26. Gastroduodenal peptic ulcer, Benign liver tumors & Lung abscess

What is the definition of GASTRODUODENAL PEPTIC ULCER?

A break in the continuity of the mucosal lining of the stomach or duodenum, resulting from the corrosive action of acidic gastric juice on vulnerable epithelium. They are most commonly due to H. Pylori infection or NSAID use.

What is the epidemiology of GASTRODUODENAL PEPTIC ULCER?

Duodenal ulcers are most common in men aged 20-45 years, with 95% found in the duodenal bulb. Gastric ulcers peak in ages 40-60 years, with 95% located on the lesser curvature.

What is the etiology of GASTRODUODENAL PEPTIC ULCER?

Gastroduodenal peptic ulcers are most commonly caused by an infection with H. Pylori or the use of NSAIDs. They result from the corrosive action of acidic gastric juice on the vulnerable epithelium.

What are the types of GASTRODUODENAL PEPTIC ULCER and their features?

The main types are duodenal and gastric ulcers. Duodenal ulcers typically present with epigastric pain relieved by food or antacids, with pain increasing 2-5 hours after eating or on an empty stomach, often causing nocturnal pain in 50-80% of cases. Gastric ulcers also cause epigastric pain relieved by food or antacids, but pain appears earlier, often within 30 minutes after eating, and 30-40% experience nocturnal pain.

What is the clinical presentation of GASTRODUODENAL PEPTIC ULCER?

The most common clinical presentation is pain, particularly epigastric pain, which is often relieved by food or antacids. However, up to 70% of patients can be asymptomatic. Other presentations include bleeding, perforation, or obstruction due to inflammation or scarring.

What are the signs of GASTRODUODENAL PEPTIC ULCER?

Signs can include epigastric tenderness, and in cases of bleeding, anemia, hematemesis, or melena may be present. Gastric acid production can be normal or increased in duodenal ulcers.

What are the symptoms of GASTRODUODENAL PEPTIC ULCER?

The most common symptom is pain, specifically aching or burning epigastric pain, often relieved by food or antacids. Other symptoms include postprandial heaviness, early satiety, vomiting, and anorexia. Pain timing varies by ulcer type: gastric pain increases shortly after eating, while duodenal pain increases 2-5 hours after eating or on an empty stomach, with nocturnal pain common for both.

What are the diagnostic methods (labs, imaging, physical examination) of GASTRODUODENAL PEPTIC ULCER and their findings?

Diagnosis involves endoscopy or gastroscopy, with biopsy preferred for gastric ulcers (6 specimens from the edge of the lesion). Radiography, such as an upper gastrointestinal series or X-ray, can reveal inflammatory changes, deformities, a niche, or a meniscus sign. Diagnostic testing for gastric acid production (BAO, MAO) and H. Pylori infection are also used.

What is the surgical treatment/management of GASTRODUODENAL PEPTIC ULCER and their indications?

Surgical treatment is indicated if complications arise, such as bleeding, perforation, or obstruction. Specific indications include gastric outlet obstruction not responding to endoscopic dilatation, failure of maximal medical treatment with severe or relapsing symptoms, and perforated peptic ulcers. Procedures include pyloroplasty, Billroth II partial gastrectomy, type I partial gastrectomy for gastric ulcers, type II partial gastrectomy for duodenal ulcers, and patch closure with omental tissue for perforations.

What are the complications of GASTRODUODENAL PEPTIC ULCER?

Complications include bleeding, perforation, and gastric outlet obstruction due to inflammation or scarring. Other potential complications are secondary peritonitis, subhepatic abscess, fistula formation, and malignant transformation, especially in gastric ulcers with a 5-10% cancer progression rate.

What are differential diagnoses of GASTRODUODENAL PEPTIC ULCER and how do we differentiate?

Differential diagnoses include chronic cholecystitis and chronic pancreatitis for duodenal ulcers, and uncomplicated hiatal hernia, atrophic gastritis, chronic cholecystitis, and irritable colon syndrome for gastric ulcers. Differentiation is aided by diagnostic methods such as endoscopy and biopsy, especially for gastric ulcers to rule out malignancy.

What is the definition of benign liver tumors?

Benign liver tumors and hepatic cysts are common masses that can occur at any age, but are particularly frequent in young women. They include types such as hepatic haemangiomas, focal nodular hyperplasia (FNH), and hepatocellular adenoma.

What is the classification of benign liver tumors and their features?

