Tropical surgical diseases

By: Samuel Assefa

Ruth Zerfu
Moderator- Dr. filagot
OUTLINE
• Introduction
• Tropical diseases
 Amoebic liver abscess
 Hydatid disease
 Necrotizing skin infections
 Cancrum oris
 E.necroticans
 Pyomyositis
 Surgically managed splenic problems
 Surgically managed typhoid
 Tropical ulcers
 Mycobacterial ulcers
 Chagas disease
 Schistosomiasis
• Diagnosis, complications and management
Introduction
• Principles of surgery in tropical countries are no different from
those in the developed countries
• Lack of optimum supporting facilities + late presentations
• Younger patients + advanced disease + malnourished
• Surgical decision making should be well made for effective Tx.
TROPICAL SURGICAL
DISEASES
1. AMOEBIC LIVER ABSCESS
• Pathogen: Entamoeba histolytica
• Transmission: Fecal-oral
Amebic cysts are excreted in stool and can contaminate drinking water
or food
• Stages:
Cystic- form in which its ingested- resistant against G.acid
Vegetative- Trophozoite formation→ proteolytic enzyme secretion→
invasion of intestinal mucosa→ dissemination to target tissues→ Liver,
lung, brain → abscess formation
Cont’d
• Most common cause of liver abscess worldwide
• Multiplication→ blockade of small intrahepatic portal radicles→
focal infarction of hepatocytes + proteolytic liver parenchyma
destruction
• Variable sizes, single or multiple
• Most common location- superior-anterior aspect of the right
lobe of the liver near the diaphragm
• Contains necrotic center with a thick reddish brown pussy material
Clinical features
• Intestinal amoebiasis
• Loose, bloody stools
• Painful defecation, tenesmus, cramps
• Fever-10-30%
• Extraintestinal amoebiasis
• Acute in onset most cases,Liver-95%, rarely lungs and brain
• Fever-85–90%
• RUQ pain or pressure sensation, hepatomegaly
• Chest pain, pleuralgia
• Diarrhea- preceeds in 33% of liver abscess cases
Management
• CBC- leukocytosis
• Serum studies- mildly elevated AP is the most common biochemical
alteration
• fluorescent antibody test- most sensitive
• Imaging- abdominal U/S, CT- extra hepatic involvement
• well-defined low-density round lesions + enhancement of the wall + peripheral edema
• Tx- 1. Medical with Metronidazole 750 mg TID for 7-10 days → abscess may
take 30-300 days to resolve
• Must be followed by U/S and CT for resolution
2.Surgical Aspiration & drainage- rare
• Medical intractability, large abscess, superinfected
• If left lobe is involved→ risk for rupture into the pericardium
2. HYDATID DISEASE
• Tapeworm- Echinococcus granulosus, E.multilocularis
• Definitive hosts- Foxes, dogs, cats
• Intermediate hosts- sheep, goats, humans
• Cysts contain scolices→ mature in the definitive host→ shed
ova→ ingested ova contain chitinous envelope dissolved by G.
Juice→ burrows through intestinal mucosa→ portal venous
system → LIVER→ mature into adult cyst
• Some may bypass the liver into the pulmonary capillary bed or
systemic circulation→ Lung (25%), spleen, brain, bones
Cont’d
• Location- right lobe of the liver, usually the anterior-inferior or
posterior-inferior segments mostly single hepatic cyst
• Clinical presentation
• Uncomplicated cysts are mostly incidental findings
• Hepatomegaly- RUQ pain→ single cyst- E.granulosus
• Malaise, nausea, vomiting
• Chest pain, cough, dyspnea, hemoptysis → infiltrative growth
→E.multilocularis
• Cyst may rupture→ anaphylactic shock
MANAGEMENT
• Confirmed via ELISA and U/S
• Imaging-
1. Ultrasound
 Cystic echinococcosis: unilocular, anechoic, smooth, well-defined hepatic
cyst with or without daughter cysts
 Eggshell calcifications within the wall of a hydatid cyst may be visible
 Alveolar echinococcosis: lesions with irregular, poorly defined margins,
central necrosis, and irregular calcifications within the cyst and cyst wall
2. CT scan: indicated for further evaluation of cysts
 Alveolar echinococcosis usually not well-defined, but shows infiltration of
the liver and surrounding tissue
 evaluating extrahepatic cysts
3. MRI: for daughter cyst characterstics
Treatment
• Observation: inactive cyst
withheterogeneous hypoechoic/hyperechoic contents, or solid, calcified wall
• Medical therapy: may be considered as the sole treatment for cysts < 5 cm
• Drug of choice: albendazole
• U/S or CT-guided percutaneous drainage
• Commonly conducted using the PAIR (puncture, aspiration, injection, reaspiration)
procedure
• Should only be done in combination with medical therapy
• Indications: > 5 cm and/or septations
• Surgery
• Goal: resect the whole cyst to prevent spillage of its content
• Indications: > 10 cm, complicated cysts
• Follow-up: Because relapse is common, patients should be closely
monitored via imaging for up to five years
NB. Caution not to rupture cyst wall→ protoscolice spillage
3.Necrotizing soft tissue infections
• Aggressive, life threatening infection with necrosis of tissue
• Cellulitis, fasciitis ,myositis
• Fasciitis is the most common
• Necrotizing fasciitis: rapidly progressive infection of superficial
and deep fascia- life threatening within hours
Fournier gangrene: NF of the external genitalia with rapid spread to
the anterior abdominal wall and gluteal muscles
Clostridial myonecrosis: C.perfringes & C.septicum
Etiology
• Both polymicrobial and monomicrobial
Polymicrobial - aerobic+ anaerobic- mostly of GI and GU origin
 E.coli, bacteroides
Monomicrobial- GAS, S.aureus
• Fourniers gangrene- mixed with facultative bacteria( E.coli,
klebsiella, Enterococcus) and anaerobic bacteria
Clinical features
• Systemic symptoms: Fever, chills, altered mental status
• Cutaneous findings
• Diffuse erythema (often manifests initially as suspected cellulitis that is not
responding to initial antibiotic)
• Extreme tenderness and pain out of proportion to the area of erythema
• Significant induration of the SCT
• Crepitus: due to the production of methane and CO2 by bacteria
• Purple skin discoloration skin necrosis and ecchymosis
• Bullae
• Loss of sensation in the affected area (paresthesias)
• Definitive diagnosis is usually made during the visualization of the
tissue during surgery
Management
• CBC- leukocytosis
• Inflammatory markers- CRP, ESR, procalcitonin
• CK levels
• Blood cultures
• Imaging- CT/MRI with or without IV contrast, U/S and X-ray
• Gas in soft tissue
• Fascial thickening and edema
• Lack of contrast- indicates necrosis
• N.B. Surgical exploration and empiric AB therapy must not be
delayed for such extensive studies
 Cont’d
• If the presentation of the patient is highly suspicious for NSTI

