Long term follow-up of amebic liver abscess: clinical and ultrasound patterns of resolution

A prospective study was undertaken to evaluate the clinical and sonographic patterns of resolution in amebic liver abscess (ALA). There were 146 patients of ALA attending the gastroenterology clinic of a tertiary care centre of whom 25 died. Of the remaining 121 patients, 107 were followed up for 20.9 +/- 11.4 months. 14 (11.3%) patients were lost to follow up before complete disappearance of the cavity. Complete disappearance of the cavity was seen in 84 (78.5%) and a reduction in volume to 50% at entry in 23 (21.5%). Abdominal pain, fever and hepatomegaly were the predominant forms of clinical presentation. On ultrasound, there were 121 cavities in 107 patients. The most frequent type of lesion was solitary, (96%) round cavity (80.4%) in the right lobe of liver (85%). Clinical and hematological parameters of resolution occurred rapidly (3.2 +/- 2.9 months). Sonographic resolution took much longer (9.6 +/- 6.8% months) in the 84 patients. The remaining 23 patients are on follow up. Three pattern of resolution were observed: Type I--where complete disappearance of the cavity occurred within 3 months (29.8%), Type II--where a gradual reduction and disappearance of the cavity occurred (64.3%) and Type III--where a rapid reduction till 25% of original cavity size remained and then a delayed resolution occurred (5.9%). There were no relapses in the patients on follow up. Factors that influenced healing time included the size of the abscess cavity at admission, hypoalbuminemia and anemia. The type of clinical presentation, nature of therapy, number or location of abscesses and time for clinical resolution did not influence the resolution time. None of the variables studied influenced the pattern of resolution. We conclude that rapid clinical resolution is common in patients with ALA. Sonographic resolution may be delayed and does not warrant additional or prolonged therapy.

Enterically transmitted non-A, non-B hepatitis mimicking acute cholecystitis

OBJECTIVES

To study the significance of cholecystitis-like presentation and increased gallbladder wall thickness (GBWT) in patients with acute viral hepatitis (AVH).

METHODS

Sixty-seven consecutive patients with acute viral hepatitis (hepatitis A:3, hepatitis B:13, and enterically transmitted non-A, non-B hepatitis: 51) were included in this prospective study. Clinical assessment and sonographic evaluation of the GBWT were carried out every week until recovery from acute hepatitis.

RESULTS

The clinical presentation in 16 patients with hepatitis A and B and in 29 patients with enterically transmitted non-A, non-B hepatitis (ET-NANB hepatitis) was typical of AVH, and the mean GBWT in these patients was 6.16 +/- 2.23 mm and 7.28 +/- 2.93 mm, respectively. The remaining 22 patients with ET-NANB hepatitis presented with features suggestive of acute cholecystitis (fever, severe pain, and tenderness right hypochondrium), and the mean GBWT in these patients (10.18 +/- 2.58 mm) was significantly higher compared with the rest of the patients with AVH (p < 0.001). The mean GBWT in patients with AVH (7.31 +/- 0.97 mm) was significantly higher compared with controls (1.76 +/- 2.17 mm) (p < 0.001). All patients with acute cholecystitis-like presentation recovered with conservative medical management. A time-dependent normalization of the thickened gallbladder wall was observed in all the patients within 6 wk.

CONCLUSION

A proportion of our patients with ET-NANB hepatitis presented with acute cholecystitis-like picture and had markedly thickened gallbladder wall on ultrasonography. These patients made an uneventful recovery, and the sonographic abnormalities disappeared within 6 wk.

Omeprazole versus famotidine in the healing and relapse of duodenal ulcer

Sixty patients with symptomatic duodenal ulcer were randomized to receive either omeprazole (20 mg each morning) or famotidine (40 mg at night time) for 2-4 weeks in a double-blind parallel group clinical trial. Healing rates were higher with omeprazole in comparison with famotidine after 2 weeks (77% vs. 40%, P < 0.001) and 4 weeks (93% vs. 80%, P = 0.2) of treatment. Assessment of daily diary cards completed by all patients revealed that omeprazole rapidly relieved ulcer-related day pain and nocturnal pain in comparison to famotidine. Treatment with omeprazole for 2 weeks was also associated with lower cumulative antacid intake (P < 0.05) and reduced absenteeism from work. Helicobacter pylori infection was present in all patients and remained unaffected by treatment with either of the drugs. None of the drugs produced any significant adverse effects. During 6 months follow-up of all the patients after ulcer healing (without maintenance therapy), ulcer relapse was seen in 40% of omeprazole- and 37% of famotidine-treated patients (P > 0.1). The duration of ulcer-free period following initial healing of ulcer was also similar in both the groups (median time: 22 weeks for omeprazole, 21 weeks for famotidine). We conclude that omeprazole is superior to famotidine in rapidly healing duodenal ulcers and achieving more rapid pain relief, but does not influence subsequent ulcer relapse.

