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Parasitic Infections
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Parasitic Infections

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  • 1. Parasitic Infections
  • 2. Amoebiasis
    • Introduction
    • Pathogenesis
    • Clinical Features
    • Investigations
    • Imaging techniques
    • Treatment
  • 3. Amoebiasis
    • Introduction
    • Pathogenesis
    • Clinical Features
    • Investigations
    • Imaging techniques
    • Treatment
  • 4. Introduction
    • Caused by Entamoeba histolytica
    • Common in the Indian subcontinent, Africa, parts of South America (> 50% population affected)
    • Mode of infection: faeco – oral
    • Substandard hygiene and sanitation
    • Amoebic liver abscess (MC extra intestinal manifestation): 10% of infected population
    • Immunocompromised and alcoholic: susceptible
  • 5. Amoebiasis
    • Introduction
    • Pathogenesis
    • Clinical Features
    • Investigations
    • Imaging techniques
    • Treatment
  • 6. Pathogenesis
    • Organism  gut (through food/water contaminated with the cyst)  cysts hatch  trophozoites  carried to colon  FLASK SHAPED ULCERS (in the submucosa)
    • Trophozoites multiply  cysts
    • Portal circulation Passed in faeces
    • Infects others
  • 7. Pathogenesis
    • Portal circulation
    • Trophozoites are filtered and trapped in the interlobular veins of the liver
    • Multiply in the portal triads; local infarction & liquefactive necrosis (proteolytic enzymes)
    • Areas ofnecrosis – coalesce to form Amoebic Liver Abscess Cavity
  • 8. Pathogenesis –Amoebic Liver Abscess
    • Right lobe> Left lobe (80% > 10%); remaining 10% are multiple
    • Right lobe: blood from the superior mesenteric artery runs n a straighter course through the portal vein into the larger lobe
    • More common in the diaphragmatic surface  pulmonary complications
    • Abscess cavity  chocolate coloured, odourless, ‘anchovy – sauce’ like fluid (mixture of necrotic liver tissue and blood)
    • Secondary infection in the cavity may occur  pus
    • Untreated abscess  likely to rupture
  • 9. Pathogenesis…
    • Chronic infection in the large bowel
    • granulomatous lesion along the large bowel; most commonly seen in the caecum
    • Amoeboma
  • 10. Amoebiasis
    • Introduction
    • Pathogenesis
    • Clinical Features
    • Investigations
    • Imaging techniques
    • Treatment
  • 11. Clinical Features: Symptoms
    • Young adult male
    • h/o pain, fever, insidious onset of non specific symptoms (anorexia, night sweats, cough, weight loss)  gradually progresses to more specific symptoms: pain in the rt upper abdomen, shoulder tp pain, hiccoughs, non productive cough
    • Past h/o bloody diarrhoea and travel to an endemic area
  • 12. Clinical Features: signs
    • Toxic, Anemic patient
    • Upper abdomen rigidity
    • Tender hepatomealy
    • Tender and bulging intercostal spaces, overlying skin edema, pleural effusion and basal pneumonitis
    • Occasionally – trace of jaundice, ascites
    • Rarely – emergency due to rupture into the peritoneal, pleural or pericardial activiy
  • 13. Amoeboma
    • Chronic granuloma
    • Arising in the large bowel, most commonly seen in the caecum
    • Prone to occur in longstanding amoebic infection that has been treated intermittently with drugs without completion of a full course
    • Suspected when a patient from an endemic area with generalized ill health, pyrexia, mass in the rt iliac fossa with a h/o blood stained mucoid diarrhoea
  • 14. Amoebiasis
    • Introduction
    • Pathogenesis
    • Clinical Features
    • Investigations
    • Imaging techniques
    • Treatment
  • 15. Investigations
    • Haematological & Biochemical investigations: anemia, leucocytosis, raised ESR, raised CRP, hypoalbuminemia, deranged LFT (particularly raised ALP)
    • Serological tests: more specific; tests for complement fixation, indirect haemagglutination, indirect immunofluorescence and ELISA.
    • Especially useful in non endemic areas
  • 16. Investigations
    • Rigid sigmoidoscopy
      • Most ulcers occur in the rectosigmoid & therefore within reach of the sigmoidoscope
      • Shallow, flask shaped or collar stud, undermined ulcers
      • Biopsy/ scrapings can be taken for microscopic examination
  • 17. Amoebiasis
    • Introduction
    • Pathogenesis
    • Clinical Features
    • Investigations
    • Imaging techniques
    • Treatment
  • 18. Imaging Techniques
    • Ultrasound: abscess cavity in the liver is seen as a hypo/ anechoic leson with ill defined borders; accurate; used for aspiration (diagnostic and therapeutic)
    • CT may be helpful if doubt in diagnosis
    • Barium enema
    • Colonoscopy & biopsy (to differentiate from carcinoma)
  • 19. Amoebiasis
    • Introduction
    • Pathogenesis
    • Clinical Features
    • Investigations
    • Imaging techniques
    • Treatment
  • 20. Treatment
    • Medical
      • Effective
      • First choice
      • Surgery reserved for complications
      • Metronidazole and tinidazole: effective drugs
      • After treatment with metro/tinidazole; diloxanide furoate which is not effective against hepatic infestation, is used for 10 days to destroy any intestinal infestation
  • 21. Management…
    • Aspiration
      • When imminent rupture of an abscess is expected
      • Helps in the penetration of metronidazole; hence reduces the morbidity
      • Theshold for aspirating an abscess in the left lobe is lower because of its predilection for rupturing into the pericardium
  • 22. Management…
    • Surgical
      • Reserved for complications of rupture into the pleural (usually the rt side), peritoneal or pericardial cavities
      • Resuscitation, drainage and appropriate lavage with vigorous medical treatment – key principles
      • Large bowel – severe h’age, toxic megacolon are rare complications
        • General principles of a surgical emergency apply
        • Resuscitation followed by resection of the bowel with exteriorisation
        • Vigorous supportive therapy
        • ICU care