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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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394 Robin Kaushik
be managed adequately by nonsurgical means (chemotherapy, percutaneous aspi-
ration, and injection), but complicated cysts usually need surgical intervention.
Free Ruptured Hydatid Cyst
The aims of surgery when dealing with secondary peritonitis from a rup-
tured hydatid cyst of the liver are:
Elimination of the visible elements in the peritoneal cavity
Sterilization of the peritoneal cavity using scolicidal agents such as 0.5%
silver nitrate solution, hypertonic saline (20%), chlorhexidine solution, or cetrimide
Source control to remove any residual parasitic element cysts from the liver,
removing the germinal layer, suturing of any visible cyst-biliary communications, obliteration of the cavity (preferably by packing it with omentum), and
drainage
Rupture of Hydatid into the Biliary Tree
Rupture of hydatid into the biliary tree usually produces obstructive jaundice and cholangitis and is often considered to be an absolute indication for surgery. However, ERCP may obviate the urgency of surgery by clearing the common
duct of the parasitic cysts, providing free drainage of bile and lowering the intraductal pressures. Patients who fail ERCP or in whom there are recurrent symptoms
can then be taken for surgery, where choledochotomy, clearance of the cyst remnants, and closure over a T tube are performed.
All emergency interventions must be followed up with albendazole (400 mg
twice daily) for at least 3 weeks.
Anisakis simplex
Illness with the Anisakis simplex nematode can present with severe abdomi-
nal pain, nausea, and vomiting, typically within a few hours of ingesting raw or
undercooked infected fish (sushi eaters be careful). The larva of Anisakis usually
involves the stomach in humans but can also occasionally affect the small bowel.
In the acute stage, the presentation has been confused with appendicitis, the patients submitted to surgery, and the true nature of the diagnosis revealed only on
histopathological examination. The diagnosis is difficult to make with certainty in
an emergency situation but can be suspected preoperatively if the patient spits out
the worm or, in endemic regions, when a history of eating raw fish a few hours
prior to the onset of symptoms can be elicited. In such cases, upper GI endoscopy
37. 1 A sia 395
can visualize and remove the parasite, with relief of symptoms. As human infections are a dead end for the parasite, no further treatment beyond symptom relief
is required if the diagnosis can be made. If undetected, the infection can present
with small bowel obstruction after 2–3 weeks and invariably requires surgical
intervention.
Liver Flukes
Liver flukes (Clonorchis sinensis) are another significant cause of biliary
symptoms, especially in the Far East. These live in the biliary tract for long periods
before causing significant symptoms, classically known as oriental cholangiohep-
atitis or recurrent pyogenic cholangitis (pain, fever, jaundice). Chronic disease
may give rise to secondary biliary cirrhosis and portal hypertension. An association of cholangiocarcinoma with this infestation has also been proposed. The
treatment is medical (praziquantel), but clearance of the bile ducts (ERCP or surgical) may be required in refractory cases.
Although a wide variety of worm infestations can give rise to acute abdominal symptoms, it is important to realize that these diagnoses are often not
made initially but after investigations or on histopathology, even in the endemic
regions. For example, appendicitis can also arise as a result of luminal obstruction by worms (Ascaris, pinworms, or Strongyloides), but the diagnosis is rarely
made pre- or intraoperatively. It is usually made retrospectively, on examination
of the specimen by the pathologist. Therefore, it is important to realize that the
symptoms of the patient can indicate the need for conservative or surgical treatment, and further therapy can be added once the specific diagnosis is made.
Africa
Graeme Pitcher · Craig Joseph
Like the many paradoxes in Africa, emergency surgery illustrates the extremes:
there may be helicopter transfer to twenty first century intensive care, or mul-
tiple cart and taxi transfers over several days to an under resourced mission
hospital. (David Dent)
The continent of Africa is as diverse as it is enormous. Its populace ranges
from the some of the most rural, uneducated, and poverty stricken, with limited
or no medical access, to wealthy first-world citizens who have access to modern,
often private, health care. The full range of abdominal emergencies exists as in
other countries, with trauma and obstetric emergencies masquerading as general surgical pathology. Though there are unique and interesting pathologies
that are seen in Africa, the vast majority of patients with abdominal emergencies
share their pathology with their Western counterparts, but because of poor access to health care, political strife, and civil wars they tend to present much later
to the surgeon in the course of their disease, often with unique sets of surgical
challenges. Delay in presentation is common to the point of being almost the
norm. In this chapter, we discuss some of the unique conditions as well as share
some tips to deal with the neglected case. Adequately treating these patients,
often in suboptimal circumstances, remains the challenge of surgery in Africa.
3 7. 2
Intussusception: Lethal and Delayed
Intussusception remains the most common acute life-threatening abdominal condition of early life. The typical Western presentation depicted by Wojciech
Górecki (> Chap.35) is, in our experience, rarely seen in indigent African
populations.
