PARASITIC INFECTIONS IN SURGERY

PRESENTOR : Dr. Suvarna Raju K

MODERATOR : Dr. Siddharth
 Parasitic Diseases in Surgery -

 Cestodes – Echinococcus granulosus, Taenia solium

 Trematodes – Clonorchis sinensus, Schistosomata

 Nematodes – Ascaris lumbricoides, Wuchereria bancrofti

 Protozoa – Entamoeba histolytica

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 Echinococcus granulosus (Dog Tapeworm)
 Causes - Hydatid disease

 Definitive host - Dog

 Intermediate host - Sheep/ Cattle/ Humans

 Most common in Sheep farming community

 Mode of Transmission - Raw vegetables or other food items contaminated with dog faeces
Life cycle
HYDATID CYST
 Clinical features
 Liver - Enlarging mass in right upper quadrant - dull pain

 Obstructive jaundice

 Pulmonary - Dyspnoea, travel through tracheobronchial tree.

 Cerebral - Raised ICP symptoms

 Anaphylactic shock - rare without any obvious cause, may cough out white material
 Investigation
 High eosinophil count.

 ELISA, immune electrophoresis.

 USG - Abnormality in the gall bladder and bile

ducts.

 CT - smooth space occupying lesion with several

septa.
 Treatment
 Depends on the organ involved, treated in a tertiary care unit- expert hepatobiliary surgeon, physician and

interventional radiologist.

 Approach decided based upon the number of cysts and their anatomical position.

 Medical – Albendazole 400 mg BD x 3 months, Praziquantel 20 mg/kg BD for 14 days

 PAIR(Puncture, aspiration, Injection, Re-aspiration)

PAIR
 Scolicidal agents - hypertonic saline(15-20%), ethanol(75-95%), 1% povidone iodine

 Radical total or partial pericystectomy with omentoplasty or hepatic segmentectomy

 Inactive and asymptomatic patients - Observation

 Laparoscopically: Marsupialisation of the cyst(de-roofing)- consisting of removal of the cyst containing the

endocyst along with the daughter cysts - most common procedure.

 Pulmonary hydatid disease
 Second most affected organ

 Cyst size - variable

 Right lung and lower lobes - Most often involved

 Usually single, but multiple cysts do occur and concomitant hydatid cysts in other organs

 Silent, incidental

 Symptoms - Cough, expectoration, fever, chest pain, hemoptysis

Uncomplicated cysts Erosion of bronchioles
 CT - Water Lily sign
 Treatment - Preserve as much of viable lung tissue as possible.

 Cystostomy

 Capittonage (suturing the walls together)

 Pericystectomy

 Segmentectomy

 Pneumonectomy (occasionally)
Taenia solium (Pig Tapeworm)
 Neurocysticercosis

 Asymptomatic to life threatening

 Can affect parenchyma, subarachnoid space, intraventricular system, ocular and spinal

 Dependant on the location, number, and stage of the cysts at presentation

 Cause of adult-onset epilepsy

 Treatment
 For Parenchymal Disease - Praziquantel and Albendazole are antiparasitic agents.

 Greater cyst reduction with Albendazole administration.

 Praziquantel dose - 50 mg/kg/d for 2 weeks.

 Albendazole dose -15mg/kg for four weeks later reduced to 15 days then to one week.

 Antiepileptic drugs.

 Exacerbation of neurologic symptoms attributed to inflammation secondary to killing of cysticerci -

Steroids used in conjunction to control resulting edema.

 Surgery reserved for complications and large cysts.

 Clonorchis sinensis (Liver Fluke)
 Causes Oriental Cholangiohepatitis / Asiatic Cholangiohepatitis.

 Affects the hepatobiliary system.

 Definitive host - Humans and other fish eating mammals.

 Intermediate host - Snails and fish

 Mode of transmission - Ingestion of infected fish and snails when eaten raw or improperly cooked.
Life cycle
 Pathogenesis:
 In humans, the parasite matures into adult worm in the intrahepatic biliary radicles
↓
 Intrahepatic bile duct dilatation with epithelial hyperplasia and periductal fibrosis, dysplasia and
cholangiocarcinoma.

 Eggs or dead worms act as nidus for stone formation in GB or CBD - which are thickened and dilated in late
stage and produce mucin rich bile.

 Dilated intrahepatic bile ducts leads to cholangitis, liver abscess, hepatitis.

 Clinical features
 May remain dormant for years.

 Non specific - Fever, malaise, anorexia, upper abdominal discomfort.

 Specific - Fever with rigors(Ascending cholangitis), obstructive jaundice due to stones, biliary colic and
pruritus from stones in CBD.

