Pitfalls in the surgical management of amoebic liver abscess.
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Biomedical subjects
Publications and source records attributed to M Verghese.
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The thoracic complications of amebiasis frequently necessitate surgical intervention. Experience with 28 patients is presented. Involvement included the pleura in 19 patients, the lungs in 10, and the pericardium in five. In 25%, more than one site was involved. Treatment consisted of measures designed to obliterate the pleural space or widely drain the pericardial sac, as indicated. Concurrent drainage of the associated amebic liver abscess was done in half the cases. The mortality rate was 36%, generally related to the poor general condition of the patients and their delay in seeking hospitalization.
Three patients had massive bleeding from proved amebic ulcers in the cecum. One had an accompanying amebic liver abscess. All were successfully treated by emergency right hemicolectomy.
Over a period of 14 1/2 years, 26 instances of amoebic perforation of the bowel occurring in 25 patients were treated surgically. Nineteen perforations occurred in males and 7 in females, whose ages ranged from 3 to 74 years. The duration of symptoms varied from 12 h up to 5 months (average 15 days). All patients were toxic and a right lower quadrant mass was present in 14. The correct diagnosis was made or suspected in 14 (54 per cent). Amoebic perforation of the bowel should be suspected in patients presenting with an acute abdomen if a past history of fever, pain and diarrhoea is obtained, particularly if a large tender mass is present in the right iliac fossa. Resectional surgery was performed in 7 patients, with a mortality of 71 per cent, whereas procedures designed to divert the faecal stream were carried out in 19, with a mortality of 43 per cent. All 6 patients with concomitant liver abscesses died. If these patients are excluded, the mortality from resections was 60 per cent and from faecal diversion 27 per cent. Faecal diversion with wide drainage is the treatment of choice for amoebic perforation of the colon.
Experiences with surgery in 83 patients with amebic liver abscess are presented. The patients' ages ranged from 8 months to 72 years; 85% were men. Symptoms had been present for an average of 4.6 weeks. In 36 (43%) the abscess already was ruptured at the time of admission to the hospital and in an additional eight it ruptured later. Rupture occurred more commonly upward through the diaphragm than downward, and into a serous cavity in 36 patients. Because of the poor general condition and associated illnesses of the patients, surgical procedures were limited to the minimum. Indications for operation were rupture or impending rupture of the abscess, failure of response to medical therapy, and inadequacy of aspiration of left lobe abscess. An additional 27 patients underwent operation because of diagnostic problems or symptoms of an acute abdomen. Two thirds of the patients had one or more complication. The overall mortality rate was 34%. Factors adversely affecting mortality rate were lack of preoperative drug therapy, rupture into a serous cavity, and presence of an associated amebic perforation of the colon.
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Thirty patients matched for age, parity, socioeconomic status and severity of pregnancy induced hypertension (PIH) were randomly allocated to treatment with metoprolol or methyldopa. The average fall in diastolic blood pressure was significant in the group treated with metoprolol as compared with the methyldopa group (p less than 0.01). There were 3 perinatal deaths in the methyldopa group and 1 in the metoprolol group; the mean birth weight of the babies was higher in cases treated with metoprolol. The results suggest metoprolol to be more efficacious with regard to control of hypertension and fetal outcome in cases of pregnancy induced hypertension.