Admit the patient immediately and consult ICU for possible septic features

Empiric antibiotic therapy and surgical exploration

• Extensive and necrotic tissue must be debrided
+
• Samples must be sent for gram staining
+
• Re-exploration every 12-36 hrs for necrotic tissue
Cont’d
• During surgical exploration, if the tissue is necrotic:
• Fascia appears swollen
• Dull gray fascia
• Possible brown exudate
• Easy dissection of tissue planes with a blunt instrument or gloved finger
• In antibiotic treatment: Start systemic, broad-spectrum
antibiotic therapy immediately after blood cultures have been obtained
• consider polymicrobial causes
3a.Cancrum oris ( gangrenous
stomatitis)
• Necrotizing infection of the mouth, nose and lips
• Children are commonly affected-HSV,scarlet fever,TB
• Begins as an ulcer→ at alveolar margin of the mouth and
rapidly spreads to involve the teeth, jawbone, cheek, tongue,
lips, and nose
• Necrophorum and Prevotella intermedia in children and
pseudomonas aerugiosa in neonates
Cont’d
• Risk factors
Malnutrition- vital factor
Bacterial infections
Poor environmental sanitation
Poor oral hygiene
Frequent exposure to human/animal feces
Prior history of viral or bacterial infection
Immunodeficiency
• Clinical features
• ulcer formation
• include swollen gums
• swollen cheek lining
Cont’d
• Diagnosis
• inflamed mucus membranes, oral cavity ulcers, and skin ulcers-
must be explained in detail during medical history
• X-ray
• MRI
• CT of the jaw, neck and head
• Blood cultures and biopsy
• Blood test- to check for immune system functioning
Treatment
• If not treated severe facial disfiguration, sepsis and pneumonia
are common complications
• Systemic antibiotics+ appropriate nutritional support + hydration
and proper electrolyte balance
• Surgical treatment: offered for debridement of affected tissue
and facial reconstruction
4. Pyomyositis (myositis tropicans)
• Definition: purulent infection of skeletal muscle
• In the tropics occurs mostly without penetrating trauma or spread from an
adjacent septic focus
• 95% S.aureus, others include S.pyogenes, E.coli
• Risk factors:
chronic ill health and debility
trauma producing muscle haematoma
Filariasis
Skin infections
Dracunculus infection( guniea worm infection)
malaria and viral myositis
Immunocompromised state (HIV)
Cont’d
• M>F, affects the bulky muscles of the lower extremities
commonly
• Clinical features
• Stage 1
 Cramps and aches of affected muscle
 Low grade fever
• Stage 2
 Abscess has formed
 90% are diagnosed in this stage
 Fever,chills, lump under the muscle and mobility issues
Cont’d
• Stage 3
• Septic shock
• High fever
• End organ damage
• Diagnostics:
• Ultrasound guided pus aspiration
• Physical examination- mobility issues, pain sensitivities, abscess
• Blood studies- leukocytosis
• Imaging- MRI- best modality for visualizing and characterizing the
abscess
Treatment
• Antibiotics+ if there is an abscess- drainage
5. Enteritis necroticans( pig bel)
• ‘Pig-Bel’ in the highlands of Papua New Guinea (PNG)
• Rare disease associated with children and diabetic patients
• following a feast of pig meat and sweet potato
• Beta-toxin producing C.perfringens type C are associated with
the disease
• concurrent ascaris infection→ prevents gut destruction of the
toxin
• Clinical presentation: abdominal pain, distention, vomiting,
and passage of bloody diarrhea
Cont’d
• The infection might also lead to shock, obstruction and
malnutrition if untreated
• Treatment:
• restoration of fluid and electrolyte imbalance by intravenous therapy
• nasogastric decompression
• Antibiotics
• IV penicillin
• If there is no improvement→ laparotomy with resection of the
gangrenous bowel segment
• Prevention- toxoid vaccine (PNG) along with the DPT vaccine