Benign liver tumors include hepatocellular adenoma, focal nodular hyperplasia (FNH), and hemangioma, with others like polycystic liver disease and liver cysts also mentioned.

What is the epidemiology of benign liver tumors?

Hepatic haemangioma is the most common, followed by focal nodular hyperplasia, and then hepatocellular adenoma, which is rare. They are more frequent in females than males, with a 6:1 ratio.

What is the etiology of benign liver tumors?

The etiology is mostly unknown, though disturbances in reproductive hormones like oestrogen may play a role. Oral contraceptive use and anabolic steroids are linked to hepatocellular adenoma, and oestrogen therapy to hepatic haemangioma growth.

What are the risk factors of benign liver tumors?

Oral contraceptive use, particularly those containing estrogen, and pregnancy are risk factors for hepatocellular adenoma. Oestrogen therapy can also be associated with increased growth in size for hepatic haemangioma.

What is the clinical presentation of benign liver tumors?

They are usually asymptomatic and often discovered incidentally during abdominal imaging. However, large tumors can present with upper abdominal pain, nausea, or postprandial fullness.

What are the symptoms of benign liver tumors?

Most are asymptomatic. When symptomatic, they can cause upper abdominal pain, nausea, or postprandial fullness. Hepatocellular adenoma can specifically cause upper abdominal pain from hemorrhage or compression, or acute intraperitoneal hemorrhage.

What are the diagnostic methods (labs, imaging, physical examination) of benign liver tumors and their findings?

The best initial diagnostic test is ultrasound. Further imaging includes contrast-enhanced CT and MRI, which are often combined for definitive diagnosis and differentiation of tumor types. Biopsy may be needed if imaging is inconclusive.

What is the conservative treatment of benign liver tumors?

Conservative treatment is often sufficient for benign liver tumors. Hemangiomas are typically managed conservatively, and liver cysts are only treated if symptomatic.

What is the pharmacological treatment of benign liver tumors?

Discontinuing oral contraceptives is a relevant management for hepatic adenoma.

What is the surgical treatment/management of benign liver tumors?

Surgical treatment is recommended if the tumors are symptomatic or if complications occur. This can include excision for hepatocellular adenoma based on size, or for polycystic liver disease and some liver cysts if they cause symptoms or have malignant potential.

What is the prophylactic measures against benign liver tumors?

Discontinuing oral contraceptives is a prophylactic measure for hepatocellular adenoma.

What is the definition of hepatocellular adenoma?

Hepatocellular adenoma is a relatively rare proliferation of hepatocytes occurring in a normal liver. It is also known as liver cell adenoma.

What is the epidemiology of hepatocellular adenoma?

It is a relatively rare benign liver tumor. It is typically found in young women.

What is the etiology of hepatocellular adenoma?

It is associated with the use of oral contraceptive pills and anabolic steroids.

What are the risk factors of hepatocellular adenoma?

The use of oral contraceptives, particularly those containing estrogen, and pregnancy are associated with an increased risk of hepatocellular adenoma.

What is the clinical presentation of hepatocellular adenoma?

It can present with upper abdominal pain, either from hemorrhage into the tumor or local compression, and acute intraperitoneal hemorrhage. It can also be asymptomatic, with larger tumors causing pain, nausea, or postprandial fullness.

What are the symptoms of hepatocellular adenoma?

Symptoms include upper abdominal pain, which can be due to hemorrhage into the tumor or local compression. Acute intraperitoneal hemorrhage is also a possible symptom.

What are the diagnostic methods (labs, imaging, physical examination) of hepatocellular adenoma and their findings?

Diagnosis involves imaging methods such as ultrasound, contrast-enhanced CT, and MRI. A biopsy may be performed if imaging is inconclusive to confirm the diagnosis.

What is the conservative treatment of hepatocellular adenoma?

For tumors between 3-5 cm, careful monitoring is recommended. Discontinuation of oral contraceptives is also part of conservative management.

What is the surgical treatment/management of hepatocellular adenoma?

Surgical removal is generally recommended for tumors larger than 5 cm due to the increased risk of bleeding or malignant transformation. For tumors between 3-5 cm, careful monitoring or removal may be considered.

What is the prophylactic measures against hepatocellular adenoma?

Discontinuing oral contraceptives is a prophylactic measure against hepatocellular adenoma.

What is the definition of focal nodular hyperplasia?

Focal nodular hyperplasia is the second most common benign liver tumor, predominantly found in young women. These masses are often discovered incidentally.

What is the classification of focal nodular hyperplasia and their features?