Selenium--its biological perspectives

Selenium is an essential trace element at lower concentrations and toxic at higher concentration. Animals can metabolize both inorganic and organic forms and convert non methylated Se to mono--or di--or tri--methylated forms, of which, mono-methylated forms are most toxic. Glutathione reductase converts selenoglutathione to H2S in liver and erythrocytes and is ultimately excreted. Se effects the toxicities of xenobiotic agents, provides antagonistic effect to Sulphur and co-administration with Zn increase Se retention in certain organs. At its toxic level (4-8 ppm) it increases Cu contents of heart, liver and kidney and has detoxifying or protecting effect against Cd and Hg. It is a prosthetic group of several seleno metalloenzymes. The concentration of the element is decreased in serum/plasma or erythrocytes of patients of AIDS, trisomy-21, Crohn's and Down's syndrome, phenylketonurea, Keshan's disease and cancer. Rather, the element has antiproliferative and cancer protecting effect. Se content of testes increases considerably during pubertal maturation and, during Se deficiency, the supply to the testes has priority over the other tissues. The element is localized in the mitochondrial capsule protein (MCP) and is involved in biosynthesis of testosterone. Neither the age of mother nor the concentration of Se during pregnancy has any effect on weight of baby or the length of pregnancy. Se levels in human milk is affected by maternal intake and its requirements by infants and young children are higher for their rapid growth. Clinical symptoms of its toxicity include severe irritations of respiratory system, metallic taste in mouth, formication of nose, signs of rhinitis, lung edema and brancho-pneumonia. The typical garlic odour of breath and sweat is due to dimethyl-selenide.

Amoebic liver abscess

Sonography is a major advance in the diagnosis of ALA. Identification of amoebic antigen in the pus is a specific immunodiagnostic test. Medical therapy with a single drug (metronidazole) is adequate in most instances. Routine needle aspiration or surgical drainage are not indicated. The abscess cavity may take up to 18 months for resolution and demonstration of such a lesion does not warrant repeated therapy unless clinical evidence of recurrence is present. Recurrences are rare. Clinical and laboratory evidences of poor prognosis are being identified, and may guide the treatment modality to be selected.

Recognition of Entamoeba histolytica lipophosphoglycan by a strain-specific monoclonal antibody and human immune sera

Western blot analysis showed that the monoclonal antibody 2D7.10 recognized lipophosphoglycan (LPG) from Entamoeba histolytica HM-1:IMSS. Sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE) pattern of [3H]galactose-labeled LPG and Western blot analysis of total lysate of E. histolytica with 2D7.10 revealed patterns similar to that of LPG with 2D7.10. This antibody could also immunoprecipitate purified LPG from the strain HM-1:IMSS after biosynthetically labeling with [3H]galactose and [32P]orthophosphate. However, no immunoprecipitation was observed when 2D7.10 was incubated with [32P]orthophosphate-labeled purified LPG from strain 200:NIH. Sera from patients suffering from invasive amoebiasis also immunoprecipitated 32P-labeled, purified LPG and could immunostain this molecule in Western blots. The human immune sera recognized carbohydrate epitopes but not the associated polypeptides of LPG, as evidenced by sensitivity to periodate digestion, mild acid hydrolysis but not to pronase treatment. It was earlier shown that 2D7.10 binds a carbohydrate epitope in a subset of axenized pathogenic strains of E. histolytica and that this epitope undergoes changes when cultured along with bacteria. These observations suggest that the E. histolytica LPG contains a strain-specific, variable epitope and that LPG is immunogenic in human.

