SURGERY IN THE TROPICS

Dr Tridip Dutta BaruahAsst Prof, Dept Of Surgery

MGMCRI

Disease Burden And Distribution

“In surgery physiology is the king, anatomy the queen: you can be the prince, but onlyprovided you have the judgement” (Mosche Schein, Professor of Surgery, CornellUniversity).

Learning Objectives

1. To be aware of common surgical problems in tropics.

2. To appreciate patients do not seek medical help until late in disease.

3. Emergency presentations of various common conditions.

Common conditions1. Typhoid.2. Tuberculosis of Small Intestine.3. Amoebiasis.4. Ascaris Lumbricoides.5. Hydatid Disease.6. Filariasis.7. Poliomyelitis.8. Leprosy.9. Asiatic Cholangiohepatitis.10.Tropical Chronic Pancreatitis.

TYPHOID

Caused by Salmonella Typhi. It gains entry to Human GIT via poor hygiene

and sanitation. Normally managed by medicines. Surgeon role only in emergency- Perforation in

typhoid ulcer

Pathology

Ingestion of contaminated food and water Colonization of peyer patches Hypertrophy of lymphoid follicles followed by

necrosis and ulceration Bowel may perforate at several sites

Diagnosis

The patient preents in or recently visited endemic area.

Patients presents with persistent high temp and is toxic.

Positve blood and stool culture and patient and the patient already on treatment.

After second week signs of peritonitis indicates perforation, confirmed with free gas in xray.

Treatment Of Bowel Perforation

Resuscitation intensive care. Commonest site of perforation is terminal

ileum, and can be multiple. Laparaotomy- choice of various procedure. In very sick patient- consider exterorisation. Close peritoneum and leave the wound open

for secondary closure.

ASCARIS LUMBRICOIDES

Ascaris Lumbricoides commonly known as round worm affects quarter of the population.

Commonest intestinal nematode Feco oral transmission. Infection more common in children.

Pathology And Clinical Features Fertilised eggs present in soil- reach intestine with

contaminated food- release larva- travel to liver via portal circulation and then through systemic circulation to lungs.

Larval stage in lungs- dry cough, chest pain, dyspnoea and fever known as Loeffler’s syndrome.

Small bowel obstruction- by bolus of adult worms in terminal ileum leading to pressure necrosis and perforation.

Worms can migrate to CBD causing ascending cholangitis and jaundice.

Investigations

Increase in eosinophil count. Stool examination may show ova and cyst. Sputum and bronchospic washing may show

charcot leyden crystals or larvae. Chest xray may show fluffy exudates. USG may show worms in SI, CBD or pancreatic

duct. Barium meal follow through may show scattered

worms in SI.

Treatment

Conservative line of management with antihelmintics is the first line of treatment.

Surgery is a last resort. Obstruction not resolved by conservative M. Perforation following obstruction

AMOEBIASIS

Amoebiasis caused by Entamoeba Histolytica. About half of the population in tropical

countries infected. Mode of transmission is Feco-Oral. Amoebic liver abscess is most common

extraintestinal menifestation, Occurs in less than 10% of infected population.

Clinical Presentation

A. Asymptomatic infectionB. Symptomatic infectionC. Intestinal diseaseD. Extra intestinal disease

Gross pathology of intestinal amebiasis showing extensive ulceration

AMOEBOMA

Chronic granuloma in large bowel, most commonly seen in caecum.

Seen in patients with long standing chronic infection not properly treated with drugs

Can be mistaken for carcinoma

AMOEBIC LIVER ABSCESS

Most Common Extra-Intestinal Menifestation Adults affected more than children (10:1) Male more than female 20% have history of dysentery

Pathogenesis

Journey of E.Histolytica to the liver1. Direct Extension from gut to liver2. Via portal circulation3. Via lymphatics

Infraction: Enzymatic Dissolution

Shaggy appearance of the walls of the abscesses

Abscess surrounded by a distinct area of severe congestion

Abscess showing a thick fibrous wall

Clinical Features Symptoms

PainDiarrhoea and / or DysenteryWeight LossCoughDyspnoea

Physical findingsLocalized tendernessEnlarged LiverFeverRales,rhonchiLocalized intercostal tendernessEpigatric TendernessJaundice

Huge Abscess Of The Inferior Surface Of The Left Lobe.

Clinical Enlargement Of The Left Lobe Of The Liver.

Point Tenderness

COMPLICATIONS

1. Rupture- Pleura/ Peritoneum/Pericardium2. Amoebic Brain Abscess3. Hemobilia4. Portal Hypertension

Treatment

Medical treatment effective and should be first choice

In large abscess- Repeated aspiration with drug treatment

Surgical treatment reserved for complications only such as ruptures.

Acute toxic megacolon and severe haemorrhage treated with intensive supportive therapy followed by resection and exteriorization.