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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_785_Библиотеки_им_академика_М_И_Перельмана
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Asia
Robin Kaushik
The spectrum of abdominal emergencies encountered in Asia is almost the
same as that encountered elsewhere in the world but with a few regional differences in pattern and presentation. As the “conventional” causes of the acute abdomen are discussed in detail elsewhere in this book, this chapter focuses on
what is specific to this vast continent—specific for example to India, as depicted
in > Fig. 37.1 .1.
Duodenal ulcer perforation remains by far the most common cause of the
acute abdomen. Although relationships with diet (predominantly rice based),
seasonal variation, genetic, and environmental factors have all been proposed to
3 7.1
Fig. 37.1.1. “Doc, my anus is burning!” The surgeon taking a sniff: “Perhaps if your
wife adds a little less curry powder...”
Robin Kaushik
University Dental College and Hospital, Chandigarh, India
M. Schein et al. (eds.), Schein’s Common Sense Emergency Abdominal Surger y,
DOI: 10.1007/978-3-540-74821-2_37.1, © Springer-Verlag Berlin Heidelberg 2010
385
386 Robin Kaushik
explain the higher incidence of duodenal ulceration in this region, the exact
cause remains unclear. Acute appendicitis, cholecystitis, and acute pancreatitis
all occur in patients in this region. Other causes of the acute abdomen one may
come across include colonic perforation, mesenteric vascular occlusion (and intestinal ischemia), and abdominal aortic aneurysms, but the incidence of these
is much less than is seen in “developed” countries. Similarly, medical causes such
as myocardial infarction and basal pneumonia may also occasionally be seen
presenting as “acute abdomen.”
Within this region, there exists a geographical variation in the diseasespecific causes presenting as acute abdomen. Although duodenal ulcer perforation remains the most common cause of acute abdomen, the incidence of small
bowel perforation can be very high, varying from nearly 40% in the Indian subcontinent to an almost negligible 6% in China and even less in Thailand. Enteric
fever, tubercular, and nonspecific small bowel perforations are common in the
Indian subcontinent, whereas Crohn’s disease, Behcet’s, radiation enteritis, adhesions, ischemic enteritis, and systemic lupus erythematosus (SLE) are the
common causes of small bowel perforation in the “far eastern” countries like
China and Japan.
I will dwell on the acute presentations of a few conditions seen commonly in
Southeast Asia: abdominal tuberculosis, amebiasis, and parasitic infestations.
Abdominal Tuberculosis
The abdomen is the most common site of extrapulmonary tuberculosis (TB).
Abdominal TB can develop in the absence of pulmonary TB and does so in nearly
two-thirds of cases. Although classified in many ways, intestinal problems due to
TB are the most common presentation of abdominal TB. The disease can affect any
part of the gastrointestinal (GI) tract from the esophagus to the rectum. The ileocecal region is most commonly affected (as a result of physiological stasis and the
presence of more lymphoid tissue). Infected Peyer’s patches ulcerate along the long
axis of the terminal ileum, and caseation of the mesenteric lymph nodes may occur.
Further disease progression usually depends on the host’s immunological status.
Abdominal TB can present as an “acute abdomen” in two main ways: intestinal (small bowel) obstruction and peritonitis.
Small bowel obstruction is the most common complication of abdominal
TB and is caused by stricture formation, adhesions, or external compression of
the lumen of the bowel by caseating mesenteric lymph nodes. Classically, the patient gives a history of recurrent attacks of small bowel obstruction (the so-called
subacute intestinal obstruction) prior to complete obstruction. Although some
surgeons prescribe antitubercular drugs in this situation and recommend waiting for a month to see a response, a patient who does not respond to conservative
measures needs to be operated on (> Chap. 21). Not uncommonly, at operation
37. 1 A sia 387
Fig. 37.1.2. Adhesions in abdominal TB
Fig. 37.1.3. Tubercles over the intestine and mesentery in abdominal TB
you may encounter dense adhesions (> Fig. 37.1 .2) that may be a challenge to even
the most talented of surgeons. Patience, and calling for help when the case seems
beyond your skills, is the key to successful management in this situation.
Caseating lymph nodes, tubercles on the bowel or mesentery (> Fig. 37.1 .3),
and small bowel strictures (> Fig. 37.1.4) should make you suspect abdominal TB
in a patient undergoing laparotomy for intestinal obstruction. In such cases, the
surgical strategy is to relieve the obstruction with resection and a primary anastomosis (ileoileal or ileocolic) whenever feasible. Stricturoplasty is another option.
388 Robin Kaushik
Fig. 37.1.4. Tubercular strictures of the ileum
Bypass of the affected segment is recommended only if resection is not pos-
sible due to dense adhesions or encasement of surrounding structures (such as
the ureters, root of the mesentery) or, in a sick patient, if operating time can be
saved by bypassing the diseased and densely adherent segment. Please remember
to take some tissue for a biopsy during surgery; it not only will confirm your diagnosis, but also will rule out other diseases such as malignancy, which can mimic
TB. Start antitubercular therapy for such patients in the postoperative period.
