Diagnosis

Diagnosis

The disease may remain dormant for many years. Clinical features are non-specific and include fever, malaise, anorexia and upper abdominal discomfort. The complete clinical picture can consist of fever with rigors due to ascending cholangitis, the common bile duct. Acute pancreatitis may occur because of obstruction of the pancreatic duct by an adult worm. Particularly when presenting in non-endemic areas, it should be noted that if a person from an endemic area complains of symptoms of biliary tract disease, Clonorchis infestation should be high in the di ff erential diagnosis. In advanced cases, liver function tests are abnormal. Confirmation of the condition is by examination of stool or duodenal aspirate, which may sho w the eggs or adult worms. Ultrasonography findings may be characteristic, showing uni form dilatation of small peripheral intrahepatic bile ducts with only minimal dilatation of the common hepatic and common bile ducts, although the latter are much more dilated when the obstruction is caused by stones. The thickened duct walls sho increased echogenicity and non-shadowing echogenic foci in the bile ducts, representing the worms or eggs. ERCP will con firm these findings. Summary box 6.6 Asiatic cholangiohepatitis: pathogenesis and diagnosis /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF

Occurs in Far Eastern tropical zones The causative parasite is Clonorchis sinensis , Opisthorchis Fasciola Produces bile duct hyperplasia, intrahepatic duct dilatation and stones Increases the risk of cholangiocarcinoma May remain dormant for many years When active, there are biliary tract symptoms in a generally unwell patient Stool examination for eggs or worms is diagnostic Ultrasonography of the hepatobiliary system and ERCP is also diagnostic

Diagnosis

It is mainly males who are a ff ected because females generally cover a greater part of their bodies with clothing, thus making them less prone to mosquito bites. In the acute presentation, there are episodic attacks of fever with lymphadenitis and lymphangitis. - Occasionally , adult worms may be felt subcutaneously . Chronic manifestations appear after repeated acute attacks - over several years. The adult worms cause lympha tic obstruc - tion, resulting in massive lower limb oedema. Obstruction to the cutaneous lymphatics causes skin thickening, not unlike the peau d’orange appearance in breast cancer, thus exacerbating the limb swelling. Secondary streptococcal infection is common. Recurrent attacks of lymphangitis cause fibrosis of the lymph channels, resulting in a grossly swollen limb with thickened skin, producing the condition of elephantiasis ( Figure 6.8 ). Bilateral lower limb filariasis is often associated with scrotal and penile elephantiasis. Early on, there may be a hydrocele underlying scrotal filariasis ( Figure 6.9 ). Chyluria and chylous ascites may occur. A mild form of the disease can a ff ect the respiratory tract, causing dry cough, and is referred to as tropical pulmonary eosinophilia. The con dition of filariasis is clinically very obvious, and thus investi gations in the full-blown case are superfluous. Eosinophilia is common and a nocturnal peripheral blood smear may show the immature forms, or microfilariae. The parasite may also be seen in chylous urine, ascites and h ydrocele fluid.

Figure 6.8 Left lower limb /f_i lariasis – elephantiasis (courtesy of Profes sor Ahmed Hassan Fahal, FRCS MD MS, Khartoum, Sudan).

Diagnosis

There should be a high index of suspicion. Investigations show a raised eosinophil count; serological tests, such as ELISA and immunoelectrophoresis, point towards the diagnosis. Ultra - - sonography and CT scan are the investigations of choice. The CT scan shows a smooth space-occupying lesion with - several septa. Ultrasonography of the biliary tract may show abnormality in the gallbladder and bile ducts, when h ydatid infestation of the biliary system should be suspected. An MRCP may even show multiple cysts communicating with the biliary tree ( Figure 6.13 ). Ultimately , the diagnosis is made by a combination of good history and clinical examination supplemented by serology and imaging. Summary box 6.9 Hydatid disease: diagnosis /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF

