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Current status of infection-related gastrointestinal and hepatobiliary diseases in Thailand.

The objective of this overview is to assess the present situation with regards to gastrointestinal and hepatobiliary diseases prevailing in Thailand. In that context, special emphasis has been put on those forms of viral hepatitis prevalent in the region, namely, hepatitis A the frequency of which has undergone a change from hyper- to hypoendemic with a resulting decline in naturally acquired immunity; hepatitis B with its tendency to cause chronic liver disease mainly due to asymptomatic infections during early childhood and the impact of mass vaccination programs on its endemicity; hepatitis C which can also lead to chronicity; hepatitis D solely found as a coinfection with hepatitis B; hepatitis E acute cases of which can sporadically be found; hepatitis G encountered in healthy subjects at a prevalence similar to that seen in patients with chronic liver disease and rather more prevalent among people at risk for contracting blood borne agents; finally the novel hepatitis TT virus with a distribution comparable to that of hepatitis G virus and a similarly unclear role as to the etiology of serious liver disease. Particularly in connection with hepatitis B we have examined the situation regarding hepatocellular carcinoma which represents one of the most common malignancies among the Thai population. Cholangiocarcinoma caused by the liver fluke Opisthorchis viverrini is the most common form of liver cancer in the northeastern part of Thailand where an estimated 70% of the population are infested with the parasite. Peptic ulcer caused by Helicobacter pylori constitutes another common gastrointestinal affliction with the overall prevalence of antibodies to the agent amounting to 63 to 74% in patients exhibiting gastroduodenal symptoms. The final part of the paper deals with HIV-related gastrointestinal and liver disease and with amebic and pyogenic liver abscesses.

Biliary Tract Diseases↗

Primary liver cell carcinoma associated with infective liver disease.

Three patients, who had primary liver cell carcinoma combined with infective disorders (one each with pyogenic liver abscess, hepatic tuberculosis and amoebic liver abscess), are presented. The importance of further investigation, particularly liver biopsy and/or peritoneoscopy, in patients with liver diseases is highlighted.

Adult↗

Intravenous sulfamethoxazole and trimethoprim for serious gram-negative bacillary infection.

Intravenous therapy with sulfamethoxazole and trimethoprim cured seven patients with serious gram-negative infection. Three patients had bacteremia, three had pneumonia, and one each had meningitis, peritonitis, pyogenic liver abscesses, and urinary tract infection. Sulfamethoxazole and trimethoprim was selected in three patients with renal failure to avoid aminoglycoside-induced nephrotoxicity, in three patients because of penicillin allergy, and in two cases because of bacterial resistance to other readily available antibiotics. Adverse drug reactions occurred in three cases and included oral monilia, transient leukopenia, and fluid overload. In contrast to the new broad-spectrum cephalosporin antibiotics, sulfamethoxazole and trimethoprim costs two to 2 1/2 times less and has not been associated with the emergence of bacterial resistance during therapy. This may favor the use of parenteral sulfamethoxazole and trimethoprim for some patients with serious gram-negative infection.

Adult↗

Obstructive jaundice due to Fasciola hepatica.

A middle aged woman presented with obstructive jaundice of 6 months duration. Radiological investigations revealed multiple pyogenic liver abscesses with the possibility of choledocholithiasis. Exploration of common bile duct revealed that Fasciola hepatica was responsible for the illness. The case is reported because of its rarity.

Cholestasis↗

Endogenous Escherichia coli endophthalmitis.

Metastatic bacterial endophthalmitis caused by Klebsiella pneumoniae is a unique but well-known phenomenon in Taiwan, where most cases occur in diabetic patients with pyogenic liver abscesses. However, endogenous Escherichia coli endophthalmitis is quite rare. The most common primary site of this infection is the urinary tract and the incidence of concurrent systemic infections, such as abscess formation and infective endocarditis, is high. This illness has a rapidly progressive clinical course associated with a poor prognosis for recovery of visual acuity. This is a report of a case of endogenous E. coli endophthalmitis originating from a renal abscess in a diabetic woman. Despite aggressive local and systemic treatment, evisceration was required to prevent the infection from spreading.

Abscess↗

Massive extra-enteric gastrointestinal hemorrhage secondary to splanchnic artery aneurysms.

BACKGROUND/AIMS: Gastrointestinal hemorrhages of obscure origin are often difficult to diagnose and manage. Of these, splanchnic artery aneurysms have emerged as an important disorder because of the increasing prevalence and formidable mortality rate associated with their rupture. We herein evaluated extra-enteric gastrointestinal bleeding related to these ruptured aneurysms. METHODOLOGY: The medical records of 17 patients with splanchnic artery aneurysms known to be exclusively manifested as gastrointestinal bleeding were reviewed. The pathogenesis, clinical picture, diagnostic tests, management, complications, and outcomes were compiled and analyzed. RESULTS: Of the seventeen patients, 12 patients had true aneurysms; 5 patients had false aneurysms. Pancreatitis, trauma, iatrogenic hepatobiliary injury, and atherosclerosis were the four major etiologies. The sensitivity rates measured by endoscopy, ultrasonography, computed tomography and visceral angiography were 20%, 50%, 67%, and 100%, respectively. An exact diagnosis was attained in 94% of the patients at the time of management. Transcatheter embolization was employed in 7 patients, complicated with hepatic and splenic infarcts, and pyogenic liver abscesses in 2 instances. Two patients had recurrent bleeding aneurysms post embolotherapy. Ten patients underwent surgical intervention which resulted in 2 cases of hepatic failure. One out of 5 patients with a true aneurysm died, while 4 out of 12 patients with false aneurysms eventually died. Overall, the mortality rate was 29%. CONCLUSION: Even though the exact diagnosis can be made in most of the patients by modern imaging studies, the mortality rate was still formidable, especially in patients with false aneurysms, in whom the underlying causal diseases substantially influenced the major outcome.

