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Severe abdominal pain. Different medical test done and prescribed antibiotic. What treatment should be done?

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Practicing since : 1996
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Dear Sir/Madam,
My partner had severe abdominal pain and GP referred her to A&E who after short investigation referred her for inpatient treatment and investigation. The hospital performed number of investigations, particularly X-ray, USS, CT, liver biopsy, colonoscopy (with biopsy), and various blood tests. After 2 weeks in hospital she was discharged without clear diagnosis in the absence of results from liver and colon biopsies as well as bacterial cultures from blood. She has been given a course of antibiotics (Metronidazole) – for 14 days. It is indeed a bit worrisome not to have any clear diagnosis after 2 weeks and we are looking for some guidance from you. Our questions:
•     Based upon the notes, is the above course of action for investigation and initial treatment appropriate? What other tests should be done?
•     Do you agree that likelihood of malignancy is low?
•     What is the likely course of treatment action in case of TB being confirmed through tests? What drug combination would be used? For how long? Is pregnancy during treatment period safe for mother and child? What is the likelihood of TB drugs affecting the liver in negative way? What is the observation schedule required during the treatment to ensure any negative impact of drugs is immediately detected?
•     What is the likely course of treatment action in case of hydatid liver cyst being confirmed through tests? What drug combination would be used? For how long? Is pregnancy for mother and child safe during the treatment period? Is there any likely negative impact of the treatment known as is the case for TB?
•     Any other guidance is appreciated.

•     What is the likely course of treatment in case bacteriological infection is confirmed through tests? What drug combination would be used? For how long? Is pregnancy safe? Any negative impacts of these drugs?


Dates of investigation
Admission date: 13 XXXXXXX 2013
Discharge date: 25 XXXXXXX 2013

Discharge Summary Text

Discharge diagnosis: ? Hydatid liver cyst – under investigation as OP. ? Hepatic TB.

Co-morbidities (acute/chronic):
•     Pyeloepritisi
•     Transfusion aged 3 in Somalia
•     Previous Vitamin D deficiency
•     TB treatment around age 3
•     Elispot test +ve
•     Presenting complaint
•     Epigastric pain

History of presenting complaint:
•     One month history of epigastric pain of gradually increasing intensity. The pain started in LUQ and moved to epigastric region. History of weight loss around 5kg (there is lack of appetite) and night sweats. Some fever.
•     GP performed scan of the liver which showed ? liver lesions. GP points out blood test with GGT 115, ALP 178m and the mentioned lesions or hypodense area. GP asked patient to present to A&E for rule out malignant pathology of the lesions.
•     A&E performed ECG, blood tests detecting IMP vitamin D deficiency and confirming incidental liver lesions through USS. Given the patient’s recent weight loss and the uncertain aetiology of the lesions A&E referred patient to inpatient department.

Examination findings:
•     Abdomen: soft, epigasstric tenderness
•     PR: Haemorrhoids at 6 o’clock
•     Breast examination: normal

Results of investigation:
•     Bloods: raised CRP, raised amylase, raised ALP
•     Abdo USS: multiple indeterminate hypoechoic liver lesions requiring further cross-sectional chracterisation and biopsy. Biggest lesion is 2.5 cm.
•     CXR: NAD
•     CT: chest, abdo, pelvis: enlarge inflammatory appearing LN are seen in right axilla and there are multiple ill-defined hypodense lesions seen in liver as see on the recent ultrasound. No focal masses lesions are identified in the chest, abdo, pelvis to suggest malignancy and in view of clinical history, an infective actiology with potential evolving liver abscesses is more likely.

•     Hydatid serology: Awaiting results.
•     HIV: negative
•     Liver biopsy: -ve for acid fast bacilli, bacterial cultures not sent.
•     Colonoscopy: Nothing with the large bowel seen. Is this not TB?

Inpatient management:
•     Reviewed by the infectious diseases team who advised she has liver biopsy. The results are seen below.
•     Successful treatment of pain through paracetamol for initial 2 days. After 2 days pain medication was not necessary as abdominal pain disappeared. Note: tramadol given on Day 2 lead to dizziness hence discontinued.
•     She was reviewed by the gastroenterologists and a colonoscopy was performed. She is treated with a two week course of Metronidazole for a possible liver abscess and she will be followed up in gastroenterology clinic in 4 weeks with Dr Foxton once the serology results are back.

New/change to medication:
•     Two week course of Metronidazole

Info given to patient:
•     Advised to see GP if pain continues. Advised to see A&E in case of any fever.
Posted Fri, 15 Feb 2013 in Abdominal Pain
Answered by Dr. Ratnakar Kini 7 hours later
Thanks for posting your query.
I am Dr.Ratnakar Kini and I am pleased to answer your query.

1. Yes, what has been done so far seems to be appropriate. An upper GI endoscopy should also have been done.

2. Yes, the likelihood of malignancy is low, though it cannot be be ruled out completely without seeing the biopsy report.

3. If it is tuberculosis, treatment would be for 12 months with INH, pyrazinamide and rifampin. There are different treatment regimen however and the treating phyisican decide based on his hospital protocol. INH and rifampin are relatively safe. But the effect of pyrizinamide on growing fetus is not known.
All the three can affect liver.

4. If hydatid liver cyst is confirmed, surgical removal can be done for cysts that are accessible. In addition, albendazole should be given for 8 weeks if surgical treatment was also done and for 28 weeks if surgical treatment is not possible. Albendazole is a category C drug and May affect the growing fetus.

5. If the cause is a bacterial infection, the treatment depends on to which antibiotic it is sensitive which will be known with the culture sensitivity report.

I hope that answers your question.
If you have no more questions, kindly accept this answer and rate this service.

Dr.Ratnakar Kini
Above answer was peer-reviewed by
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