Many patients present as having intestinal obstruction.
Because of bowel loop distension, the typical abdominal mass may be dif-
ficult to palpate.
Many patients are mistakenly treated for dysentery.
Acute peritonitis from perforations, usually at the point of pressure of the
lead point on the receiving bowel, is often present.
Graeme Pitcher
Department of Surgery, Division of Pediatric Surgery, University of Iowa Children’s Hospital, Iowa City,
IA 52242-1086, USA
M. Schein et al. (eds.), Schein’s Common Sense Emergency Abdominal Surger y,
DOI: 10.1007/978-3-540-74821-2_37.2, © Springer-Verlag Berlin Heidelberg 2010
397
398 Graeme Pitcher · Craig Joseph
Prolapse
Intussusception
Colo col ic i nt us susception i s u ni que ly common in sout he rn Af ric a, t yp ica ll y
in older children.
The intussusception may protrude from the anus and be mistaken for a
rectal prolapse. Being able to pass one’s finger up adjacent to the presenting bowel
for a considerable distance on rectal examination should make this distinction
(> F ig. 37.2.1).
Intestinal obstruction in a child less than 4-years-old without evidence of
an incarcerated hernia or previous surgery is intussusception unless proven
otherwise.
Fewer patients with intussusception in our area can be treated by radiologically guided pressure reduction. In well-resuscitated patients in the age range
3 months to 2 years, with a nontender abdomen and no sign of established
Fig. 37.2.1. Distinguishing between rectal prolapse and intussusception. In rectal
prolapse, the examining finger cannot slide between the prolapsed bowel and the anal
verge, whereas in intussusception the finger can slide in alongside the intussusception
presenting at the anal verge
37.2 Africa 399
intestinal obstruction, reduction (preferably with air) can be attempted and is
successful in about a third of patients. Duration of symptoms is not used as an
absolute contraindication to air reduction because that would preclude almost
all patients. Other patients are best treated by open surgical exploration as resection rates for bowel ischemia and perforation are high.
Appendicitis: Neglected Perforation Still a Fatal Disease
The management of appendicitis in the developing world is no different
from anywhere else. One possible exception is to recognize the patient with
life-threatening long-standing perforation, often of up to 2–3 weeks duration.
Such patients usually present with severe sepsis, dehydration, wasting, organ
dysfunction, and a grossly distended abdomen with diffuse peritonitis and
multiple loculated collections. They are best managed by very aggressive preoperative resuscitation, antibiotic treatment, and exploration by a midline
laparotomy—not laparoscopically...
Ascaris Infestations
The Ascaris parasite has certainly found a happy home in the intestinal tract
of many Africans. The most common presentation to the surgeon is with intestinal
obstruction. Most patients will report vomiting the worms or passage of worms
rectally. Plain abdominal X-rays show a picture of intestinal obstruction with the
typical curvilinear shadows of worms in the lumen of the bowel. Most patients can
be treated conservatively with fluid resuscitation and nasogastric drainage.
Vermicidal agents are traditionally not used in the acute stage of obstruction for
fear of paralyzing the worms in the bolus and aggravating the situation (but this
may be a myth!). Disobstruction is aided by the administration of Gastrografin
(which is slippery and hypertonic), given usually from above via nasogastric tube
(> Fi g. 37.2.2) but also as an enema in cases of distal obstruction. Indications for
surgical intervention include peritonitis, severe systemic toxicity, failure to respond
in 24–36 hrs, and severe rectal bleeding.
Leiomyopathy
Leiomyopathy is a common problem in African children. We have seen more
than 50 cases. It is not well described in the textbooks or literature because it is
virtually nonexistent in developed countries, and the cause is not known; we think
that it is a toxic injury from enemas or other muti (see the section on enemas).
400 Graeme Pitcher · Craig Joseph
Fig. 37.2.2. Gastrografin administered via nasogastric tube in obstructed patient.
Note linear shadows indicating worms in proximal bowel
This condition presents with an onset of (initially fairly benign and asymptomatic) abdominal distension at 3–7 years of age followed by progressive massive, predominantly gaseous distension with frank obstructive features and
progression to death from intestinal failure, usually before the third decade of
life. The cause is unknown, and pathology of affected bowel (usually starting
distally and progressing more proximally) shows replacement of muscle in the
muscularis propria with sheets of fibrous tissue. These patients are typically
enormously distended clinically and radiologically but usually show no signs of
intestinal obstruction and often arrive in surprisingly little distress, eating normally. The abdomen is soft and tympanitic to percussion.