Perforation of the intestine is another way in which abdominal TB can
present. The signs and symptoms are those of peritonitis, and it is rare to be able
to make the diagnosis of a tubercular perforation pre- or even intraoperatively.
These perforations usually occur in the distal small intestine, proximal to tubercular strictures. These are usually “blowouts” secondary to distension of the
bowel. Occasionally, free perforations of tubercular ulcers can be encountered in
the absence of strictures and distal obstruction; these carry a very high mortality. For such cases, resection and primary anastomosis whenever feasible are
again the preferred surgical option, rather than simple closure (which is associated with a high incidence of leak and fistula formation). Exteriorization is an
acceptable alternative in sick and debilitated patients.
Amebiasis
The protozoan infection common in this region is amebiasis. This is caused
by Entamoeba histolytica and spreads through the feco-oral route, usually leading
to disease of the large intestine and liver. Although this remains primarily a medical disease, it can occasionally cause acute abdominal symptoms that necessitate
surgical consultation and intervention.
37. 1 A sia 389
As a surgeon, you may encounter acute abdominal conditions due to ame-
biasis in the following patterns:
Amoebic liver abscess (possibly complicated)
Peritonitis (secondary to colitis or rupture of a liver abscess)
Intestinal obstruction or lower GI bleeding secondary to granuloma forma-
tion (rare)
A liver abscess is the most common complication of amebiasis and usually
presents as an acute illness with right upper quadrant pain, moderate fever, and
tender hepatomegaly. The abscess is usually solitary and confined to the right
lobe (> Fig. 37.1.5), but occasionally can be multiple and even in the left lobe
(> Fig. 37.1. 6). Although the stools are often not positive for the amoeba, serology
Fig. 37.1.5. Solitary amoebic liver abscess
Fig. 37.1.6. Multiple amoebic liver abscesses
390 Robin Kaushik
Fig. 37.1.7. Pyogenic liver abscess
is positive in the majority of cases, and negative serology safely excludes this
diagnosis. On imaging (ultrasound [US] and computed tomographic [CT] scan),
these abscesses appear as hypoechoic masses with smooth margins, in contrast
to pyogenic abscesses (> Fig. 37.1 .7). Technetium-99m liver scanning can diagnose amoebic liver abscesses, which appear as cold lesions on the scan (i.e., they
do not take up the radioisotope), but this investigation is rarely required.
The management of uncomplicated amoebic liver abscess is purely medi-
cal, with oral metronidazole 800 mg three times a day for at least 10 days the
treatment of choice. The patient starts to respond within a couple of days, with
clinical improvement occurring in the form of relief of fever, abdominal pain,
and signs. If there is no improvement in the clinical condition or if the patient
deteriorates, think of alternative diagnoses, such as secondary infection or pyogenic abscesses: aspirate the abscess under US or CT guidance and culture.
Routine percutaneous or surgical drainage of amoebic liver abscesses is
rarely required, because medical therapy alone has been shown to be equally
effective. However, aspiration may be necessary when there is a large sized
abscess (>10 cm); when there is no improvement in the condition of the patient
within 72 hrs; in left lobe or peripheral abscesses; or in cases of diagnostic uncertainty (e.g., when the abscess is associated with negative serology for amebiasis). The aspirate is the typical “anchovy sauce” pus, which is usually sterile, but
may contain the characteristic trophozoites (scrapings of the wall of the abscess
are a better source of trophozoites).
Rupture of such a liver abscess is a dangerous condition, with a high mortality. The rupture usually presents acutely with the classical features of peritonitis, and such a patient needs laparotomy (or laparoscopy) without undue delay to
remove all the pus and muck from the peritoneal cavity. The abscess cavity in the
liver is opened widely and irrigated completely to remove any residual pus.
37. 1 A sia 391
A wide bore tube drain is then placed into this cavity, to be removed a few weeks
later, once it stops draining and there is evidence of shrinkage in size on serial
US. Occasionally, the abscess may rupture in a slow manner, leading to a slow
leak and a localized collection that may be drained under radiological guidance,
thereby avoiding a formal laparotomy.
Peritonitis in amebiasis can also occur from perforation of a colon that is
usually severely affected. In fact, amebiasis is considered to be the most common
cause of colonic perforation in this region and an important cause of fulminant
colitis and toxic megacolon. These perforations are commonly multiple. The co-
lon is dilated and friable and easily injured during surgery, compounding the
surgeon’s problems. After cleaning out the abdomen, deal with the perforationbearing segment of the colon. This is usually achieved by limited resection of the
affected segment of the colon (not necessarily a formal or classical anatomical
resection) with exteriorization of the proximal and distal ends. Reconstruction
is usually deferred in view of the poor condition of the patient and the risk of
anastomotic breakdown, which could be fatal in such debilitated patients. A few
authors have treated this situation with a diverting ileostomy without resection
when there is limited contamination of the peritoneal cavity and self-sealing of
the perforation by the omentum. They reported similar mortality to that following colonic resection; however, such “clean” cases are encountered very rarely.