FNH masses are typically small, less than 5 cm, and are found equally in the left and right liver. Larger cavernous hemangiomas have been associated with FNH.

What is the epidemiology of focal nodular hyperplasia?

It is the second most common benign liver tumor, predominantly found in young women. It is more common in females than males.

What is the etiology of focal nodular hyperplasia?

The exact etiology is unknown, but it is thought to be related to developmental vascular malformation.

What is the clinical presentation of focal nodular hyperplasia?

These masses are usually found incidentally during imaging or laparotomy because they are typically asymptomatic. Large tumors, however, might present with upper abdominal pain, nausea, or postprandial fullness.

What are the symptoms of focal nodular hyperplasia?

FNH is typically asymptomatic. When symptomatic, large tumors may cause upper abdominal pain, nausea, or postprandial fullness.

What are the diagnostic methods (labs, imaging, physical examination) of focal nodular hyperplasia and their findings?

FNH is often found incidentally during abdominal imaging. Diagnosis and monitoring are done using CT and MRI. Ultrasound is often the best initial test.

What is the conservative treatment of focal nodular hyperplasia?

Monitoring using CT or MRI is the primary approach, and if the tumor does not grow, no further treatment is needed. Overall, conservative treatment is often sufficient.

What is the surgical treatment/management of focal nodular hyperplasia?

Surgical treatment may be considered if FNH becomes symptomatic and/or complications arise.

What is the definition of hemangioma?

Hemangioma is the most common benign tumor of the liver, originating from malformations of blood vessels.

What is the classification of hemangioma and their features?

Hemangiomas can be small capillary types, which are clinically insignificant, or larger cavernous types, sometimes associated with FNH. They generally carry no risk of bleeding or malignant transformation.

What is the epidemiology of hemangioma?

It is the most common benign liver tumor. It is more common in females than males.

What is the etiology of hemangioma?

Hemangiomas result from malformations of blood vessels. There may be a hormonal component, as oestrogen therapy is associated with increased growth in size.

What are the risk factors of hemangioma?

Oestrogen therapy is associated with increased growth in size, indicating a possible hormonal risk factor.

What is the clinical presentation of hemangioma?

Hemangiomas are typically asymptomatic and discovered incidentally. Symptomatic tumors, causing abdominal pain or nausea that interferes with lifestyle, may warrant removal, but spontaneous rupture is rare.

What are the symptoms of hemangioma?

Hemangiomas are usually asymptomatic. If symptoms occur, they include abdominal pain and nausea.

What are the diagnostic methods (labs, imaging, physical examination) of hemangioma and their findings?

Diagnosis is made using imaging techniques such as ultrasound, contrast-enhanced CT, and MRI.

What is the conservative treatment of hemangioma?

Treatment is typically conservative.

What is the surgical treatment/management of hemangioma?

Surgical removal may be recommended only for symptomatic tumors that cause abdominal pain or nausea and interfere with lifestyle. Surgery is generally considered if symptoms or complications arise.

What is the definition of polycystic liver disease?

Polycystic liver disease is an inherited condition, often associated with polycystic kidney disease.

What is the etiology of polycystic liver disease?

It is an inherited condition.

What is the clinical presentation of polycystic liver disease?

Most cases are asymptomatic, but the liver can become massively enlarged and press on adjacent organs, potentially causing upper abdominal pain, nausea, or postprandial fullness.

What are the symptoms of polycystic liver disease?

Most individuals are asymptomatic. However, when the liver becomes massively enlarged and presses on adjacent organs, symptoms such as upper abdominal pain, nausea, and postprandial fullness can occur.

What are the diagnostic methods (labs, imaging, physical examination) of polycystic liver disease and their findings?

Diagnosis typically involves imaging methods such as ultrasound, contrast-enhanced CT, and MRI. A biopsy might be used if imaging results are inconclusive.

What is the conservative treatment of polycystic liver disease?

Most cases of polycystic liver disease do not require surgery, and conservative treatment is often sufficient.

What is the surgical treatment/management of polycystic liver disease?

Surgery to remove or open some cysts is required if the liver is massively enlarged and pressing on adjacent organs. This can be done laparoscopically or by open approach, and in rare severe cases, liver transplantation may be recommended.

What is the definition of liver cysts?

Liver cysts are common benign formations within the liver.

What is the classification of liver cysts and their features?

Specific types mentioned include biliary cystadenomas and choledochal cysts, which are rare and have a potential to become cancerous.