Figure 6.11 Anteroposterior (a) and lateral (b) views of computed tomographic scans showing a large hydatid cyst of the right adrenal gland. The patient presented with a mass in the right loin and underwent an adrenalectomy (courtesy of Dr PP Bhattacharyya, Kolkata, India). In the UK, the usual sufferer is a sheep farmer While any organ may be involved, the liver is by far the most commonly affected Elective clinical presentation is usually in the form of a painful lump arising from the liver Anaphylactic shock due to rupture of the hydatid cyst is the emergency presentation CT scan is the best imaging technique – the diagnostic feature is a space-occupying lesion with a smooth outline with septa Figure 6.12 Computed tomographic scan showing disseminated hydatid cysts of the abdomen. The patient was started on albendazole but was lost to follow-up (courtesy of Dr PP Bhattacharyya, Kolkata, India).

Diagnosis

The disease targets the anterior horn cells, causing lower motor neurone paralysis. Muscles of the lower limb are a ff ected twice as frequently as those of the upper limb ( Figures 6.30 and 6.31 ). Fortunately , only 1–2% of su ff erers develop paralytic symptoms but, when they do occur, the disability causes much misery ( Figure 6.32 ). When a patient develops fe ver with muscle weakness, Guillain–Barré syndrome needs to be excluded. The latter has sensory symptoms and signs. Cerebrospinal fluid analysis should help to di ff erentiate the two conditions. Diagnosis

The patient, usually male, is almost always below the age of 40 years and from a poor socioeconomic background. The clinical presentation is abdominal pain, thirst, polyuria and features of gross pancreatic insu ffi ciency causing steatorrhoea and malnutrition. The patient looks ill and emaciated. Initial routine blood and urine tests confirm that the patient has type 1 diabetes mellitus. This is known as fibro calculous pancreatic diabetes, a label that is aptly descriptive of the typical pathological changes. Serum amylase is usually nor mal; in an acute exacerbation, it may be elevated. A plain abdominal radiograph shows typical pancreatic calcifica in the form of discrete stones in the duct ( Figure 6.33 ). Ultra sonography and CT scanning of the pancreas confirm the diagnosis. An ERCP , as an investigation, should only be done when the procedure is also being considered as a therapeutic manoeuvre for removal of ductal stones in the pancreatic head by papillotomy . Diagnosis of tropical chronic pancreatitis /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF

Figure 6.33 Plain radiograph of the abdomen showing large stones along the main pancreatic duct typical of tropical chronic pancreatitis (courtesy of Dr V Mohan, Chennai, India). The usual sufferer is a type 1 diabetic under 40 years of age Serum amylase may be elevated in an acute exacerbation Plain radiograph shows stones along the pancreatic duct Ultrasonography and CT scan of the pancreas con /f_i rm the diagnosis ERCP should be used as an investigation only when combined with a therapeutic procedure

Diagnosis

Any of the cervical group of lymph nodes (jugulodigastric, submandibular, supraclavicular, posterior triangle) can be involved. The patient has the usual general manifestations of tuberculosis: evening pyrexia, cough (maybe from pulmonary tuberculosis) and malaise; if the su ff erer is a child, failure to thrive is a significant finding. Locally there will be regional lymphadenopathy where the lymph nodes may be matted; in late stages a cold abscess may form – a painless, fluctuant, mass which is not warm; significantly there are no signs of inflammation ( Figure 6.34 ), hence it is called a ‘cold abscess’. This is a clinical manifestation of underlying caseation. Left untreated, the cold abscess, initially deep to the deep fascia, bursts through into the space just beneath the superficial fascia. This produces a bilocular mass with cr oss-fluctuation. This is called a ‘collar-stud’ abscess. Eventually this may burst thr ough the skin, discharging pus and forming a tuberculous sinus and eventually might ulcerate ( Figure 6.35 ) . The latter typically has watery discharge with undermined edges as the tubercle bacilli destroy the subcutaneous tissue faster than the rest and thrive in the relatively anoxic environment. Diagnosis