Parasitic Infestations of the Abdomen
A variety of parasites can cause chronic and acute abdominal symptoms.
The important ones that can cause an acute abdomen are listed in > Table 37.1.1.
Ascariasis
By far the most common helminthic infestation is by Ascaris (ascariasis).
This usually remains asymptomatic but may present with the passage of the worm
through the anus or the mouth. As a surgeon, you may encounter Ascaris in the
following situations:
Intestinal obstruction. This is usually a partial small bowel obstruction
but at times may become complete due to impaction of the worms (which may be
further aggravated by spasm of the bowel) or by volvulus of the worm-containing
obstructed segment of the bowel. The initial management is conservative, with
nasogastric suction, intravenous fluids, antibiotics, and oral piperazine (dose
of 75 mg/kg body weight). However, a few authors believe that antihelminthic
therapy should be avoided initially as it could actually worsen the symptoms
and convert a partial obstruction to a complete one. There are also reports of
successful relief of partial worm obstruction by the instillation of Gastrografin
through the nasogastric tube; because it is hyperosmolar, Gastrografin probably
392 Robin Kaushik
Table 37.1.1. Parasites and the acute abdomen
Name Geographical
Ascaris
lumbricoides
Echinococcus
granulosus
Anisakis
simplex
Clonorchis
sinensis
distribution in Asia
Worldwide Feco-oral
Middle East, Indian
subcontinent
Japan Ingestion of undercooked,
Orient Ingestion of infected
Transmission Acute conditions
Intestinal
obstruction
Bowel perforation
Cholangitis
Pancreatitis
Appendicitis
Handling of infected dogs
raw infected fish
fish (undercooked, raw,
frozen, dried, or pickled)
Jaundice
Peritonitis
Infection
Anaphylaxis
Intestinal
obstruction
Anaphylaxis
Cholangitis
acts by dehydrating and separating the worm bolus (
>
Chap. 21). However, if
the obstruction is complete or there is failure of conservative management, then
these patients need to have an operation. The management at laparotomy should
aim to milk the obstructing mass of worms into the large bowel, from where they
will pass spontaneously through the anus. An impacted bolus that cannot be
manipulated needs a longitudinal enterotomy to remove the worms; remember
to close this transversely.
Occasionally, perforation of the intestine may occur by the worm burrowing
either through the normal wall or through areas of pre-existing lesions (ulcers,
etc.). The management remains the same as for peritonitis from other causes.
Ascariasis of the biliary tract is the most common extraintestinal site for
the worm, and you may be surprised to hear that biliary ascariasis is the second most common cause of acute biliary symptoms (after calculi) in the world.
The presentation can either be uncomplicated (clinical presentation similar to
acalculous cholecystitis) or complicated (recurrent cholangitis, jaundice, or pan-
creatitis). The worm can usually be detected on US as a thin, echogenic tubular
structure, which may even show movements, or as a worm bolus (the “spaghetti”
37. 1 A sia 393
sign). The majority of patients with biliary ascariasis respond to conservative
management (intravenous fluids, antibiotics, antispasmodics, and antihelminthics), and the worm spontaneously re-enters the bowel. Mebendazole (100 mg
twice a day for 3 days) and albendazole (single dose of 400 mg) are considered
the drugs of choice, but again, there are a few authors who believe that therapy
against Ascaris should be deferred until it moves out of the biliary system and
into the intestine (the dead parasite cannot migrate). Therapeutic ERCP may be
considered in patients with complicated disease and in those who do not respond
to conservative therapy. At ERCP, the worm is removed by the Dormia basket,
taking care not to perform a sphincterotomy (as this may be associated with
recurrent biliary ascariasis). If ERCP is unsuccessful in extracting the parasites,
there has been fragmentation and partial extraction, or there are associated strictures, surgery is indicated. The aim of surgery is to achieve complete clearance
of both the biliary tract (at common bile duct exploration) and the intestine of
the worm, with adequate treatment of any associated conditions (such as hepaticojejunostomy when biliary stricture is present). If no further procedure other
than ductal clearance is required, choledochotomy and closure over a T tube is
recommended. Postoperative deworming is essential in all such cases.
Echinococcus
Echinococcus is another important parasite that can cause acute abdominal
symptoms. It gives rise to hydatid disease of the liver (> Fig. 37.1.8), which is
usually a chronic condition unless the hydatid ruptures freely into the peritoneal
cavity (peritonitis) or into the bile ducts (jaundice, cholangitis). Asymptomatic,
small (<4-cm), deep-seated, calcified, and uncomplicated hydatids of the liver can
Fig. 37.1.8. Appearance of liver hydatid on CT scan
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