Dept Of Surgery
Tuberculosis
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M. tuberculosis as causative agent for
tuberculosis
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Robert Koch1886
TB ? A Multi-system Infection
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? Extra-pulmonary form of TB account for 10-15per cent of all cases and up to 50 per cent of
patients with AIDS.
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? TB of the gastrointestinal tract is the sixth most
frequent form of extra-pulmonary site, after
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lymphatic, genitourinary, bone and joint,miliary and meningeal tuberculosis.
Pathogenesis
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The postulated mechanisms by which the
tubercule bacilli reach the gastrointestinal tract
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are:(i) hematogenous spread from the primary lung focus in
childhood, with later reactivation;
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(ii) Ingestion of bacilli in sputum from active pulmonary focus;
(iii) direct spread from adjacent organs;
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(iv) through lymph channels from infected nodes.--- Content provided by FirstRanker.com ---
Pathogenesis
? The most common site of involvement-
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ileocaecal region
? Frequency of bowel involvement declines as
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one proceeds both proximally and distallyfrom the ileocaecal region.
Pathology
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Most active inflammation in submucosa.
Bacil in depth of mucosal glands
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Inflammatory reactionPhagocytes carry bacil i to Peyers Patches
Formation of tubercle
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Tubercles undergo necrosis
Portis (1953)
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Pathology
Submucosal tubercles enlarge
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Endarteritis & edema
Sloughing
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Ulcer formationAccumulation of col agenous tissue
Thickening & Stenosis
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(Howel & Knapton, 1964)
Pathology
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Inflammatory process in submucosa penetrates to serosaTubercles on serosal surface
Bacil i reach lymphatics
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Bacil i via lymphatics
Lymphatic obstruction
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Regional lymph nodesof mesentery and bowel
? Hyperplasia
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Thick fixed mass
? Caseation necrosis
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? Calcification(Boyed, 1943)
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FORMS OF GI TB
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UlceroconstrictiveHypertrophic
60% of patients
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10% of patients
Highly virulent
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ChronicMostly smal Intestinal
Mostly Ileocoecal
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Mixed 30% of patients
(Howel & Knapton, 1964)
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Clinical Features? acute, chronic or acute on chronic.
? Constitutional symptoms of fever (40-70%), pain (80-
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95%), diarrhoea (11-20%), constipation, alternating
constipation and diarrhoea, weight loss (40-90%),
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anorexia and malaise.? Pain-either colicky due to luminal compromise, or
dull and continuous when the mesenteric lymph
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nodes are involved.
Diagnosis
Paustian in 1964 stated that one or more of the following four criteria
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must be fulfil ed to diagnose abdominal tuberculosis:
(i) Histological evidence of tubercles with caseation necrosis;
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(ii) a good typical gross description of operative findings with biopsy ofmesenteric nodes showing histologic evidence of tuberculosis;
(ii ) animal inoculation or culture of suspected tissue resulting in growth
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of M. tuberculosis
(iv) histological demonstration of acid fast bacil i in a lesion
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Non specific findings include raised ESR, anemia, hypoalbuminemia? Plain X ray
? Small Bowel Barium Meal
? Barium Enema
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? Ultrasonography? CT Scan
? Colonoscopy
? Laparascopy
? Immunological Tests (value undefined)
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? Ascitic Fluid ExaminationManagement
? Antitubercular therapy
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? The recommended surgical procedures todayare conservative:
? Stricturoplasty
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? Resection AnastomosisAmoebiasis
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Introduction? Causative agent: Entamoeba histolytica
? Entamoeba histolytica is the second leading cause of
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mortality due to parasitic disease in humans. (The
first being malaria). Amebiasis is the cause of an
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estimated 50,000-100,000 deaths each year.Entamoeba histolytica : life cycle
Clinical manifestations
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? Dysentery- principal manifestation? Appendicitis or amebic ceacal mass
? Amoebic granuloma
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? Fibrous stricture
? Intestinal obstruction
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? Paracolic abscess, ischiorectal abscess and fistulaDiagnosis
? Sigmoidoscopic examination
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? Immunodiagnosis? Microscopy
? Antigen Detection
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? Molecular diagnosis
Amoebicides
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Tissue amoebicides? Metronidazole 500?750 mg three times a day for 5?10 days
? Tinidazole 2g once a day for 3 days is an alternative to metronidazole
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Luminal Amoebicides
? Paromomycin 500 mg three times a day for 10 days
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? Iodoquinol 650 mg three times a day for 20 daysSurgical Intervention
Filariasis
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? MC cause of lymphedema? Wucheria bancrofti (nematode) in 90% of cases
? Features
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Acute
? Fever
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? Headache? Malaise
? Inguinal & axil ary lymphadenitis
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? Lymphangitis, Cel ulitis
? Funiculo-epididymo-orchitis
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-ChronicLymphedema of legs
Hydrocele
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Abdominal lymphatic varices
Treatment
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? Elevation or periodic compression
? Firm support bandage or compression garment (MLLB)
? Complex decongestive therapy (CDT)
? Massage (MLD)
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? Drugs? Foot and skin hygiene
? Surgery is rarely performed to remove hypertrophied lymph
channels or obstructed lymph channels
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Symptomatic and supportive Treatment for other symptoms and signs
Typhoid
Introduction
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? Acute enteric infectious disease
? Caused by salmonella typhi (S.Typhi)
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? Prolonged fever, relative bradycardia, apathetic facialexpressions,roseola,splenomegaly,hepatomegaly,
leukopenia.
