Intestinal and extraintestinal amoebiasis

General surgery ppt - PG

1. Intestinal and Extraintestinal Amoebiasis Surgery-Microbiology Meet Dr.Achu Jacob Philip Dr.Isabella

2. Introduction Epidemiology Life cycle of Entamoeba histolytica Pathogenesis Pathology Clinical features Laboratory diagnosis Management

3. Amebiasis ia an infection with the intestinal protozoan Entamoeba histolytica . 90% asymptomatic. It is the third most common cause of death from parasitic disease. Asymptomatic forms are mainly caused by E.dispar .- Self limiting (homosexual men & AIDS patients) Intestinal lesions mainly involve the cecum,sigmoid colon and the rectum. Distant abscess occur in liver ,lung and brain. Introduction

4. Definition : Amoebiasis is an infection caused by Entamoeba histolytica with or without symptoms (WHO - 1969) Synonyms include entamoebiasis , amoebiosis , amoebic dysentery or bloody flux.

5. Global burden of the disease : 40-50 million cases of amoebic colitis and amoebic liver abscess 70,000 deaths anually 10% world population 90% of those infected are asymptomatic, 1% may develop invasive/ extraintestinal amoebiasis . Epidemiology

6. China, Central and South America, Indian subcontinents In India : Prevalence is 15% (3.6% to 47.4%) Maharashtra, Tamil Nadu, Chandigarh

7. Risk factors Agent factors Host factors Virulence of organism Intestinal m icrobiota Sex Age Alcoholics Immunocompromised (HIV)  male homosexuals

8. During amoebiasis there is a significant decrease in absolute quantification of Bacteroides , Clostridium coccoides , Clostridium leptum , Lactobacillus and an increase in Bifdobacterium species. Lactobacillus species might be protective in the context of protozoan infections ( Preidis et al., 2011; Travers et al., 2011). Thus a decrease in protective, commensal Lactobacillus species during E. histolytica infection might influence the severity of disease.

9. Morphological forms of E.histolytica

10. Life cycle of Entamoeba histolytica

11. Pathogenesis of intestinal amoebiasis

12. Contd..

13. Virulence factors of Entamoeba histolytica

14. Pathology – Gross appearance Intestinal specimen from a patient with acute amoebic colitis Colon (primarily in the cecum ), sigmoid colon, and rectum 2 types of ulcers : nodular and irregular Intervening mucosal folds may appear normal

15. Submucosa : susceptible to the lytic action of the parasite, and produces abundant microhemorrhages Bowel lumen Amoebic ulcer with neutrophilic infiltration Mucosa Submucosa

16. Course of intestinal amoebiasis

17. CLINICAL FEATURES INTESTINAL AMEBIASIS: Symptomatic amebic colitis develops 2-6 weeks after ingestion of infectios cysts. Gradual onset of lower abdominal pain,mild diarrhea,malaise,weight loss,back pain. Caecal movements may mimic acute appendicitis Stools will contain little fecal matter and will consist of mainly of blood and mucus.

18. Fulminant intestinal infection Clinical features: Severe abdominal pain High Fever Profuse diarrhoea Occurs predominantly in children Also patients receiving glucocorticoids Megacolon Patient will be having shock like features Severe bowel dilation with intramural air. Syndrom of Postamebic colitis Persistent diarrhoea following documented cure of amebiasis Complication

19. AMEBIC LIVER ABSCESS: Febrile,Rt upper quadrent pain(dull or pleuritic ) radiating to the shoulders. Malaise,weight loss and hepatomegaly Complication Pleuropulmonary involement (20 – 30%) Sterile effusion Hepatobronchial fistulae Rupture of abscess

20. OTHER SITES Genitourinary Tract : Direct extension Genital ulcer,Profuse discharge Cerebral Involvement Occurs in 0.1% patients. Syptoms depends on size and site of lesion.

21. Amoeboma Chronic granuloma arising in the large bowel . MC : Caecum Occurs in longstanding amoebic infection (with in complete treatment ) Mistaken for carcinoma C/f: Pyrexia , Mass in RIF Blood stained mucoid diarrhoea .

22. Specimen collection : Intestinal amoebiasis  Stool samples Extraintestinal amoebiasis Aspirated pus Laboratory diagnosis

23. Direct examination  Saline and iodine wet mounts Culture Immunodiagnosis Molecular methods  Polymerase chain reaction

24. Trophozoites Cysts

25. Treatment Tissue amoebicides Intestinal and Extra intestinal amoebicides Nitroimidazoles : Metronidazole , Tinidazole , Ornidazole , Secnidazole , Satranidazole , Nimorazole Alkaloids : Emetine and Dehydroemetine Extra intestinal amoebicides : Chloroquine Luminal amoebicides Amides: Diloxanide furoate , Nitazoxanide Quinolines : Iodoquinol , Quiniodochlor Antimicrobials: Paromomycin , Tetracyclines To eliminate the invading trophozoites To eradicate the intestinal cysts of Entamoeba histolytica (source of infection)

26. Intestinal amebiasis Luminal amebicides Tissue amebicides Nitroimidazole – Metronidazole Metronidazole 800 mg TDS x 7-10 days (in severe cases 500 mg slow IV 6 hourly till oral therapy can be instituted) OR Tinidazole 2 g OD x 3 days + Luminal amoebicide

27. AMEBIC LIVER ABSCESS Metronidazole 800 mg TDS x 10 days (in serious cases – IV metronidazole x 10 days) OR Tinidazole 2 g oral daily x 3 - 6 days + Luminal amoebicide ASPIRATION OF LIVER ABSCESS To rule out a pyogenic abscess,mainly in multiple lesion. No clinical response in 3 -5 days. Threat of imminent rupture. Left lobe abscess

28. Case 1: 29yr old male came with C/o – Abdominal Pain Fever Vomiting Patient presented with dull aching pain in the right hypochondium for 1week. Associated with low grade fever, with no chills or rigor Vomiting four episodes – mainly food particles,non bilious. Patient febrile not in septic shock Tender hepatomegaly . TC : 16900,DC – N 86,L 10,M3,E1. ESR : 75 LFT Normal

29. Well defined hypoechoic lesion 11.1 x 8.2 x 7.8 hyperechoic septation

30. Treatment Given Inj Metronidazole was started . Pig Tail catheter inserted under local and abscess drained. Patient responded to treatment

31. Case2 42 year old presented with acute abdomen Soft , Hepatomegaly .

32. USG : Features S/o liver abscess (volume 2006cc) involving the right lobe of liver with ? Focal subcapsular rupture. Moderate ascitis

33. Abscess of right lobe of liver.

34. Sloughed out wall of the amebic abscess on right lobe of liver .

35. Thank you