Jouf University Phase II, Year III

Gastrointestinal System Block (CMD-332)

PBL: 5 - Tutor’s Copy: Abdominal pain with fever

Part – I

Mr. Ahmed, a 35-year-old Saudi engineer, presented to the PHC with 3 days
of fever, rigors, anorexia and abdominal pain. The condition started two
weeks after arrival from a business trip to Kenya. He stayed there for 3
weeks during which he suffered from loose bowel motions for 3 days
associated with blood, mucus and tenesmus that stopped without treatment.
On examination, the temperature was 39 °C, otherwise no abnormality was
seen. The general practitioner prescribed ciprofloxacin 500 mg twice daily
for 5 days. However, the condition progresses and he started to suffer from
upper right abdominal dull aching pain that radiates to the right shoulder and
lower chest as well as nausea, sweating, and malaise. The patient denies any
change in urine, bowel habits or itching. Therefore, the patient was referred
to hospital for more assessment and management. On examination, the
patient was pale, toxic, sweaty, temperature 38.9 °C, pulse 95/min. Bl. pr.
110/70 mm Hg, the liver was moderately enlarged (5 fingers below the right
costal margin) with point tenderness, no jaundice, or pedal edema. The
specialist asked for laboratory investigations and urgent abdominal
ultrasonography.

Investigations showed:

1. White blood cell count: 12.8/mL (67% polymorphonuclear leukocytes

and 11% band cells). A second count showed a left shift to 33%
bands.
2. Liver enzymes:
a. Alkaline phosphatase 116 IU/L (30-120 IU/L)
b. Alanine aminotransferase 57 IU/L (5-56 IU/L)
c. Bilirubin 1.1 mg/dL. (0.2-1.2 mg/dL)
3. A chest x-ray film showed elevation of the right hemi-diaphragm.
Abdominal ultrasonography revealed an enlarged tender liver with a
longitudinal span of 18 cm. There was a single sub-capsular cystic
lesion in the posterior segment of the right lobe measuring 8X5X3 cm,
 with irregular wall and internal echoes. The gall bladder, spleen and
both kidneys were normal, no ascites.

4. Fecal leukocytes, ova, and parasites were not seen on stool examination
5. Repeated blood culture results were negative.
6. Serum amebic antibody test was positive.

The patient was given a full course of metronidazole, 750 mg tid for 10 days
and he experienced relief of symptoms after 5 days. The specialist arranged
for another visit for follow up after two months.
Part – II

Two months later, Mr. Ahmed visited the outpatient clinic follow-up. He
reported none of the previous symptoms including the upper quadrant
abdominal pain. Repeat abdominal ultrasonography revealed a non-tender
liver, with a longitudinal span of 15 cm and the same lesion with the less
dimensions [7x4.1x2.7 cm]. Mr. Ahmed was worried about the persistence
of the lesion and asked for the possibility of aspiration or surgery. The
physician assured him that complete resolution could take more than one
year and no harm or complications are expected to occur.