SURGICAL MANIFESTATIONS OF

AMOEBIASIS
INTRODUCTION
AMOEBIASIS
Motile protozoan parasite- Entamoeba histolytica
Common in India, Africa, Central & South America
30-50 million symptomatic cases annually
40,000 - 1,00,000 deaths

ENTAMOEBA HISTOLYTICA
Life cycle
2 stages
Infectious cyst
Motile trophozoite
Feco-oral transmission
INFECTION
3 outcomes
Asymptomatic
Invasive amebiasis- amebic colitis
Extra-intestinal disease
85
%
10
%
5%
AMEBIC COLITIS & TYPHLITIS
Adherence of trophozoites to colonic mucosa
Secrete cysteine proteases
Contact dependent cytolysis of epithelial cells
Immune related tissue damage
Cecum & ascending colon
AMEBIC COLITIS
Mucosal thickening
Multiple punctate ulcers
Flask shaped ulcers
Minimal inflammatory
response
CLINICAL FEATURES
Amebic dysentery
1-3 wks after exposure
Abd cramps, tenesmus, fever
Bloody or mucoid diarrhea
Tenderness in left iliac fossa-
Sir Philip Manson Bahr amoebic point
AMEBIC COLITIS-
MANAGEMENT
Supportive treatment
Luminal agent -paromomycin 25-35 mg/kg/ day in three
divided doses for seven days
Tissue agents -metronidazole [500-750 mg TID for 10 days]
or tinidazole [2 g OD for 3-5days]
SURGICAL COMPLICATIONS OF
AMOEBIC COLITIS
Amoebomaright side common
Perforation, bleeding, peritonitis
Stricture rectum and colon
Obstruction
Pericolic, ischiorectal abscess and fistula formation
Amoebic typhlitis
amoebic liver abscess
APPENDICITIS
Acute or chronic appendicitis
Pts recover with antiamebic therapy
Appendix may be gangrenous or perforated
Surgical outcome is poor
Complications -cecal blowout, fistulas, amebiasis cutis
ACUTE FULMINANT AMEBIC
COLITIS
severe type with sloughing of
colonic and rectal mucosa
torrential bleeding, toxicity which
can be life-threatening
TOXIC MEGACOLON
massive distension and thickening of
the colon
With tissue destruction, edema,
venous thrombosis, and perforation
with an accompanying purulent
peritonitis
very high mortality
AMEBOMA
In 5% patients with dysentery
chronic granuloma arising in the large bowel
most commonly seen in the caecum, ascending colon
Presents as a right iliac fossa mass
apple-core in appearance and resembling a carcinoma
5 to 30 cm in diameter and may be multiple
shows abundant granulation tissue, edema, neovascularity,
inflammatory cells and live Entamoeba histolytica

Ameboma may cause
intusussception
Obstruction

DIFFERENTIAL DIAGNOSIS FOR
AMOEBOMA
Appendicular mass
Ileocaecal tuberculosis
Carcinoma colon
Retroperitoneal tumour
Lymph node mass
STRICTURES
In about 1% of cases
In rectum, rectosigmoid, anal canal
Annular or long strictures
Usually single
INTESTINAL OBSTRUCTION
Toxic megacolon
Ameboma
Intusussception
Strictures
HEMORRHAGE
Accounts for 5% of lower GI bleed
Occurs in acute phase
Erosion of ulcer into vessels nearby
Selective angiography and ligation of bleeder may be
needed in persistent bleeding
Resection of involved segment
AMEBIC LIVER ABCESS
trophozoites reach the liver through the portal venous system
enzymatic cellular hydrolysis- localised hepatic necrosis ( liquifactive) producing
a cavity
contains acellular proteinaceous debris surrounded by a rim of invasive amebic
trophozoites
tend to abut the Glissons capsule
anchovy sauce pus
Solitary, large abcess
right lobe postero-superior region involved (80%)

Clinical features
20 to 40 years of age, male
fever, chills, anorexia, right upper quadrant pain
Pleuritic or right shoulder pain - irritation of the right hemidiaphragm
O/E
May be icteric
tender, soft hepatomegaly
intercostal tenderness, increased warmth, cutaneous edema
toxemia - suggestive of an added bacterial infection
PYOGENIC VS AMEBIC
ABCESS

DIAGNOSIS

Stool studies- microscopy, ELISA, PCR
scrapings or biopsy of rectal mucosa during sigmoidoscopy
serology
Imaging
IMAGING
Plain Xrays
USG abdomen
CT
TREATMENT
metronidazole (750 mg orally, TID) ( 5-10 days)
luminal agents:
paromomycin (30 mg/kg TID 5 to 7 days)
iodoquinol (650 mg orally TID for 20 days)
diloxanide furoate (500 mg orally TID for 10 days)
ROLE OF USG GUIDED
ASPIRATION
When pyogenic liver abscess cannot be ruled out
Anti-amebic drugs contraindicated- as in pregnancy
Secondary infection
Fever and pain persist for more than 5 to 7 days after starting
antiamebics
Rupture is imminent in an extremely large abscess (>10 cm) (left lobe
abcess)
Percutaneous catheter drainage (PCD) is better than percutaneous
needle aspiration (PNA) for management of large liver abscesses (>10
cm)
INDICATIONS FOR SURGERY
Even after repeated aspirations if abscess cavity fills again
Thick pus
Multiloculated abscess
Left lobe abscess, because of danger of rupture into pericardial
cavity
Ruptured abscess
Caudate lobe abscess
COMPLICATIONS OF ALA
RUPTURE INTO PERITONEUM
contained by the diaphragm, abdominal
wall, and/or omentum
can fistulize into a hollow viscus
peritoneal rupture -abdominal pain,
peritonitis
Management - emergancy exploration
PLEURO PULMONARY
COMPLICATIONS
7% to 20% of patients
Reactive effusions and atelectasis
rupture of the abscess through the diaphragm
amebic empyema
erosion into a bronchus
Surgical management- open decortication of the abcess
RUPTURE INTO THE PERICARDIUM

in 1.3% to 2% of cases
mortality rates from 30% to 60%
result from left-sided or more centrally located hepatic abscesses
C/F range from a pericardial rub with muffled heart tones to cardiac tamponade
Management:
Early recognition of cardiac complications
close hemodynamic monitoring
administration of tissue amebicidal agents
adequate pericardial drainage
CUTANEOUS AMEBIASIS
By implantation or by direct spread from the rectum
Cutaneous ulcers tender, painful, and malodorous
Ulcers- shallow, and the edges are well defined: the floor of
the ulcer is covered with a dirty gray slough, undermined
contain few neutrophiles
trophozoites are concentrated under the margin of the ulcer
along the line between necrotic and viable tissue

Amebiasis of anal skin, genital skin,
cervix, and penis
hyperplasia of squamous
epithelium punctuated by small
shallow ulcers containing
trophozoites
"cauliflower-like" appearance
? squamous cell carcinoma
THANK YOU