The disease may remain dormant for many years. Clinical features are non-specific and include fever, malaise, anorexia and upper abdominal discomfort. The complete clinical picture can consist of fever with rigors due to ascending cholangitis, the common bile duct. Acute pancreatitis may occur because of obstruction of the pancreatic duct by an adult worm. Particularly when presenting in non-endemic areas, it should be noted that if a person from an endemic area complains of symptoms of biliary tract disease, Clonorchis infestation should be high in the di ff erential diagnosis. In advanced cases, liver function tests are abnormal. Confirmation of the condition is by examination of stool or duodenal aspirate, which may sho w the eggs or adult worms. Ultrasonography findings may be characteristic, showing uni form dilatation of small peripheral intrahepatic bile ducts with only minimal dilatation of the common hepatic and common bile ducts, although the latter are much more dilated when the obstruction is caused by stones. The thickened duct walls sho increased echogenicity and non-shadowing echogenic foci in the bile ducts, representing the worms or eggs. ERCP will con firm these findings. Summary box 6.6 Asiatic cholangiohepatitis: pathogenesis and diagnosis /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF

Occurs in Far Eastern tropical zones The causative parasite is Clonorchis sinensis , Opisthorchis Fasciola Produces bile duct hyperplasia, intrahepatic duct dilatation and stones Increases the risk of cholangiocarcinoma May remain dormant for many years When active, there are biliary tract symptoms in a generally unwell patient Stool examination for eggs or worms is diagnostic Ultrasonography of the hepatobiliary system and ERCP is also diagnostic

Diagnosis

It is mainly males who are a ff ected because females generally cover a greater part of their bodies with clothing, thus making them less prone to mosquito bites. In the acute presentation, there are episodic attacks of fever with lymphadenitis and lymphangitis. - Occasionally , adult worms may be felt subcutaneously . Chronic manifestations appear after repeated acute attacks - over several years. The adult worms cause lympha tic obstruc - tion, resulting in massive lower limb oedema. Obstruction to the cutaneous lymphatics causes skin thickening, not unlike the peau d’orange appearance in breast cancer, thus exacerbating the limb swelling. Secondary streptococcal infection is common. Recurrent attacks of lymphangitis cause fibrosis of the lymph channels, resulting in a grossly swollen limb with thickened skin, producing the condition of elephantiasis ( Figure 6.8 ). Bilateral lower limb filariasis is often associated with scrotal and penile elephantiasis. Early on, there may be a hydrocele underlying scrotal filariasis ( Figure 6.9 ). Chyluria and chylous ascites may occur. A mild form of the disease can a ff ect the respiratory tract, causing dry cough, and is referred to as tropical pulmonary eosinophilia. The con dition of filariasis is clinically very obvious, and thus investi gations in the full-blown case are superfluous. Eosinophilia is common and a nocturnal peripheral blood smear may show the immature forms, or microfilariae. The parasite may also be seen in chylous urine, ascites and h ydrocele fluid.

Figure 6.8 Left lower limb /f_i lariasis – elephantiasis (courtesy of Profes sor Ahmed Hassan Fahal, FRCS MD MS, Khartoum, Sudan).

Diagnosis

There should be a high index of suspicion. Investigations show a raised eosinophil count; serological tests, such as ELISA and immunoelectrophoresis, point towards the diagnosis. Ultra - - sonography and CT scan are the investigations of choice. The CT scan shows a smooth space-occupying lesion with - several septa. Ultrasonography of the biliary tract may show abnormality in the gallbladder and bile ducts, when h ydatid infestation of the biliary system should be suspected. An MRCP may even show multiple cysts communicating with the biliary tree ( Figure 6.13 ). Ultimately , the diagnosis is made by a combination of good history and clinical examination supplemented by serology and imaging. Summary box 6.9 Hydatid disease: diagnosis /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF

