SURGERY IN THE TROPICS

SURGERY IN THE TROPICS

INTRODUCTION Parasitic infestations International travel Life cycles of the parasite

SURGERY IN THE TROPICS

AMOEBIASIS Amoebiasis is caused by Entamaeba histolytica Indian subcontinent,Africa and parts of Central and South America Asymptomatic carriers Faecal-oral route due to poor hygeine and saanitation Amoebic liver abscess 10% Immunocompromised and alcoholic

SURGERY IN THE TROPICS

AMOEBIASIS
PATHOGENESIS

Organism enters the gut through food or water contaminated with cyst. In the small bowel cyst hatch and release trophozoites and are carried to large bowel. In the large bowel flask shaped ulcers form in the submucosa The trophozoites multiply which then form cysts and then enter the portal circulation. The cysts are passed in the faeces as an infective form that infects other humans as a result of insanitary conditions. The cysts entering the portal circulation----Amoebic hepatitis/abscess Right lobe 80%,Left lobe 10%,multiple 10% Abscess (anchovy sauce)fluid which is choclate coloured and odourless. Trophozoite in the wall of abscess Ch granulamatous inflammation AMOEBOMA

AMOEBIASIS Clinical Features Young adult male Insidious onset of non-specific symptoms Anorexia,fever,night sweats,malaise,cough and wt loss Pain rt hypochondrium,shoulder tip pain,hicough Past history of bloody diarrhoea O/E ,Patient toxic and anaemic Upper abdominal rigidity,tender hepatomegaly,intercoastal tenderness,overlying skin oedema,pleural effusion and pneumonitis Occasionally tinge of jaundice/ascites Rarely may present in emergency due to rupture into the peritoneal,pleural or pericardial cavity.

SURGERY IN TROPICS
AMOEBOMA
Ch granuloma Caecum Longstanding amoebic infection treated intermittently with drugs. D/D carcinoma INVESTIGATIONS Anaemia,leucocytosis,raised ESR and C-reactive protein,hypoalbuminaemia,deranged LFT Serological tests Sigmoidoscopy Imaging techniques a)Ultrasound scan b)CT scan c)Barium enema

SURGERY IN TROPICS
Diagnostic pointers for infection with Entamoeba histolytica

Bloody mucus diarrhoea Upper abdominal pain,fever,cough,malaise In chronic cases,a mass in the right iliac fossaamoeboma Sigmoidoscopy shows typical ulcers-Biopy and scrappings may be diagnostic Serological tests are hoghly sensitive and specific outside endemic areas Ultrsound and CT scans are the imaging methods of choice

SURGERY IN TROPICS
TREATMENT

Medical treatment is very effective In large abscesses repeated aspiration is combined with drug treatment Surgical treatment is reserved for complications such as rupture into pleural,peritoneal or pericardial cavities Acute toxic megacolon and severe haemorrhage are intestinal complications that are treated with intensive supportive therapy followed by resection and exteriorisation When an amoeboma is suspected in a colonic mass,cancer should be excluded by appropriate imaging.

SURGERY IN TROPICS
ASCARIS LUMBRICOIDES

It is the commonest intestinal nematode affecting man Typically found in a humid atmosphere and poor sanitary conditions;hence is seen in the tropics and developing countries Larvae cause pulmonary symptoms;adult worms cause GI,biliary and pancreatic symptoms Distal ileal obstruction due to bolus of worms,ascending cholangitis and obstructive jaundice from infestation of bile duct Acute pancreatis Perforation of small bowel is rare

SURGERY IN TROPICS
INVESTIGATIONS/TREATMENT

Eosinophil count Stool examination Sputum or bronchoscopic washings Chest xray Barium meal and FT Ultrasound scan MRCP Conservative management with anthelmintics is the first line of treatment even in obstruction Surgery

SURGERY IN THE TROPICS

ASIATIC CHOLANGIOHEPATITIS
Occurs in the far Eastern tropical zones Causative parasite is Clonorchis sinensis Produces bile duct hyperplasia,duct dilatation and stones Increases the risk of cholangiocarcinoma May remain dormant for many years When active,there are biliary tract symptomsin a generally unwell patient Stool exam for eggs and worms is diagnostic Ultrasound scan/ERCP Treatment a)Medical treatment can be curative b)Surgical treatment c)Prevention

SURGERY IN THE TROPICS

TROPICAL PANCREATITIS
Occurs in developing countries due to malnutrition Cassava ingestion Dilatation of pancreatic ducts with large intraductal stones Fibrosis of the pancreas A high incidence of pancreatic cancer in those affected by the disease Type 1 diabetic under 40yrs of age Serum amylase Plain xray Ultrasound/CT scan/ERCP Treatment Medical/Surgical

SURGERY IN THE TROPICS

TYPHOID
Samonella typhi Poor hygeine and sanitation Perforation of typhoid ulcerPeritonitis Pathology a)Organism colonise peyers patches--necrosisulcer b)If patient left untreated or inadequately treated ---perforation and bleeding Diagnosis High fever and toxic Positive blood and stool culture After second week ,signs of peritonitis is due to perforation Chest xray---Free gas

SURGERY IN THE TROPICS

TYPHOID Treatment of bowel perforation

Manage in intensive care Resuscitate and give intravenous antibiotics Laparotomy and choice of different procedures to deal with perforation