SUMMARY Two hundred and thirty six patients with amoebic liver abscess were investigated for cholestasis, its mechanism and the natural course of the disease. Cholestasis was seen in 29% of cases and it presented with some unusual features: it was frequently seen in young men (mean age 38-6±6-3 years) (87%) with acute onset (69%) and was associated with signs of peritonism, or peritonitis (28%), splenomegaly (12%) and hepatic encephalopathy (coma 13%). Raised diaphragm was seen only in 37% of cases. Alcoholism may have contributed to the cholestasis in 37% of cases. Multiple (43%) and single (32%) large liver abscesses, especially on the inferior surface of the liver (25%), were common in jaundiced patients with amoebic liver abscess, while size and number of abscesses were directly related to the raised serum bilirubin concentrations. Bromsulphalein excretion (BSP) was found to be significantly reduced (p<001) in patients with jaundice (60%). Retrograde injection of contrast media into the common bile duct during six necropsies showed compression by amoebic liver abscess on the hepatic ducts. The mortality (43%) and the complications were significantly higher (p<0.001) in patients with jaundice. The aspiration/surgical drainage of amoebic liver abscess together with a combination of metronidazole and di-iodohydroxyquinoline was more effective than either metronidazole alone, or dehydroemetine with chloroquine.
Lymphoma developing in an ileostomy is an extremely rare complication. The presentation is similar to the commoner, yet still rare, adenocarcinoma but the staging and management of the condition differs.A 78 year old man was referred to the surgical outpatient clinic by the stoma care clinical nurse specialist. He was having increasing difficulties with his long standing right iliac fossa end ileostomy that had been created 20 years earlier for ulcerative colitis. He noticed that it was functioning but prolapsed, extending to approximately 10 cm from the skin surface. It was very hard, swollen with a diameter of 6.4 cm, with the tip appearing bruised and black, stenosed, and bleeding to the touch. These changes had occurred over a six month period and been associated with several episodes of bleeding. It was painless but he was having great difficulty in obtaining a satisfactory seal with the stoma appliances. His weight was steady and his appetite good. He was a hypertensive on treatment and was otherwise well.Examination confirmed the above findings of a swollen, necrotic, and stenosed stoma (see fig 1) and also revealed two skin deposits adjacent to the stoma and a large parastomal hernia. A clinical diagnosis of a malignant change in an ileostomy was made and after discussion with the patient, a decision to undertake an en-bloc excision and refashioning of the stoma was made. A preoperative biopsy was not carried out as it was felt that it would not change the above management plan.A midline laparotomy was carried out to clinically stage the disease. No obvious mesenteric or para-aortic nodal enlargement was detected. The liver and spleen were impalpable due to adhesions. The ileostomy was excised en-bloc with the abdominal wall through a transverse elliptical incision. A new end ileostomy was fashioned in the left iliac fossa.Histology revealed a B-cell non-Hodgkins lymphoma of the ileum. The tumour appeared to have been completely excised.Standard staging tests showed that the tumour appeared to be localised. In view of its large size and grade II histology and hence a high probability of occult disease, chemotherapy was offered with PACEBO (prednisolone, Adriamycin, cyclophosphamide, etoposide, bleomycin, and oncovin), an eight week protocol discussed by the British National Lymphoma Investigation for elderly patients with non-Hodgkin's lymphoma.
A n 18-year-old female was referred to the gastroenterology clinic with a 3-month history of postprandial vomiting, colicky lower abdominal pain and 3 kg weight loss. Her bowels were regular with no bleeding or mucous discharge per rectum. She had no urinary or gynaecological symptoms and no significant past history. Her paternal grandfather had died of colon cancer, aged 60 years. She was pale but abdominal examination was unremarkable. Full blood count revealed iron-deficiency anaemia and, at upper GI endoscopy, multiple fundal hyperplastic polyps were identified. Severe duodenitis was present although a Helicobacter pylori urease test was negative. At colonoscopy, numerous polyps carpeted the colon suggesting familial adenomatous polyposis (FAP). Biopsies confirmed the presence of dysplastic adenomata and also revealed submucosal pigmentation suggestive of melanosis coli. Fundoscopy revealed congenital hypertrophy of retinal pigment epithelium (CHRPE) and genetic testing revealed a mutation in the APC gene on chromosome 5. Her parents and sister were screened and found to be free of the disease clinically and not to harbour the mutation.She was counselled with regards to a restorative proctocolectomy but, at operation, multiple enlarged pigmented lymph nodes > 2 cm in diameter were found in the small bowel mesentery. Node biopsy and frozen section showed no evidence of malignancy but the presence of dense pigmentation (Fig. 1)
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