Figure 6.11 Anteroposterior (a) and lateral (b) views of computed tomographic scans showing a large hydatid cyst of the right adrenal gland. The patient presented with a mass in the right loin and underwent an adrenalectomy (courtesy of Dr PP Bhattacharyya, Kolkata, India). In the UK, the usual sufferer is a sheep farmer While any organ may be involved, the liver is by far the most commonly affected Elective clinical presentation is usually in the form of a painful lump arising from the liver Anaphylactic shock due to rupture of the hydatid cyst is the emergency presentation CT scan is the best imaging technique – the diagnostic feature is a space-occupying lesion with a smooth outline with septa Figure 6.12 Computed tomographic scan showing disseminated hydatid cysts of the abdomen. The patient was started on albendazole but was lost to follow-up (courtesy of Dr PP Bhattacharyya, Kolkata, India).

Diagnosis

The disease targets the anterior horn cells, causing lower motor neurone paralysis. Muscles of the lower limb are a ff ected twice as frequently as those of the upper limb ( Figures 6.30 and 6.31 ). Fortunately , only 1–2% of su ff erers develop paralytic symptoms but, when they do occur, the disability causes much misery ( Figure 6.32 ). When a patient develops fe ver with muscle weakness, Guillain–Barré syndrome needs to be excluded. The latter has sensory symptoms and signs. Cerebrospinal fluid analysis should help to di ff erentiate the two conditions. Diagnosis

The patient, usually male, is almost always below the age of 40 years and from a poor socioeconomic background. The clinical presentation is abdominal pain, thirst, polyuria and features of gross pancreatic insu ffi ciency causing steatorrhoea and malnutrition. The patient looks ill and emaciated. Initial routine blood and urine tests confirm that the patient has type 1 diabetes mellitus. This is known as fibro calculous pancreatic diabetes, a label that is aptly descriptive of the typical pathological changes. Serum amylase is usually nor mal; in an acute exacerbation, it may be elevated. A plain abdominal radiograph shows typical pancreatic calcifica in the form of discrete stones in the duct ( Figure 6.33 ). Ultra sonography and CT scanning of the pancreas confirm the diagnosis. An ERCP , as an investigation, should only be done when the procedure is also being considered as a therapeutic manoeuvre for removal of ductal stones in the pancreatic head by papillotomy . Diagnosis of tropical chronic pancreatitis /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF

Figure 6.33 Plain radiograph of the abdomen showing large stones along the main pancreatic duct typical of tropical chronic pancreatitis (courtesy of Dr V Mohan, Chennai, India). The usual sufferer is a type 1 diabetic under 40 years of age Serum amylase may be elevated in an acute exacerbation Plain radiograph shows stones along the pancreatic duct Ultrasonography and CT scan of the pancreas con /f_i rm the diagnosis ERCP should be used as an investigation only when combined with a therapeutic procedure

Diagnosis

Any of the cervical group of lymph nodes (jugulodigastric, submandibular, supraclavicular, posterior triangle) can be involved. The patient has the usual general manifestations of tuberculosis: evening pyrexia, cough (maybe from pulmonary tuberculosis) and malaise; if the su ff erer is a child, failure to thrive is a significant finding. Locally there will be regional lymphadenopathy where the lymph nodes may be matted; in late stages a cold abscess may form – a painless, fluctuant, mass which is not warm; significantly there are no signs of inflammation ( Figure 6.34 ), hence it is called a ‘cold abscess’. This is a clinical manifestation of underlying caseation. Left untreated, the cold abscess, initially deep to the deep fascia, bursts through into the space just beneath the superficial fascia. This produces a bilocular mass with cr oss-fluctuation. This is called a ‘collar-stud’ abscess. Eventually this may burst thr ough the skin, discharging pus and forming a tuberculous sinus and eventually might ulcerate ( Figure 6.35 ) . The latter typically has watery discharge with undermined edges as the tubercle bacilli destroy the subcutaneous tissue faster than the rest and thrive in the relatively anoxic environment. Diagnosis