A prospective randomized double blind trial comparing prednisolone and 4-aminosalicylic acid enemas in acute distal ulcerative colitis

A prospective double blind and randomized study was conducted to compare 4-aminosalicylic acid (4-ASA) and prednisolone-21-phosphate enemas in inducing remission in patients with acute distal ulcerative colitis. Patients with ulcerative colitis distal to the splenic flexure as assessed by flexible colonoscopy, barium enema and histology were included in the study. Of 40 consecutive patients, 20 were randomized to each of the two treatment groups. Clinical evaluation was done weekly; sigmoidoscopy and histology were performed at entry and at the end of 4 weeks. Therapy was discontinued in four patients treated with prednisolone enemas due to worsening of symptoms. The clinical improvement was significant in the remaining patients (P less than 0.001) and was similar in the two groups (P greater than 0.1). Sigmoidoscopic and histological improvement were better with 4-ASA than with prednisolone enemas. No adverse effects were observed in any of the patients treated. The present study suggests that 4-ASA is a safe and effective treatment for inducing remission in acute distal ulcerative colitis.

Prospective randomized comparison of sodium tetradecyl sulfate and polidocanol as variceal sclerosing agents

A prospective randomized controlled study was designed to evaluate differences in efficacy and complication rate between the two most commonly used sclerosing agents, sodium tetradecyl sulfate (STD) and polidocanol. Of 52 patients with esophageal variceal bleeding, 26 were randomized to receive sclerotherapy with 1.5% STD and 26 to receive 1% polidocanol at weekly intervals. Eradication of varices was achieved in 88% patients each of the STD and polidocanol group. There was no significant difference between patients injected with STD and polidocanol with regard to re-bleeding (27% vs. 15%) and mortality (11.5% in both). The use of STD, in contrast to polidocanol, was associated with a higher incidence of complications in terms of severe retrosternal pain (27% vs. 4%), deep ulceration (53% vs. 23%), dysphagia (88% vs. 46%), and stricture formation (27% vs. 8%). It was concluded that these two agents were similar in efficacy. However, polidocanol was superior due to a lower incidence of complications.

Plasma concentrations of fibronectin and C3d in patients with amoebic liver abscess

By means of simple and specific ELISA techniques, the plasma concentrations of soluble fibronectin and C3d, a breakdown product of C3 complement, were determined in patients with amoebic liver abscesses (ALA) and in healthy controls. The mean plasma fibronectin concentrations in 23 patients with ALA and in 20 controls were found to be 441 +/- 89 mg/l and 442 +/- 66 mg/l, respectively. The difference between these two values was not statistically significant. The mean C3d value in 21 patients with ALA, however, was found to be 84 +/- 14 AU/l which was significantly different from the value of 12 +/- 4.7 AU/l noted in 20 healthy persons. Plasma concentrations of these two proteins are discussed in relation to their possible implications in the immunopathogenesis of amoebic liver abscess.

Gallbladder abnormalities in acute viral hepatitis: a prospective ultrasound evaluation

We carried out a prospective case controlled study to evaluate the temporal sequence of sonographic abnormalities in acute viral hepatitis (AVH) and their resolution patterns. Correlations were established between the sonographic abnormalities and the clinical and biochemical profiles. Fifty-six patients within 2 weeks of onset of illness (37 within 1 week and 19 between 1 and 2 weeks) underwent real-time ultrasound at weekly intervals until clinical and biochemical resolution. Abnormal sonographic patterns were found in 55 of 56 (98.2%) patients. The wall thickness was abnormal (6.1 +/- 4.3 mm) in 55 (98.2%) cases, luminal abnormalities observed in 33 (58.9%) cases, and alterations in volume in 14 (25%) cases. Complete resolution took place in 53 (96.4%) cases by 12 weeks. A wall thickness of greater than 7 mm and abnormal luminal contents were more frequent in patients studied within 1 week of illness than later (p less than 0.05). No other correlations could be established between the different sonographic patterns and the clinical and biochemical profiles at any stage of the illness. We conclude that sonographic abnormalities are common in patients with AVH, with resolution as the rule with clinical recovery.

Diagnostic utility of ultrasonography in hepatic venous outflow tract obstruction in a tropical country

The present study was undertaken to define the role of ultrasonography (US) in screening and diagnosis of hepatic venous outflow tract obstruction. Forty-five consecutive patients clinically suspected to have hepatic venous outflow tract obstruction were included in the study for screening by US and for assessment of patency or block in the hepatic vein (HV) and/or inferior vena cava (IVC). Four patients were excluded from the study. Eleven patients had a diagnosis other than hepatic venous outflow tract obstruction and all these patients were found to have patent HV and IVC. Thirty patients were finally diagnosed to have hepatic venous outflow tract obstruction. Using US, as a screening test 27 (90%) out of 30 such cases were correctly identified as cases of hepatic venous outflow tract obstruction and in these cases the site of block in hepatic venous outflow tract (major HV and/or IVC) was correctly diagnosed in 90% of the cases. Our results indicate that US is a sensitive and accurate test and should be the initial investigation for screening and identifying the site of obstruction in patients with hepatic venous outflow tract obstruction.

