Clinical and Endoscopic Management of Synchronous Amoebic Liver Abscess and Bleeding Colonic Ulcers.

BACKGROUND: Intestinal amebiasis is endemic in India, with myriad clinical presentations. The liver is the most common extra-intestinal organ to be involved in invasive amoebiasis up to 37% of cases. Synchronous presentation of hepatic and intestinal disease is unusual, and presentation as acute gastrointestinal bleed, or amoeboma even more atypical. GOALS: We aimed to assess the frequency of synchronous hepatic and colonic amebiasis and the efficacy of endoscopic management of colonic bleeding. RESULTS: We screened 52 consecutive patients with amebic liver abscess for synchronous intestinal amoebiasis and report the clinical course of 28 patients (mean age 48.3 years, all male) with amoebic liver abscess (ALA), (mean size, 7.2 ± 2.8 cm) who presented to us with lower gastrointestinal bleed requiring endotherapy. Patients with synchronous infection had higher bilirubin, liver enzymes and prothrombin time. Most needed percutaneous drainage of the liver abscess, and had prolonged hospital stay. They had ileocaecal ulcers with active bleeding; ulcer with adherent clot in 10(50%), and visible vessel in 8(37.5%), or active ooze in 4(12.5%). One patient had an ulcerated rectal mass, which appeared malignant on endoscopy, which was later found to be an amoeboma on microscopy. Hemostasis was achieved with dilute epinephrine injection, one patient required argon plasma coagulation, and 4 subjects required haemoclip placement at the site to control ooze from a visible vessel. CONCLUSION: Synchronous hepatic and intestinal amoebiasis is not uncommon, and often requires endoscopic haemostasis in case of gastrointestinal bleeding due to colonic disease. We report the successful endoscopic control of bleeding amoebic ulcers in all 24 patients.

Difficult to Treat Recurrent Pyogenic Cholangitis With Portal Pylephlebitis in the Setting of Idiopathic CD4+ Lymphocytopaenia.

Recurrent pyogenic cholangitis (RPC) is a disease characterized by multiple strictures of the biliary tree, impaired biliary drainage, formation of intrahepatic biliary pigment stones and recurrent bouts of cholangitis. We report the case of a 39-year-old businessman with diagnosed chronic calcific pancreatitis, who presented to us with recurrent episodes of cholangitis, leading to portal pyaemia, and progressive liver failure, which could not be controlled despite adequate biliary drainage. The patient rapidly developed progressive liver failure and sepsis-related coagulation failure. He was also found to have idiopathic CD4+ T cell lymphocytopenia (ICL), which resulted in refractory sepsis and formation of metastatic abscesses in the lung and spleen. ICL is now recognised in patients with recurrent and difficult to treat opportunistic infections. The combination of RPC, sepsis and liver failure in the setting of an acquired immunosuppressed state makes this a unique management scenario.