The disease may remain dormant for many years. Clinical features are non-specific and include fever, malaise, anorexia and upper abdominal discomfort. The complete clinical picture can consist of fever with rigors due to ascending cholangitis, the common bile duct. Acute pancreatitis may occur because of obstruction of the pancreatic duct by an adult worm. Particularly when presenting in non-endemic areas, it should be noted that if a person from an endemic area complains of symptoms of biliary tract disease, Clonorchis infestation should be high in the di ff erential diagnosis. In advanced cases, liver function tests are abnormal. Confirmation of the condition is by examination of stool or duodenal aspirate, which may sho w the eggs or adult worms. Ultrasonography findings may be characteristic, showing uni form dilatation of small peripheral intrahepatic bile ducts with only minimal dilatation of the common hepatic and common bile ducts, although the latter are much more dilated when the obstruction is caused by stones. The thickened duct walls sho increased echogenicity and non-shadowing echogenic foci in the bile ducts, representing the worms or eggs. ERCP will con firm these findings. Summary box 6.6 Asiatic cholangiohepatitis: pathogenesis and diagnosis /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF

Occurs in Far Eastern tropical zones The causative parasite is Clonorchis sinensis , Opisthorchis Fasciola Produces bile duct hyperplasia, intrahepatic duct dilatation and stones Increases the risk of cholangiocarcinoma May remain dormant for many years When active, there are biliary tract symptoms in a generally unwell patient Stool examination for eggs or worms is diagnostic Ultrasonography of the hepatobiliary system and ERCP is also diagnostic

Diagnosis

It is mainly males who are a ff ected because females generally cover a greater part of their bodies with clothing, thus making them less prone to mosquito bites. In the acute presentation, there are episodic attacks of fever with lymphadenitis and lymphangitis. - Occasionally , adult worms may be felt subcutaneously . Chronic manifestations appear after repeated acute attacks - over several years. The adult worms cause lympha tic obstruc - tion, resulting in massive lower limb oedema. Obstruction to the cutaneous lymphatics causes skin thickening, not unlike the peau d’orange appearance in breast cancer, thus exacerbating the limb swelling. Secondary streptococcal infection is common. Recurrent attacks of lymphangitis cause fibrosis of the lymph channels, resulting in a grossly swollen limb with thickened skin, producing the condition of elephantiasis ( Figure 6.8 ). Bilateral lower limb filariasis is often associated with scrotal and penile elephantiasis. Early on, there may be a hydrocele underlying scrotal filariasis ( Figure 6.9 ). Chyluria and chylous ascites may occur. A mild form of the disease can a ff ect the respiratory tract, causing dry cough, and is referred to as tropical pulmonary eosinophilia. The con dition of filariasis is clinically very obvious, and thus investi gations in the full-blown case are superfluous. Eosinophilia is common and a nocturnal peripheral blood smear may show the immature forms, or microfilariae. The parasite may also be seen in chylous urine, ascites and h ydrocele fluid.

Figure 6.8 Left lower limb /f_i lariasis – elephantiasis (courtesy of Profes sor Ahmed Hassan Fahal, FRCS MD MS, Khartoum, Sudan).

Diagnosis

There should be a high index of suspicion. Investigations show a raised eosinophil count; serological tests, such as ELISA and immunoelectrophoresis, point towards the diagnosis. Ultra - - sonography and CT scan are the investigations of choice. The CT scan shows a smooth space-occupying lesion with - several septa. Ultrasonography of the biliary tract may show abnormality in the gallbladder and bile ducts, when h ydatid infestation of the biliary system should be suspected. An MRCP may even show multiple cysts communicating with the biliary tree ( Figure 6.13 ). Ultimately , the diagnosis is made by a combination of good history and clinical examination supplemented by serology and imaging. Summary box 6.9 Hydatid disease: diagnosis /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF

