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Pain In The Upper Right Abdomen


Pain In The Upper Right Abdomen


حالة سريرية

الوصف الكامل Background

A 23 year old graduate student complaining of fever and pain in the upper right abdomen was admitted to the hospital for diagnosis and treatment.

الشكوى الرئيسية CC
fever and pain in the upper right abdomen
كتابة حرة وطرح موضوع النقاش!
It is a clinical case which depends on discussion...

so we will take step by step....

Question 1 :

Is this likely an infection problem?

A) Yes
B) No

Question 2:

What organ systems might be involved?

A) Neurological
B)Renal
C) Intestinal
D) Respiratory
E) More than one of the above

Question3:

What types of infectious agents can cause abdominal pain?

A) Bacteria
B) Protozoa
C) Helminths
D) Viruses
E) All of the above

mbs2380's picture
by
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AS I said before ,I will talk about the history later
mbs2380's picture
mbs2380
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Q1:YES(FEVER)m

....................
Q2:E

............
Q3:E

????????????????????

Green Wave's picture
Green Wave


[eng]well done,Green wave<<

Question 1:
A

Question2:
E

mbs2380's picture
mbs2380
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Now:

The student had just returned from a 3 month group expedition to the Galapagos Islands. In route the group stopped in Costa Rica and many developed diarrhea. With symptomatic treatment (kaopectate) all but the patient recovered in a few days. His diarrhea became worse and within a week he was passing l0-l2 liquid stools per day; he reported cramping, abdominal pain and some stools appeared bloody. He took a medication (Enterovioform) recommended by a local pharmacist and improved but continued to have loose stools and lost weight during the stay in the Galapagos Islands. On the trip back to the university he became feverish and developed the pain the upper right abdomen. He had no previous history of any chronic illness.

Question 4 - Single Best Answer

The bloody stools and fever indicate?

A) a toxigenic infection
B) food poisoning
C) an inflammatory diarrhea

Question 5 - Single Best Answer

The patient's disease in Costa Rica is likely an infectious diarrhea that could be caused by which of the following agents?

A) Enterotoxigenic E. coli, a typical cause of traveler's diarrhea
B) Shigella, Salmonella, Campylobacter
C) Entamoeba histolytica
D) Giardia, Cryptosporidia
E) Both B and C

mbs2380's picture
mbs2380
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Come on guys ,it is a peace of cake

mbs2380's picture
mbs2380
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4a
5A

Buzz_LightYear

Quote:
peace

piece

mbs2380's picture
mbs2380
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Quote:
4a
5A

About the Question 4:

The bloody stools and fever indicate>>

why did u say a toxigenic infection????

and about 5:

u said A ,but in this case the diarrhea is bloody not watery as that we see in traveler's diarrhea....

Try again...Eye-wink

mbs2380's picture
mbs2380
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A
becuase toxigenic infection doesn't ivvase the epithelium of intestina so it doesn't produce blood

E

actually it's good case I'm looking forward to discussing it with u Bassam

moonberg's picture
moonberg
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4=B
5=B
رفعت الاقلام و جفت الصحفCool

abo harb
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4= c
5= e or c

qusei

Quote:
Moonberg said:
A
becuase toxigenic infection doesn't ivvase the epithelium of intestina so it doesn't produce blood

Your explanation is totally right ,but our patient had bloody diarrhea ,so we will omit A,and because of the fever ,we will take c
he reported cramping, abdominal pain and some stools appeared bloody

and about number 5 ,moonberg,qusei ,u both are right,,because both b and c cause infectios diarrhea

Abo harb,sorry u missed it

so the answers are"

4 ,c
5 e

Quote:
actually it's good case I'm looking forward to discussing it with u Bassam

me too,doctor..

mbs2380's picture
mbs2380
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Physical examination revealed a well developed, white male who appeared chronically ill. On admission the following was observed; temperature, 37.6; BP, l34/78; and pulse, 84 and regular. In the following days, the patient exhibited a daily fever (39C) spiking in the afternoon. A smooth, very tender liver edge was palapable 3 fingerbreaths below the right costal margin and there was moderate tenderness over the cecal area. Rectal examination revealed some dark, semiformed stool which was guaiac positive for occult blood. Other physical findings were not remarkable. Blood count indicated a moderate leukocytosis (l7,000) with 70% polymorphonuclear leukocytes. Blood chemistries were within normal limits except for an elevated alkaline phosphatase. Urinalysis was unremarkable.