Case report: unusual CT appearances in a case of Budd-Chiari syndrome

We describe a case of Budd-Chiari Syndrome due to hepatic venous blockage in which there were multiple space-occupying lesions on CT simulating tumour deposits. Ultrasound directed liver biopsy and laparoscopy proved these to be areas of haemorrhagic necrosis consistent with Budd-Chiari Syndrome without any evidence of malignancy. The CT finding of multiple large focal non-enhancing areas in liver does not always indicate tumour deposits in a patient suspected to have Budd-Chiari Syndrome.

Constrictive pericarditis masquerading as Budd-Chiari syndrome

Budd-Chiari syndrome (BCS) and constrictive pericarditis (CP) share many common clinical features. Over the last year we encountered three patients in whom CP clinically mimicked BCS. Two of the three did not even have raised jugular venous pressure. One patient with severe jaundice and hepatic coma ultimately died. Liver biopsy features were not discriminating. The final diagnosis of CP was established by echocardiography, chest computed tomography (CT), or cardiac catheterization. We conclude that in all patients with apparent BCS and atypical features, a noninvasive test like echocardiography or chest CT should be done to rule out treatable illness like CP before embarking on such invasive procedures as liver biopsy for diagnosis.

Control of variceal bleed with metoclopramide

The efficacy of parenteral metoclopramide in the control of active variceal bleeding was assessed in a prospective, randomized, double blind, placebo controlled trial. Patients with portal hypertension due to different etiologies (cirrhosis, non cirrhotic portal fibrosis and extrahepatic portal venous obstruction) with endoscopically documented active variceal bleeding entered the study. Forty nine consecutive patients were randomized after pre-entry stratification for Child's scores. Intravenous metoclopramide (20 mg) or 2 ml dextrose was administered in all patients while the first endoscopy documented an active variceal bleeding. All patients were subjected to a second endoscopy 15 minutes later to determine control of bleeding. Rebleeding rate, transfusion requirement, adverse effects and mortality were analysed. Twenty of the 25 patients treated with metoclopramide stopped bleeding compared to 5 of 24 in the control group (p less than 0.05). Rebleeding occurred in 4 of 20 in the metoclopramide group and 4 of 5 in the control group within 72 hours (p less than 0.05). The number of patients requiring blood transfusion (10 vs 16) and the transfusion requirement (1.8 +/- 2.2 vs 3.6 +/- 2.1 units) were significantly lower (p less than 0.01) in the metoclopramide group than in the control group. Mortality was similar and there were no complications due to therapy. We conclude that intravenous metoclopramide is a safe and effective agent for the control of acute esophageal variceal bleeding.

Clinical profile of multiple amoebic liver abscesses

Of 70 consecutive patients with amoebic liver abscess admitted over a 3 year period, 15 (21.4%) had multiple abscesses. This condition, like solitary abscess, was a disease of the 2nd to 5th decade with a male preponderance. Multiple abscesses were more frequently associated with fever, jaundice, upper abdominal pain, pneumonitis and tender hepatomegaly. The left lobe of the liver was always enlarged in patients with multiple abscesses and 86% of patients required drainage of an abscess cavity. The presence of more severe clinical course, jaundice and left lobe hepatomegaly should raise the suspicion of multiple abscesses. After confirmation of the diagnosis by imaging technique, the abscess cavity should be aspirated for quick relief and cure.

Gallstone disease in north India: clinical and ultrasound profile in a referral hospital

We studied the prevalence of gallstones in patients with upper abdominal pain, heaviness, or discomfort by ultrasound examination of the gallbladder. The actual ultrasound examination was performed by a clinical gastroenterologist blinded to the symptoms. Of 1,680 consecutive dyspeptic patients, 500 (29.8%) had gallstones. The gallbladder was contracted in 450 (91.2%), normal-size in 36 (7.2%), and distended in 8 (1.6%). Biliary colic was more frequently the presenting complaint in patients with a contracted gallbladder than in those with normal size gallbladder (p less than 0.001). Dyspepsia was more frequent in the presence of a normal size gallbladder than a contracted one (p less than 0.001). We conclude that ultrasonography of the gallbladder by the clinician has a high diagnostic yield, and the symptom complex has an excellent correlation with the sonographic appearance.