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? Intestinal perforation, intestinal hemorrhage? Antigens: located in the cell capsule
H (flagellar antigen).
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O (Somatic or cell wall antigen).Vi (polysaccharide virulence)
"widal test"
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Transmission
? Fecal-oral route
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? Close contact with patients or carriers? Contaminated water and food
? Flies and cockroaches
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S.Typhi.
liverspleengall
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BM ,ect2nd bacteremia
early stage&acme stage
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(1-3W
stomach
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(Bac. In gall
mononu
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clear
phagocy
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tes )Bac. In
Lower
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feces
ileum
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peyer's patches &S.Typhi eliminated
mesenteric lymph nodes
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convalvescence stage
(4-5w)
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LN Proliferate,swel1st bacteremia
necrosis
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defervescence stage
thoracic
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(Incubation stage)Enterorrhagia,i
3-4w
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duct
10-14d
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ntestinalperforation
Pathology
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? Essential lesion:
Proliferation of RES (reticuloendothelial system )
specific changes in lymphoid tissues & mesenteric lymph
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nodes."Typhoid nodules"
? Most characteristic lesion:
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ulceration of mucous in the region of the peyer's patchesof the small intestine
Complications
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? Intestinal hemorrhage? Intestinal perforation
? Toxic hepatitis
? Acute cholecystitis
? Nephritis
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? Hemolytic uremic syndrome.? Toxic myocarditis
? Bronchitis, bronchopneumonia
? Toxic encephalopathy
? Meningitis
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Diagnosis
? white blood cell count is normal or decreased
? Blood culture
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? Urine and stool cultures? Serological tests(Widal test)
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Treatment
? Isolation and rest
? Good nursing care and supportive treatment
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? Intravenous injection to maintain water and acid-base andelectrolyte balance
? Antibiotics:
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? Quinolones
? Chloramphenicol
? Cephalosporines
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? Treatment of complicationsAscariasis
Introduction
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? a common cream colored roundworm that isparasitic in the intestines of humans
? Most common helminthic human infection
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? Largest nematode to infect the human intestine
? Definitive host : Humans or pigs
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Modes of transmission? Occurs mainly via ingestion of water or food
? Occasionally inhalation of contaminated dust
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? Children playing in contaminated soil may acquire the parasite
from their hands
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Prior infection does not confer protective immunityLife Cycle
Symptoms
Symptoms associated with larvae migration
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? hemorrhagic/ eosinophilic pneumonia, cough (Loeffler's Syndrome)
? Breathing difficulties and fever
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? asthmatic attacks, pulmonary infiltration and urticariaSymptoms associated with adult parasite in the intestine
? Usual y asymptomatic
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? Abdominal discomfort, nausea in mild cases
? Malnutrition in host especial y children in severe cases
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? Sometimes fatality may occur when mass of worm blocks the intestineDiagnosis
? Stool microscopy
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? Eosinophilia
? Imaging
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? Ultrasound? Endoscopic Retrograde Cholangiopancreatography
Treatment
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? Mebendazole? Albendazole
? Pyrantel pamoate
? Ivermectin
? Piperazine citrate
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? Levamisole