Figure 6.11 Anteroposterior (a) and lateral (b) views of computed tomographic scans showing a large hydatid cyst of the right adrenal gland. The patient presented with a mass in the right loin and underwent an adrenalectomy (courtesy of Dr PP Bhattacharyya, Kolkata, India). In the UK, the usual sufferer is a sheep farmer While any organ may be involved, the liver is by far the most commonly affected Elective clinical presentation is usually in the form of a painful lump arising from the liver Anaphylactic shock due to rupture of the hydatid cyst is the emergency presentation CT scan is the best imaging technique – the diagnostic feature is a space-occupying lesion with a smooth outline with septa Figure 6.12 Computed tomographic scan showing disseminated hydatid cysts of the abdomen. The patient was started on albendazole but was lost to follow-up (courtesy of Dr PP Bhattacharyya, Kolkata, India).

Diagnosis

The disease targets the anterior horn cells, causing lower motor neurone paralysis. Muscles of the lower limb are a ff ected twice as frequently as those of the upper limb ( Figures 6.30 and 6.31 ). Fortunately , only 1–2% of su ff erers develop paralytic symptoms but, when they do occur, the disability causes much misery ( Figure 6.32 ). When a patient develops fe ver with muscle weakness, Guillain–Barré syndrome needs to be excluded. The latter has sensory symptoms and signs. Cerebrospinal fluid analysis should help to di ff erentiate the two conditions. Diagnosis

The patient, usually male, is almost always below the age of 40 years and from a poor socioeconomic background. The clinical presentation is abdominal pain, thirst, polyuria and features of gross pancreatic insu ffi ciency causing steatorrhoea and malnutrition. The patient looks ill and emaciated. Initial routine blood and urine tests confirm that the patient has type 1 diabetes mellitus. This is known as fibro calculous pancreatic diabetes, a label that is aptly descriptive of the typical pathological changes. Serum amylase is usually nor mal; in an acute exacerbation, it may be elevated. A plain abdominal radiograph shows typical pancreatic calcifica in the form of discrete stones in the duct ( Figure 6.33 ). Ultra sonography and CT scanning of the pancreas confirm the diagnosis. An ERCP , as an investigation, should only be done when the procedure is also being considered as a therapeutic manoeuvre for removal of ductal stones in the pancreatic head by papillotomy . Diagnosis of tropical chronic pancreatitis /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF

Figure 6.33 Plain radiograph of the abdomen showing large stones along the main pancreatic duct typical of tropical chronic pancreatitis (courtesy of Dr V Mohan, Chennai, India). The usual sufferer is a type 1 diabetic under 40 years of age Serum amylase may be elevated in an acute exacerbation Plain radiograph shows stones along the pancreatic duct Ultrasonography and CT scan of the pancreas con /f_i rm the diagnosis ERCP should be used as an investigation only when combined with a therapeutic procedure

Diagnosis

Any of the cervical group of lymph nodes (jugulodigastric, submandibular, supraclavicular, posterior triangle) can be involved. The patient has the usual general manifestations of tuberculosis: evening pyrexia, cough (maybe from pulmonary tuberculosis) and malaise; if the su ff erer is a child, failure to thrive is a significant finding. Locally there will be regional lymphadenopathy where the lymph nodes may be matted; in late stages a cold abscess may form – a painless, fluctuant, mass which is not warm; significantly there are no signs of inflammation ( Figure 6.34 ), hence it is called a ‘cold abscess’. This is a clinical manifestation of underlying caseation. Left untreated, the cold abscess, initially deep to the deep fascia, bursts through into the space just beneath the superficial fascia. This produces a bilocular mass with cr oss-fluctuation. This is called a ‘collar-stud’ abscess. Eventually this may burst thr ough the skin, discharging pus and forming a tuberculous sinus and eventually might ulcerate ( Figure 6.35 ) . The latter typically has watery discharge with undermined edges as the tubercle bacilli destroy the subcutaneous tissue faster than the rest and thrive in the relatively anoxic environment.