Colon perforation in amebiasis

Surgical Infections in Low- and Middle-Income Countries: A Global Assessment of the Burden and Management Needs

Background: The burden of surgical infections in low- and middle-income countries (LMICs) remains poorly defined compared with high-income countries. Although there are common infections necessitating surgery prevalent across the world, such as appendicitis and peptic ulcer disease, other conditions are more localized geographically. To date, comprehensive assessment of the burden of surgically treatable infections or sequelae of surgical infections in LMICs is lacking. Methods: We reviewed the literature to define the burden of surgical infections in LMICs and characterize the needs and challenges of addressing this issue. Results: Surgical infections comprise a broad range of diseases including intra-abdominal, skin and soft tissue, and healthcare-associated infections and other infectious processes. Treatment of surgical infections requires a functional surgical ecosystem, microbiology services, and appropriate and effective antimicrobial therapy. Systems must be developed and maintained to evaluate screening, prevention, and treatment strategies. Solutions and interventions are proposed focusing on reducing the burden of disease, improving surveillance, strengthening antibiotic stewardship, and enhancing the management of surgical infections. Conclusions: Surgical infections constitute a large burden of disease globally. Challenges to management in LMICs include a shortage of trained personnel and material resources. The increasing rate of antimicrobial drug resistance, likely related to antibiotic misuse, adds to the challenges. Development of surveillance, infection prevention, and antimicrobial stewardship programs are initial steps forward. Education is critical and should begin early in training, be an active process, and be sustained through regular programs.

Multiple colonic and ileal perforations due to unsuspected intestinal amoebiasis-Case report and review

Amoebiasis, caused by the intestinal protozoan Entamoeba histolytica, though a relatively common parasitic disease in the tropical and subtropical regions, is uncommon in the developed countries. In these countries, as amoebic colitis shares similar clinical symptoms and endoscopic features with inflammatory bowel disease (IBD), these cases can be easily unrecognized and misdiagnosed. In this case report, we discuss the case of an adult patient with invasive intestinal amoebiasis, who was initially managed as Crohn's disease on corticosteroid treatment and subsequently rapidly deteriorated and developed multiple perforations in the colon and ileum. Despite total colectomy followed by resection of the small bowel, he died of multiple organ failure and sepsis within two months of his initial clinical presentation of diarrhea with abdominal pain. The learning point of this case is that invasive intestinal amoebiasis should be considered as a differential diagnosis at the first clinical adult presentation of IBD-like symptoms despite suggestive endoscopic findings of Crohn's like ulcers. Regardless of negative endoscopic biopsies, due to the low sensitivity of microscopic examination, serology test for antibody and molecular test for Entamoeba DNA are recommended for accurate detection and identification of Entamoeba species, especially in the high risk populations with recent travel to endemic zones and for patients with immunosuppression and comorbidities such as diabetes mellitus, tuberculosis, alcoholism, HIV/AIDS and in pregnant women. Amoebiasis should be completely ruled out prior to corticosteroid administration, to avoid severe complications such as fulminant intestinal amoebiasis which is associated with an inherently high mortality.

Colonic perforation due to amebiasis, a rare and lethal complication

Amebiasis is still a major healthcare concern, especially in developing countries like Ecuador. The lack of sanitary control and hygiene measures make parasites infections still a burden for patients and physicians. Despite infections due to this parasites are usually mild, severe infections and fatal outcomes although rare still occur. Bowel perforation is a rare complication of amebiasis, and unfortunately, it continues to be almost fatal. We present a case of an Ecuadorian patient who presented to the emergency room with an acute abdomen, despite adequate surgery and critical care, the patient regrettably died. Bowel perforation due to Entamoeba histolytica was the final diagnosis.

Colocutaneous fistula secondary to amoebiasis

Here we present an interesting and extremely rare case of a 66 year old male who developed a colocutaneous fistula secondary to amoebiasis. The patient presented with an acute history of right lower abdominal pain, weight loss and a palpable mass. A CT scan demonstrated a fluid filled cavity in the right iliac fossa consistent with an appendiceal abscess which was drained under radiological guidance. However, following drainage his symptoms remained requiring open surgical drainage, and a controlled caecostomy was performed due to a small caecal perforation. Despite appropriate conservative therapy he failed to progress, and developed localised sepsis in the right iliac fossa with a colocutaneous fistula, requiring a formal right hemicolectomy. The histological examination confirmed the presence of abundant trophozoites of Entamoeba histolytica.We highlight the fact that in the modern age of immigration and long distance travel, it will become increasingly likely that the so-called 'tropical' diseases will present throughout the world. This case also highlights the need to keep an open mind in cases that do not progress as expected, and to react accordingly to any unusual developments.

Amebiasis

Amebiasis is an important cause of death from parasitic disease worldwide. The causative organism is Entamoeba histolytica, which has an infective cyst stage and a pathogenic and motile trophozoite stage. The clinical presentation can vary from an asymptomatic carrier state to fulminant colitis and colonic perforation. The majority of patients can be managed medically. However, a small percentage of patients require urgent exploration and resection with an associated high mortality rate. Early recognition and initiation of medical therapy including treatment of asymptomatic carriers are vital to preventing catastrophic outcomes.