Further tests were done to identify the cause of the abdominal symptoms. Computerized tomogram (CT) and sonogram of the abdomen indicated a rather large defect in the right lobe of the liver consistant with an abscess and a gastrointestinal series detected an annular defect in the cecal area. A chest X-ray was unremarkable except for an elevation of the right diaphragm. Sigmoidoscoic examination was unrevealing.

Question 6 - Single Best Answer

The examination suggested a liver abscess in the right lobe elevating the right diaphragm and a possible bleeding colonic ulcer(s). What infection(s) would be consistant with these finding and the earlier diarrheal disease?

A) None. Little probability of any relationship between current liver lesion and earlier diarrheal disease.
B) No specific infection . Bowel ulceration regardless of cause may lead to a pyogenic liver abscess by bowel bacteria.
C) Entamoeba histolytica
D) Rotavirus
E) Leptospirosis

mbs2380's picture
mbs2380
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C) Entamoeba histolytica
Green Wave's picture
Green Wave


IT IS C

qusei

well done,qusei and Green wave"

But let us discuss other posibilities:

A) None. Little probability of any relationship between current liver lesion and earlier diarrheal disease:
it is wrong because Invasive organisms in the gut could readily reach the liver via the portal circulation>

B) No specific infection . Bowel ulceration regardless of cause may lead to a pyogenic liver abscess by bowel bacteria: it is wrong because A pyogenic liver abscess is unusual ; the liver has strong natural defenses against bacterial invasion

D) Rotavirus:Roto virus does not produce liver disease but is a common cause of diarrheal disease

E) Leptospirosis:Leptospires can infect the liver, but they do not cause diarrhea or liver abscesses.and as we know it is one of the spirochetes.

So the answer is :
C) Entamoeba histolytica:Entamoeba histolytica can secondarily colonize extraintestinal sites of which the liver is the most frequent. An enlarged tender liver with a abscess in the right lobe, particularly when preceeded by an inflammatory diarrhea developed in an area where invasive amebiasis is endemic suggests hepatic amebiasis.

mbs2380's picture
mbs2380
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Question 7 - Single Best Answer

To establish a diagnosis of amebic liver abscess?

A) the presence of E. histolytica in a stool examination would be expected.
B) there would always be a history of colitis.
C) serologic tests could prove that amebiasis was the cause of the abscess.
D) the abscess could be aspirated and the content examined for amebae.
E) a therapeutic trial could confirm a presumptive diagnosis

mbs2380's picture
mbs2380
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Fecal microscopy will be positive for amebae in only a few of cases, serology is sensitive, the only problem with it is that it could be positive in uninfected people living in endemic areas which is not the case of our traveler patient, so I go with C.
Yes, the abscess could be aspirated but this intervention is not necessary right now, I may use it if patient keeps deteriorating after therapy.
Id choose to begin empiric therapy for a patient living in an endemic area where serology cant prove a current illness.

Saggio Italiano
طبيب مقيم

Quote:
Fecal microscopy will be positive for amebae in only a few of cases

I agree with u because stool specimens are often negative for E. histolytica in cases of amebic abscess
so we will omit A

Quote:
serology is sensitive, the only problem with it is that it could be positive in uninfected people living in endemic areas which is not the case of our traveler patient, so I go with C

But there is another problem with serology test that titers may remain high for extended periods and a positive test only indicates past or present amebic infection and, therefore, the possibility of hepatic amebiasis..so ,he could be infected from along time ago,..

Quote:
the abscess could be aspirated but this intervention is not necessary right now, I may use it if patient keeps deteriorating after therapy

Well,liver biopsy is risky and not recommented for diagnosis,except for cases such u mentioned..

Quote:
Id choose to begin empiric therapy for a patient living in an endemic area where serology cant prove a current illness.

but,what about our patient,he doesn;t live in an endemic area,will u begin emperic therapy for him,?

