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Question 8#

 A 30-year-old man presents with right upper quadrant pain. He has been well except for an episode of diarrhea that occurred 4 months ago, just after he returned from a missionary trip to Mexico. He has lost 7 lb. He is not having diarrhea. His blood pressure is 140/70, pulse 80, and temperature 37.5°C (99.5°F). On physical examination there is right upper-quadrant tenderness without rebound. There is some radiation of the pain to the shoulder. The liver is percussed at 14 cm. There is no lower quadrant tenderness. Bowel sounds are normal and active. Which of the following is the most appropriate next step in evaluation of the patient? 

A) Serology and ultrasound
B) Stool for ova and parasite
C) Blood cultures
D) Diagnostic aspirate
E) Empiric broad-spectrum antibiotic therapy

Correct Answer is A

Comment:

The history and physical examination suggest amebic liver abscess. Symptoms usually occur 2 to 5 months after travel to an endemic area. Diarrhea usually occurs first but has usually resolved before the hepatic symptoms develop. The most common presentation for an amebic liver abscess is abdominal pain, usually RUQ. An indirect hemagglutination test is a sensitive assay and will be positive in 90% to 100% of patients. Ultrasound has 75% to 85% sensitivity and shows abscess with well-defined margins. Stool will not show the trophozoite at this stage of the disease process. Blood cultures and broad-spectrum antibiotics would be ordered in cases of pyogenic liver abscess, but this patient’s travel history, the chronicity of his illness, and his lack of clinical toxicity suggest Entamoeba histolytica as the probable cause. Aspiration is not necessary unless rupture of abscess is imminent. Metronidazole remains the drug of choice for amebic liver abscess.