Holiday report PEARLS 12/28: liver abscesses, gut ischemia, and a word on thrombocytosis

Take-home point: for all liver abscesses, treat empirically with flagyl to start!

 

Liver abscesses

  • HH’s chart (not quite a 2×2 table):
  Pyogenic Amebic
Organism Often polymicrobial (though in Taiwan, think about monomicrobial Klebsiella) E histolytica
# of lesions Single or multiple Single
CXR Uncommon to see pleural effusion 50% with R pleural effusion
Location Can be anywhere R lobe predominant
  • Check out some June 2015 PEARLS for an “Approach to liver abscesses” via our BLOG, ucsfmed.wordpress.com!
    • Some high yield refreshers from the old post:
      • Etiology is often from hematogenous seeding or direct spread from portal circulation or biliary infection
      • For E histolytica, send serologies! For pyogenic, 50% of BCx are positive. Dx is confirmed by aspiration
      • If you see cysts, think Echinococcus

 

Mesenteric ischemia vs ischemic colitis

  Acute mesenteric ischemia (small bowel infarction – often involves SMA; can be from emboli, arterial or venous thrombi, or vasoconstriction) Ischemic colitis
Presentation Severe abd pain disproportionate to exam; ill-appearing(bloody diarrhea often uncommon until late) Hematochezia, diarrhea, abd pain
Dx CT angio Colonoscopy
Tx Surgery with anticoagulation, vasodilator tx Supportive

 

And as a side note, some points about thrombocytosis!

  • Can be clonal or secondary (reactive).
    • >80% of the time it is reactive!
    • Clonal: think of myeloproliferative disorders: Essential thrombocytosis, polycythemia vera, myelofibrosis, CML, MDS. (95% of pts with PCV and 50% of pts with ET are JAK2+)
  • Patients with clonal thrombocytosis can have symptoms/complications, including arterial or venous thrombosis OR bleeding (risk of bleeding is higher when the platelet count is >1 million)
  • Management for clonal thrombocytosis:
    • From a great NEJM review article (attached here)

 

 

Evernote: https://www.evernote.com/shard/s34/sh/f2a1e75b-0107-430d-b6ec-4212348bc2cb/f3b2e78567b0181ee322233d2e8acbb9

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