatment
MRI may further distinguish
VS
VS
Abscesses (look same on CT and
USS):
Fluid collection with surrounding
edema, stranding and inflamm
-
tion that may contain loculated
subcollections.
Tumors: Appear solid
with areas of calcific
-
tion.
If necrosis and bleeding
can have fluid-filled
appearance
Cysts appear as fluid
collections without
surrounding stranding
or inflammation.
Imaging
Risk factors:
Diabetes.
Underlying hepatobiliary pathology.
Pancreatic malignancy.
Liver transplant.
Organisms:
The
Streptococcus
milleri group (S. anginosis, S. constellatus and S. intermedius)- can dissemi
-
nate
Other gram-positive organisms (including S. aureus and S. pyogenes)-in 60%.
Candida species (usually in chemo patients).
Klebsiella pneumoniae.
TB (uncommon).
Burkholderia pseudomallei (Melioidosis)-consider if patient is from South East Asia and Northern