Adult↗

[Gastrointestinal problems in elderly patients].

The following article contains a short review on gastrointestinal problems of the elderly. The diseases of the esophagus occurring in the elderly are not much different from those in younger patients. Clinically relevant in the stomach are above all bleeding ulcerations and the gastric carcinoma occurring more frequently in advanced age. The pyogenic liver abscess is diagnosed primarily in the elderly and is at a rule the consequence of an infection of the gall bladder and other abdominal sites. The hepatocellular carcinoma does not grow rapidly in the elderly, but its accompanying unfavourable survival rate at five years is also approximately 5 per cent. In the case of symptomatic cholelithiasis, older high risk patients do especially profit from minimally invasive laparoscopic surgical procedures. Today, bile duct calculi are preferably treated by endoscopic papillotomy and following extraction of the calculi. The pancreas is subjected to atrophy, lipomatosis and fibrosis at the advanced age. However, these changes are rarely of clinical relevance. A frequent problem in clinical practice is that of constipation, from which 35% of patients suffer above the age of 65 years. Another typical symptom of the elderly is the incontinence, the different causes are being discussed. In advanced age, gastrointestinal hemorrhages are mostly occurring above the Treitz's ligament. Hemorrhages of the lower gastrointestinal tract occur mostly in the form of diverticle bleedings and those of angiodysplasias in the elderly. The diverticulosis is also a disease observed in over 50 per cent of patients above 70 years, but it is symptomatic in only part of the patients. When suspecting an inflammatory bowel disease in the elderly, the possibility of a mesenterial ischemia must always be considered as differential diagnosis. The classical chronic inflammatory bowel diseases can, however, also occur at advanced age. The colon carcinoma is one of the most frequent lethal causes in the Western countries 90 per cent of the cases of colon carcinoma are found in patients older than 50 years of age. Intensive attention is therefore required in this age group.

Aged↗

Biochemical and ribotypic comparison of Actinomyces pyogenes and A pyogenes-like organisms from liver abscesses, ruminal wall, and ruminal contents of cattle.

OBJECTIVE: To isolate Actinomyces pyogenes and A pyogenes-like (APL) organisms from the ruminal wall and ruminal contents of cattle and compare them with isolates from liver abscesses from the same animals, using ribosomal DNA restriction fragment length polymorphism analysis or ribotyping. PROCEDURE: Specimens of liver abscesses, ruminal walls, and ruminal contents were collected from 59 cattle at slaughter. All beta-hemolytic, pinpoint colonies that were gram positive, pleomorphic rod-shaped, and catalase negative, and that hydrolyzed casein and gelatin were presumptively identified as A pyogenes and were characterized biochemically, using an identification kit. The isolates that resembled A pyogenes but fermented mannitol or raffinose, or both, were called APL organisms. Isolates from the ruminal wall and ruminal contents were compared with liver abscess isolates from the same animal by use of ribotyping. RESULTS: Actinomyces pyogenes and APL organisms were isolated more frequently from the ruminal wall than from ruminal contents. Ruminal isolates of A pyogenes and APL had biochemical characteristics similar to those of the isolates from liver abscesses. Among 6 sets of isolates (4 A pyogenes and 2 APL), 2 isolates from liver abscesses had ribopatterns identical to the corresponding ruminal wall isolates. Also, the APL organisms isolated from the ruminal content matched with the corresponding liver abscess isolates for both sets of specimens tested. CONCLUSIONS: The ruminal wall may be the niche for A pyogenes and APL organisms in the rumen. The genetic similarity, on the basis of ribotyping among isolates from liver abscesses, the ruminal wall, and ruminal contents of the same animal suggests that A pyogenes and APL organisms that cause liver abscesses originate from the rumen.

Abscess↗

[Descriptive study of 39 cases of hepatic abscess of pyogenic and amebic origin].

Thirty nine cases of liver abscess--33 pyogenic (LAP) and 6 amebic (LAA)--attended in our hospital between 1980 and 1994, were reviewed. Mean patient age was 55.66 years (LAP) and 35.83 years (LAA), while the relation male/female was 2.3:1 and 5:1 respectively. The most usual underlying pathology in LAP was bile duct disease (39.39%). Four patients with LAA had travelled to endemic areas. Fever was the most frequent clinical finding (71.79%). Echography and/or CT scan confirmed the diagnosis in 32 patients (82.05%), with a sensitivity of 86.66 and 95.65% respectively. Positive cultures were found in 74.35% (39.13% polymicrobials), being E. Coli and K. Pneumoniae the most frequently isolated bacteria. In LAP pus cultures were positive in 73% and blood cultures in 55%. Diagnosis of LAA was made by wet mount smears/serology (3/3). Percutaneous drainage was performed in 41.02%, surgical drainage in 48.71 and 15.38% (all with LAP) received antibiotics exclusively. Four patients died (3 with LAP and 1 with LAA).

Adult↗

Pyogenic abscess of the liver.

The author records the case histories of 27 patients suffering from liver abscess admitted during the period 1946-60 to the Radcliffe Infirmary, Oxford. Seventeen were examples of multiple and 10 of single abscess. In most cases the primary source was determinable. Despite there being only one survivor of the 10 patients with a solitary abscess, the author considers the condition easily curable if recognized early.

Abscess↗