 Acute pancreatitis - obstruction of pancreatic duct by adult worm.

 Investigations
 LFT- abnormal

 Examination of stool/duodenal aspirate - eggs or adult worms

 USG -
(i)Uniform dilatation of small peripheral intrahepatic bile ducts with only minimal dilatation of CHD
and CBD.
(ii) Thickened duct walls(increased echogenicity, non- shadowing echogenic foci in bile ducts)

 ERCP for confirmation.

 Treatment
 Drug of choice - Praziquantel and Albendazole

 Challenge to surgeons when stones are present in GB and CBD

 Cholecystectomy with exploration of CBD performed.

 This is followed by Choledochoduodenostomy.

 Some prefer to do Choledochojejunostomy to a Roux loop. Roux loop brought upto the abdominal wall –
access loop.
 Schistosomata
 Schistosomiasis - Caused by Schistosoma. Infection occurs when cercaria larvae are shed into fresh water by
the snail(intermediate host).

 Penetrate the skin of humans in water.

 Schistosomiasis of the bladder - S. hematobium.

 Portal hypertension caused by S. japonicum in the superior mesenteric vein and S. mansoni in inferior
mesenteric vein
 Ascaris lumbricoides
 Also called ‘Round worm’- commonest intestinal nematode to infest humans.

 Larva causes pulmonary symptoms.

 Adult worm causes intestinal symptoms.

 Mode of spread - Faeco-oral route.

Life cycle
 Life cycle
 Larvae pierce the mucosa of small intestine to enter the lymphatics.

 Lymphatics Venules Right heart Lungs( Pulmonary Symptoms )

 Lungs Swallowed into esophagus again when coughed and mature into adult worms in 1-2 months
and cause intestinal symptoms.
 Clinical features
 Larval stage in lungs - Dry cough, wheezing, dyspnoea, fever
(Loeffler’s syndrome)

 Adult worm in intestine: Malnutrition, failure to thrive (in children) and abdominal pain.

 CBD - Ascending cholangitis, obstructive jaundice

 MPD – Features of acute pancreatitis.

 Small intestinal obstruction may occur - in terminal ileum - SURGICAL EMERGENCY!

Rarely perforation may occur from ischaemic pressure necrosis from the bolus of worms.
 Investigations
 Eosinophilia, Stool examination for ova, Sputum shows Charcot Leyden crystals or the larvae

 Chest x-ray - fluffy exudates

 USG: Worm in CBD or pancreatic duct

Barium meal and follow Through
MRCP - Adult worm in CBD
 Medical treatment
 Pulmonary phase - self limiting disease so treated symptomatically.

 Single dose Albendazole - 400 mg, Pyrantel pamoate-11mg/kg (max 1g),

Ivermectin(150-200 mcg/kg) or Mebendazole 100mg BD for 3 days – can precipitate intestinal obstruction.

 Intermittent/Subacute intestinal obstruction - IV fluids, NG suction , hypertonic saline enema

 Surgical treatment
 Done only in case of intestinal obstruction that has not resolved with conservative management or in case of

perforation.

 At laparotomy- bolus of worms milked through the ileocaecal valve into colon. Post op hypertonic enemas

given to let the worms out through stools.

 In case of gangrene/ perforation - Resection and anastomosis done

 In healthy bowel wall - Enterotomy and removal of worms to be done

 When perforation occurs, it is brought out as ileostomy in the presence of a number of worms.

 CBD or pancreatic duct obstruction- endoscopic removal.

 If fails, laparoscopic or open exploration of the CBD is necessary.

 A full course of antiparasitic treatment must follow any surgical intervention

 Wuchereria bancrofti
 Causes Filariasis

 Carried by Vector - Mosquito (Culex)

 Variant parasite - Brugia malayi and B. timori.

 WHO: 2nd common cause for long term disability after leprosy.

 Affects the lymphatic system in its chronic phase.

Pathogenesis
 Clinical features
 Episodic attacks of fever, lymphadenitis.

 Lymphangitis - leads to fibrosis of lymphatic channels.

 Massive lower limb edema.

 Skin thickening(obstruction of cutaneous lymphatics).

 Stemmer’s sign
 Secondary Streptococcal infection.

 B/L lower limb filariasis - associated with scrotal and penile elephantiasis.

 Hydrocele with or without recurrent attacks of epididymo orchitis.

 Chyluria, chylous ascites.

 Mild respiratory symptoms - dry cough TROPICAL PULMONARY EOSINOPHILIA

 Investigations

 Eosinophilia

 Nocturnal(10 pm - 4am) peripheral blood smear - Mobile Microfilariae (immature forms)

 Urine, ascites, hydrocele fluid may show presence of parasite.