What is the epidemiology of liver cysts?

Liver cysts are common and can occur at any age.

What is the clinical presentation of liver cysts?

Usually asymptomatic. Only treated if the patient experiences symptoms related to the cyst. Large cysts may cause upper abdominal pain, nausea, or postprandial fullness.

What are the symptoms of liver cysts?

Most liver cysts are asymptomatic. If symptoms occur, they are related to the cyst and can include upper abdominal pain, nausea, or postprandial fullness.

What are the diagnostic methods (labs, imaging, physical examination) of liver cysts and their findings?

Diagnosis involves imaging methods such as ultrasound, contrast-enhanced CT, and MRI. A biopsy may be performed if imaging is inconclusive.

What is the conservative treatment of liver cysts?

Liver cysts are usually asymptomatic and are only treated if symptoms are experienced. Conservative treatment is often sufficient.

What is the surgical treatment/management of liver cysts?

Surgery may be recommended in rare cases for types like biliary cystadenomas or choledochal cysts due to their potential to become cancerous. Surgical treatment is also considered if the cysts are symptomatic or complications arise.

What is the definition of LUNG ABSCESS?

Lung abscess is a localised collection of pus and necrotic tissue within the lung parenchyma caused by microbial infection. It is most commonly a complication of necrotising pneumonia secondary to aspiration.

What is the classification of LUNG ABSCESS and their features?

Lung abscess can be classified as primary or secondary. A primary lung abscess occurs in normal lung parenchyma, typically due to aspiration, while a secondary abscess occurs in patients with immunocompromise, pre-existing disease, or due to hematogenous spread.

What is the etiology of LUNG ABSCESS?

The etiology includes complication of necrotising pneumonia secondary to aspiration, bronchial obstruction, abscess from systemic sepsis, pulmonary trauma, and direct extension from extraparenchymal infection. Pathogens can be bacterial (most commonly anaerobic), parasitic (e.g., entamoeba histolytica), or fungal (e.g., aspergillus spp.).

What are the risk factors of LUNG ABSCESS?

Aspiration is the most common risk factor, especially with impaired consciousness or swallow. Other risk factors include increased oropharyngeal bacterial growth (e.g., periodontal disease), bronchial obstruction (e.g., lung cancer), immunocompromised state, pneumonia, bronchiectasis, and impaired respiratory mucus clearance (e.g., cystic fibrosis).

What is the clinical presentation of LUNG ABSCESS?

Patients present with fever and may appear chronically ill. They describe recent onset of foul-smelling sputum production.

What are the symptoms of LUNG ABSCESS?

Symptoms include fever, cough with production of foul-smelling purulent sputum, night sweats, hemoptysis, anorexia, weight loss, fatigue, and pleuritic chest pain. Massive hemoptysis can also occur.

What are the diagnostic methods (labs, imaging, physical examination) of LUNG ABSCESS and their findings?

Diagnosis is based on chest radiograph (initial) and IV contrast CT (for confirmation and differential diagnosis). Imaging typically shows a spherical intraparenchymal cavity with thick irregular walls and an air-fluid level within the cavity. Lab findings include an elevated white blood cell count; blood and sputum cultures should be done, though they may not always be positive. Bronchoscopy can also be used.

What is the pharmacological treatment of LUNG ABSCESS?

Treatment involves starting broad-spectrum antibiotics with anaerobic coverage, which is successful in 75% of cases. Clindamycin or ampicillin-sulbactam are used if there is no risk for MRSA, while linezolid or vancomycin are used if MRSA is suspected.

What is the interventional treatment of LUNG ABSCESS?

Interventional therapy includes drainage, which can be bronchoscopic or image-guided percutaneous. Management of the underlying cause, such as bronchoscopy-guided removal of a foreign body or treatment of bacterial tonsillitis, is also part of interventional management.

What is the surgical treatment/management of LUNG ABSCESS?

Surgical options include chest tube drainage or surgical resection of the lung abscess with surrounding tissue, such as lobectomy, segmentectomy, or pneumonectomy. Indications for lobectomy include chronic symptoms, serious haemorrhage, and suspicion of carcinoma.

What are 3 main differential diagnoses of LUNG ABSCESS and how do we differentiate?

Three differential diagnoses for cavitary lung lesions include pleural empyema with air-fluid level, bullae or cysts with air-fluid level, and pulmonary infarction. Others include tuberculosis, aspergillosis, and cavitating pulmonary metastasis. The sources do not provide information on how to differentiate between these conditions.