Actually ,I am not very satisfied with the answer mentioned in my reference,but he said that E is right and continued to say :
This is a practical, frequently used approach but strictly speaking does not prove the diagnosisExclamation Exclamation .

I will not continue with this case until other doctors say their opinion and what they would do to this patient????

mbs2380's picture
mbs2380
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)

Quote:
the abscess could be aspirated and the content examined for amebae

From the abscess edge .

qusei

Quote:
From the abscess edge .

yes u are right:
Amebae are present only in the living tissue at the periphery of an abscess ,but as we said liver biopsy is risky and not recommented for diagnosis.

mbs2380's picture
mbs2380
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now let us continue:

In this case repeated stool examinations failed to find diagnostic stages of E. histolytica (cysts or trophozoites). Blood cultures for bacteria were negative and stool cultures demonstrated no pathogens. Serology for amebiasis was not done. Although a diagnosis was not established, the history and clinical findings were considered highly suggestive of amebic abscess and a therapeutic trial was initiated with metronidazole (Flagyl), an effective treatment for amebiasis. Within 5 days there was no fever and less hepatic tendeness. In 6 weeks a liver scan showed reduction in the right lobe defect and within 12 months the liver defect had disappeared. Stool examinations for parasites remained negative and there was no diarrhea or evidence of intestinal bleeding.

This case has presented a common and dangerous complication of amebiasis. It is estimated that there are worldwide 50 million cases of invasive amebic colitis or liver abscess with l00,000 to 400,000 deaths per year.

Even though Entamoeba histolytica must be considered a major intestinal pathogen most infections are asymptomatic with no invasion of the mucosa. E. histolytica is widely distributed infecting approximately l0% of the world's population but invasive amebiasis is a major clinical problem only in certain regions.

mbs2380's picture
mbs2380
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Question 8 - Single Best Answer

The reason(s) for the regional differences in the importance of clinical amebiasis are complex. A most important factor is considered to be?


A) The sanitary conditions and practices which permit repeated, heavy amebic infections.
B) The diet and nature of the intestinal bacterial flora of a population.
C) The malnutrition and low nonspecific resistance which are common in regions endemic for invasive amebiasis.
D) A genetic predisposition for invasive amebiasis in populations native to endemic areas.
E) The presence of strains of E. histolytica differing in pathogenicity and geographic distribution.

mbs2380's picture
mbs2380
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Quote:
The sanitary conditions and practices which permit repeated, heavy amebic infections.
qusei

Quote:
The sanitary conditions and practices which permit repeated, heavy amebic infections

There is a high prevalence of infection in these regions but there are populations with high prevalence and a low incidence of clinical disease

Quote:
B) The diet and nature of the intestinal bacterial flora of a population

There is evidence that ingestion of certain bacteria by amebae augment invasiveness; diet and intestinal flora influence pathogenicity but are not considered the primary determinants of invasive or noninvasive amebiasis.

Quote:
c) The malnutrition and low nonspecific resistance which are common in regions endemic for invasive amebiasis

These factors probably influence severity and chronicity of disease and perhaps susceptability to infection but severe, invasive amebiasis occurs independent of these conditions.

Quote:
D) A genetic predisposition for invasive amebiasis in populations native to endemic areas.

No evidence for this...

Quote:
E) The presence of strains of E. histolytica differing in pathogenicity and geographic distribution

It is the correct answer
Evidence now indicates that E. histolytica is actually 2 morphologically identical species , one pathogenic (invasive) and the other commensalic. The prevalence of these species varies by region. There are several virulence factors promoting mucosal invasion and tissue spread by amebae but the differences in pathogenic and nonpathogenic E. histolytica require clarification.

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mbs2380
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Question 9 - Single Best Answer

Diagnosis of amebiasis is often difficult to establish. Of the listed diagnostic procedures which is the most reliable and cost effective?

A) Microscopic examination of stool specimens
B) Sigmoidoscopic or proctoscopic examination
C) Serologic tests
D) Stool culture for amebae
E) Detection of amebic antigen in stools

and pay attention that this q is different from q 7,because this q is about amebiasis in general not its abcesses in liver>>>>

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mbs2380
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