 Treatment
 Diethylcarbamazine 2mg/kg TID for 12 days or as a single dose or Albendazole 400 mg with Ivermectin 200
microgram/kg in a single dose with or without DEC (early stage-before gross deformities)

 Intermittent pneumatic compression and graduated compression stocking (pressure of 40 mmHg) - in early
stages of limb swelling.

 Hydrocele - Excision and eversion of sac, if necessary excision of redundant skin

 Surgeries for lymphedema

 Homans’ Procedure

 Thompson’s reduction Operation

 Charles procedure

 Sistrunk operation
 Other Filarial worms
 Dracunculus medinensis (the guinea worm), which produces discharging sinuses on the legs and back and

sometimes severe cellulitis. Treatment is to carefully extract the worms from the sinuses.

 Onchocerca volvulus - producing multiple subcutaneous nodules and blindness.

 Loa loa - producing multiple subcutaneous swellings usually transient and occasionally a visible worm

beneath the conjunctiva.

 Entamoeba histolytica
 Causes Amoebiasis

 Majority of the cases are asymptomatic.

 Mode of transmission is Faeco-oral route.

 Due to substandard hygiene and poor sanitary.

Pathogenesis
 Intestinal amoebiasis - Flask shaped ulcer in submucosa.

 Liver abscess - Cavity contains chocolate coloured, odourless, anchovy sauce like fluid with mixture of necrotic liver tissue
and blood.

 Pus in abscess is sterile unless secondarily infected

 Chronic infection of the large bowel - Amoeboma

 Clinical features
 Young adult male, History of travel to endemic area might be present.

 Non specific symptoms - abdominal pain, anorexia, fever, night sweats, malaise, cough and weight loss.

 Pain in right upper abdomen, right shoulder tip, hiccoughs and non-productive cough

 Bloody diarrhoea may be present

 Has extra-intestinal manifestations involving liver, lung, brain and skin.

 Toxic, anaemic

 Upper abdominal rigidity, tender hepatomegaly, tender and bulging intercostal spaces.

 Pleural effusion and basal pneumonitis - late manifestation

 Rarely present an emergency - rupture of abscess into pleural, pericardial and peritoneal cavity.
 Amoeboma
 Chronic granuloma arising in large bowel, commonly seen in caecum.

 Easily mistaken for carcinoma.

 Seen in resource poor countries.

 Suspect in endemic area with generalised ill health, pyrexia, mass in right iliac fossa with a history of blood
stained mucoid diarrhoea.
 Investigations
 Anaemia, Leukocytosis, ESR, CRP

 Deranged LFT, Alkaline phosphatase

 Stool - for amoeba.

 Serological tests - more specific, Complement fixation, indirect haemagglutination, ELISA

 Flexible sigmoidoscopy - OPD basis – shallow skip lesions, ‘flask shaped’ or ‘collar-stud’ undermined ulcer.
 Imaging techniques

 USG - abscess cavity, hypoechoic or anechoic lesion with ill-defined borders. Internal echoes suggest

necrotic material or debris.

 Cause multiple microabscesses or single large abscess.

 Also used for aspiration, both diagnostic and therapeutic.

 Colonoscopy with biopsy is mandatory as it is indistinguishable from carcinoma.

CT - Raised right hemidiaphragm, pleural effusion, evidence of pneumonitis.
 Medical treatment
 Intestinal and early hepatic amoebiasis - Metronidazole (800 mg TID for 5-10 days) or Tinidazole/Ornidazole (2g
OD for 3 days)

 Eliminate luminal cysts - Diloxanide furoate or Paramomycin 500 mg TID for 10 days.

 Aspiration - When imminent rupture of an abscess is expected and also helps penetration of the drug into pleural,
pericardial and peritoneal cavity.

 If secondary infection present - appropriate treatment considered.

 Surgical treatment
 If rupture into pleural, peritoneal or pericardial cavity

 Resuscitation, drainage, appropriate lavage with vigorous medical treatment - key principles.

 In large bowel - toxic megacolon and severe haemorrhage (rare)

 Managed by resection of bowel with exteriorisation

 Amoeboma - Colonic resection especially if cancer cannot be excluded

 Miscellaneous
 Chaga’s disease - Caused by Trypanasoma cruzi. Restricted to Latin America.

Surgical problem - megaesophagus and megacolon, due to loss of submucosal

parasympathetic ganglion cells.

 References
 Bailey and Love’s Short Practice of Surgery- 27th edition

 Textbook of Medical Parasitology, CKJ Panicker- 6th edition

 Maingot’s Abdominal Operations – 12th edition