Non-surgical treatment of biliary liver abscesses: efficacy of endoscopic drainage and local antibiotic lavage with nasobiliary catheter.

BACKGROUND: It is universally recognized that the most frequent cause of hepatic abscess is biliary disease. The aim of this study was to determine the efficacy of endoscopic drainage and local antibiotic lavage via nasobiliary catheter in the treatment of liver abscesses of biliary origin. METHOD: From January 1994 to December 1995, twenty-two cases of pyogenic liver abscess were treated. Diagnosis was established with ultrasound, computed tomography, endoscopic retrograde cholangiography, and laboratory tests. All patients were assigned prospectively to endoscopic or other non-surgical forms of therapy, depending on the etiology of the pyogenic process. Patients in whom this treatment failed underwent surgical drainage. Twenty patients had hepatic abscesses of biliary origin. In this subgroup, a nasobiliary catheter was placed into the biliary tree for continuous antibiotic lavage (infusion technique: 1 to 1.5 mL/min for 8 to 10 days) after endoscopic sphincterotomy. Two patients had hepatic abscesses of hematogenous and amebic origin, respectively. They were treated only with the appropriate systemic antibiotics. RESULTS: Nineteen patients of the biliary subgroup (95%) and the two patients with non-biliary disease (100%) had complete resolution of the abscesses. "Salvage" surgical drainage was required in only one patient (4.5%). There was no treatment related mortality. CONCLUSION: Endoscopic sphincterotomy and local antibiotic lavage via an endoscopically placed nasobiliary catheter is a safe and effective treatment for biliary liver abscesses. It should be considered as first-line treatment in this subgroup of patients with liver abscesses. Percutaneous or surgical drainage modalities should be reserved for patients in whom endoscopic treatment fails.

Oral candidiasis as a marker of acute retroviral illness.

All reported clinical characteristics of acute retroviral illness with the human immunodeficiency virus (HIV) are nonspecific. Signs and symptoms described are associated with a variety of acute infections. We report the cases of three patients in whom the acute retroviral illness was characterized by transient oral candidiasis and unexplained high lactate dehydrogenase values, with or without transient pulmonary infiltrate, in the context of an acute febrile illness. The clinical findings correlated with a severe reduction in the number of CD4 cells. We believe that thrush could be a marker of acute retroviral infection, as it is not a feature of any other heterophil-negative mononucleosis-like syndrome. We propose that in any patient having transient thrush and acute viral syndrome, the possibility of HIV infection should be aggressively pursued serologically, regardless of the patient's HIV risk status, provided that the usual causes of candidiasis (eg, diabetes mellitus, antibiotic use, and dentures) can be excluded.