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This Video discuss a NEET PG 2023 Recall Question from Internal Medicine.
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Alcoholic patient with loose motions a few days ago now presents with pain at the right hypochondrium & USG Shows an abscess with 75 cc volume. Next best step?
A. PAIR
B. Medical management
C. Surgical management
D. Percutaneous drainage
Correct Answer - B
Explanation
The scenario describes an alcoholic patient who presents with pain in the right hypochondrium and ultrasonography reveals an abscess with a volume of 75 cc. Given the information, it appears the patient has developed a liver abscess, possibly an amoebic liver abscess considering the history of loose motions.
Now, let's analyze the options:
A.The PAIR technique (Puncture, Aspiration, Injection, Re-aspiration) is primarily used in the treatment of hydatid cysts caused by the Echinococcus parasite. Hydatid cysts most commonly affect the liver but can also occur in other organs like the lungs, brain, and kidneys. The PAIR technique is minimally invasive and is often preferred over traditional surgery due to its lower complication rates and shorter hospital stays.
Here are the main indications for the use of the PAIR technique:
Size and Type of Cyst: PAIR is typically indicated for hydatid cysts larger than 5 cm in diameter. The cyst should be unilocular or have few septations (type I or II according to the WHO classification of hydatid cysts).
Accessibility of the Cyst:
The cyst should be accessible for percutaneous puncture, meaning it should be in a position where it can be safely reached with a needle.
Absence of Biliary Communication:
PAIR is best suited for cysts without communication with the biliary tree, as this reduces the risk of complications like chemical cholangitis.
Inoperable Patients:
Patients who are not good candidates for surgery due to high surgical risk (e.g., due to age, comorbidities, or poor general condition) may be considered for PAIR.
Cyst Location:
While liver cysts are the most common indication, PAIR can also be used for cysts in other organs if they are accessible and meet other criteria.
Patients’ Preference:
Some patients may prefer a less invasive approach than traditional surgery, making PAIR an option after thorough discussion of the risks and benefits.
Recurrence or Failure of Previous Treatment:
PAIR can be considered in cases where previous surgical or medical treatments have failed or where cysts have recurred.
It's important to note that PAIR is not suitable for all hydatid cysts. Contraindications include:
Cysts with multiple daughter cysts or extensive septations - type III or IV.
Cysts with communication to the biliary tract.
Superinfected cysts.
Cysts in certain critical locations, like the brain, where percutaneous techniques carry high risk.
B. Medical management: Medical management with metronidazole or tinidazole is the treatment of choice for amoebic liver abscess. However, large or symptomatic abscesses may need intervention for rapid relief.
C. Surgical management: This is typically reserved for abscesses that fail other treatments, or in cases of complications like rupture of the abscess into the peritoneal cavity.
D. Percutaneous drainage: Similar to PAIR, percutaneous drainage involves aspirating the contents of the abscess, but without the infusion of drugs. It's an option for abscesses that are not amoebic in origin or for those that do not respond to medication.
Given the size of 75 cc or 7.5 cm, assuming a spherical shape, it's on the borderline. Immediate aspiration might not be the immediate step, especially without a trial of medical therapy. The presence of an amoebic liver abscess can be further confirmed by serological tests.
Given this re-evaluation and understanding the typical approach to managing amoebic liver abscesses, the correct answer seems to be B. Medical management. Starting the patient on metronidazole or tinidazole and monitoring for improvement would be the preferred initial approach.