The common pitfall with this condition is to look at the X-ray, assume a
life-threatening obstruction, operate to find huge loops of colon, and then perform a stoma. These stomas are massive and bulky, prone to complications, and
generally fail to adequately relieve distension. Instead, these patients are best
served by rectal decompression by tube or endoscopy, a regular “bowel program”
(mainly “from below”), and nutritional support. No form of surgery helps these
patients significantly, although a small number can be palliated by total colectomy and ileorectal anastomosis for a few years.
37.2 Africa 401
Fig. 37.2.3. Multiple colonic perforations in an HIV-positive infant with CMV
colitis
HIV-Related Abdominal Emergencies (see > Chap. 36)
The high incidence of HIV/AIDS, and the associated opportunistic infections, in particular tuberculosis, greatly increases the possible spectrum of pathology. The most common abdominal complications of HIV/AIDS in our experience
are cytomegalovirus (CMV) enteritis and perforation in the young infant (3–18
months of age) and abdominal tuberculosis in the older child.
Typically, CMV disease presents with acute abdominal distension, vomiting,
and cardiovascular collapse in a severely immunocompromised and malnourished child. At laparotomy, multiple, sometimes hundreds, of small perforations
(> Fig. 37. 2. 3) are found along the entire length of bowel. Histology will sometimes
reveal the typical intracytoplasmic viral inclusions. Even with aggressive treatment, including the use of intravenous ganciclovir, prognosis is poor.
Traditional “Witch Doctor” Enemas
Although there is a paucity of literature on the topic, the use of traditional
muti enemas is commonplace among many of the African tribes (see > Fi g. 37.2.4).
The addition of toxic chemicals by the traditional healer or Sangoma, such as potassium dichromate (a potent caustic agent), can result in corrosive injuries causing tissue necrosis, perforations (> Fi g. 37.2.5), or late strictures. Mechanical
instrumentation alone can result in direct rectal trauma, and any of these injuries
may lead to peritonitis or retroperitoneal necrotizing fasciitis. The clinical picture may be further complicated by the addition of nephrotoxins, typically
402 Graeme Pitcher · Craig Joseph
Fig. 37.2.4. “Hey Doc, let me just call for second opinion. Yes, I am calling my
Sangoma”
Fi g. 37. 2 .5 . A CT abdomen sagittal reconstruction of a 5-year-old boy treated errone-
ously for acute appendicitis found later to have a large posterior rectal perforation with a
retrorectal collection—a complication of a “traditional enema.” The arrows on left point
out the bladder and rectum, whereas the large air-filled structure posterior to the rectum
arrowed on right is the collection
37.2 Africa 403
Cantharidins (an extract that the Tswana tribe derive from grinding the bodies of
dead blister beetles that is used to augment potency and as an abortifacient), resulting in acute renal failure. Patients are often not forthcoming with a history of
having used traditional medicines, and a very high index of suspicion is required.
Studies have shown that the majority of African infants and children admitted to
hospital with gastroenteritis have already been administered traditional enemas.
It is also vitally important to ascertain if the onset of illness pre-dated the administration of the muti or not. It is a common mistake to blame all the sequelae on
the potion and therefore miss other underlying conditions.
Sigmoid Volvulus and Ileosigmoid Knotting (see > Chap. 25)
Unlike in the “developed,” world where sigmoid volvulus typically affects
elderly patients, in Africa it tends to occur in younger males. The African variety
of sigmoid volvulus is associated with a degree of megacolon/rectum, and the
bowel wall and mesosigmoid are thick and relatively resistant to ischemia. Bowel
necrosis is therefore less common than in the thinner-walled colons of the older
Western counterparts but still occurs when prolonged delay in presentation occurs. Patients presenting with bowel necrosis require prompt resuscitation and
emergency resection. Primary anastomosis is considered safe if an experienced
operator is present and the patient’s condition is stable. Cases presenting without
signs of bowel necrosis or perforation should undergo sigmoidoscopic decompression. This is best achieved via the use of a rigid sigmoidoscope inserted with
the patient kneeling on all fours with the buttocks elevated above head and shoulders. Typically, a “flatus” (rectal) tube is inserted following successful decompression. Due to the high recurrence rate, patients should have a definitive procedure
during the same hospital admission (> Chap. 25).
Ileosigmoid knotting is a rare condition in which the ileum wraps itself
around the sigmoid colon, causing a closed-loop obstruction with the potential
for gangrene in both viscera. It occurs mainly in Africa, Asia, and the Middle
East, typically in healthy individuals of middle age. It is thought to be caused by
redundancy of the mesenteries of both the sigmoid and the ileum and possibly
aggravated by a high-bulk diet. Principles of management include resection of
bowel when necessary and applying judgment as discussed regarding the advisability of primary anastomosis.
Typhoid Fever
Infection contracted by feco-oral transmission of the Gram-negative bacillus
Salmonella typhi is still an important cause of small bowel perforation and peritonitis in poorer communities. Initially characterized by high fevers and a relative
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