1. The document discusses common surgical conditions seen in tropical regions, including typhoid, tuberculosis, amoebiasis, ascariasis, and tropical diseases. 2. It provides details on the pathogenesis, clinical presentation, diagnosis, and treatment of typhoid perforation, ascariasis infection and obstruction, and amoebic liver abscess. 3. The document emphasizes that patients in tropical regions often do not seek medical help until diseases have progressed significantly, sometimes resulting in emergency presentations of conditions like typhoid perforation or ascariasis obstruction.

1. SURGERY IN THE TROPICS
Dr Tridip Dutta Baruah
Asst Prof, Dept Of Surgery
MGMCRI

2. Disease Burden And Distribution

3. “In surgery physiology is the king, anatomy the
queen: you can be the prince, but only
provided you have the judgement”
(Mosche Schein, Professor of Surgery, Cornell
University).

4. 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.

5. Common conditions
1. 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.

6. 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

7. 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

8. 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.

9. 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.

10. 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.

11. 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.

12. 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.

13. 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

14. 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.

15. Clinical Presentation
A. Asymptomatic infection
B. Symptomatic infection
C. Intestinal disease
D. Extra intestinal disease

18. Gross pathology of intestinal
amebiasis showing extensive
ulceration

23. 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

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

25. Pathogenesis
Journey of E.Histolytica to the liver
1. Direct Extension from gut to liver
2. Via portal circulation
3. Via lymphatics
Infraction: Enzymatic Dissolution

26. Shaggy appearance of the walls of
the abscesses

27. Abscess surrounded by a distinct
area of severe congestion

28. Abscess showing a thick fibrous wall

29. Clinical Features
Symptoms
Pain
Diarrhoea and / or Dysentery
Weight Loss
Cough
Dyspnoea
Physical findings
Localized tenderness
Enlarged Liver
Fever
Rales,rhonchi
Localized intercostal tenderness
Epigatric Tenderness
Jaundice

30. Huge Abscess Of The Inferior
Surface Of The Left Lobe.

31. Clinical Enlargement Of The Left
Lobe Of The Liver.

32. Point Tenderness

33. COMPLICATIONS
1. Rupture- Pleura/ Peritoneum/Pericardium
2. Amoebic Brain Abscess
3. Hemobilia
4. Portal Hypertension

34. 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.