Fulminant amebic colitis

Amebiasis is the acute and chronic disease produced by Entamoeba histolytica, an entity which occurs in endemic fashion in many of the tropical and subtropical areas of the world, capable of affecting diverse organs of the body, especially the colon. Amebiasis has different clinical forms of presentation, varying from the asymptomatic carrier state to severe, although not frequent, fulminant or necrotizing colitis, characteristically associated with high morbidity and mortality. We hereby report a series of 50 adult patients with fulminating amebic colitis managed at our institution between January, 1971 and July, 1989, with a global mortality of 60%. Early diagnosis, treatment with effective antiamebic agents--specifically metronidazole--and opportune aggressive surgical intervention have resulted in better survival rates. We had no survivors prior to 1970; our current survival rate is still a dismal 40%, indicating the very severe nature of the disease.

Colectomy for necrotizing amebic pancolitis in early childhood with survival

A case of necrotizing amebic pancolitis in a 6-year-old boy with asplenia, partial situs inversus, and cyanotic congenital heart disease is reported and the literature is reviewed briefly. Our patient was managed successfully by prompt colectomy, ileostomy, a Stamm gastrostomy, and extensive drainage of the peritoneal cavity with administration of metronidazole postoperatively and prolonged jugular vein Broviac catheter hyperalimentation. This child may be the first survivor of total colonic amebic necrosis in childhood. Necrotizing amebic colitis appears to be more hazardous in infancy and childhood than in adult years. Malnutrition and additional illnesses and malformations may produce greater immunocompromise in the very young, placing them at greater risk for the ultimate of amebic intestinal complications, total colonic necrosis and disintegration.

Necrotizing amebic colitis: a frequently fatal complication

Acute necrotizing amebic colitis is an uncommon but life threatening development with a high mortality rate, even when properly diagnosed and treated. We report six cases of acute necrotizing amebic colitis, none of which were diagnosed preoperatively. At operation, five of the six patients had friable, necrotic, and gangrenous colon. A right hemicolectomy with ileostomy was performed in two patients and a subtotal colectomy with ileostomy was performed in four patients. Five of the six patients died within 4 weeks of operation. The sole survivor was the patient who had received metronidazole preoperatively. Only after histologic examination of the surgical specimen was the diagnosis made in all cases. If the diagnosis can be made preoperatively and antiamebic therapy instituted, surgical resection may decrease the high mortality rate of this disease.

Fulminant amebic colitis

Nine patients with fulminating amebic colitis who were treated surgically from 1975 to 1982 are presented. Only those who had bowel resections with exteriorization of the cut ends survived. The pertinent literature is reviewed briefly.

Amebic colitis. Preventing morbidity and mortality from fulminant disease

Uncomplicated amebic colitis is readily treated and has a mortality rate of less than 0.5%. Complications necessitating surgical intervention develop in only 6% to 11% of patients with symptomatic disease. However, the mortality rate in these patients ranges from 40% to 100% and stems in part from delays in diagnosis and treatment. Patients with known amebic colitis who show signs of systemic toxicity or of localized or generalized peritonitis are at high risk for complications; surgical consultation should be obtained. Patients who are thought to have acute appendicitis, diverticulitis, or obstructive or perforative carcinoma but have a history of dysentery atypical of that in these conditions should also be evaluated for amebiasis. Such patients should be treated presumptively until the diagnosis of amebic colitis can be excluded.

Fulminating amoebic colitis: a clinical evaluation

Eleven cases of fulminating amoebic colits seen in 5 years are reported. Only people of low socioeconomic status were affected and most were in good health previously. The disease appeared to follow a fulminant course from the onset and was rarely a secondary phenomenon superimposing on the chronic amoebic dysentery. The diagnosis was difficult due to severe systemic manifestations and the periodic absence of Entamoeba histolytica in the stool. The development of colonic necrosis was often masked by the severe preexisting local signs and perforation could occur in spite of adequate anti-amoebic therapy. Mortality was related to late diagnosis, delayed recognition of irreversible colonic necrosis and inadequate surgical treatment.

To reduce the present 55 per cent mortality further it is proposed that, in an endemic area, early specific antiamoebic therapy is justified in severe and undiagnosed colitis. Even under specific anti-amoebic treatment the patient with severe amoebic colitis remains a potential surgical candidate. Surgery is indicated when the patient continues to deteriorate in spite of the therapy, when there is an acute episode which signifies perforation, or when severe diarrhoea, toxaemia and abdominal tenderness persist after a full course of specific anti-amoebic therapy. Primary total resection of the diseased colon is the treatment of choice.

Fatal intestinal amoebiasis

The clinical presentation of amoebic colitis are diverse. Amoebiasis is comparatively rare in the U.K. and, unless the clinician is aware of the condition, wrong diagnosis often leads to delay in appropriate treatment resulting in high mortality. Diagnosis rests on clinical suspicion, stool examination, sigmoidoscopy with rectal biopsy and serological tests. Amoebiasis is readily treatable and death from it should be very rare.

Amoebic perforation of the bowel: experiences with 26 cases

Over a period of 14 1/2 years, 26 instances of amoebic perforation of the bowel occurring in 25 patients were treated surgically. Nineteen perforations occurred in males and 7 in females, whose ages ranged from 3 to 74 years. The duration of symptoms varied from 12 h up to 5 months (average 15 days). All patients were toxic and a right lower quadrant mass was present in 14. The correct diagnosis was made or suspected in 14 (54 per cent). Amoebic perforation of the bowel should be suspected in patients presenting with an acute abdomen if a past history of fever, pain and diarrhoea is obtained, particularly if a large tender mass is present in the right iliac fossa. Resectional surgery was performed in 7 patients, with a mortality of 71 per cent, whereas procedures designed to divert the faecal stream were carried out in 19, with a mortality of 43 per cent. All 6 patients with concomitant liver abscesses died. If these patients are excluded, the mortality from resections was 60 per cent and from faecal diversion 27 per cent. Faecal diversion with wide drainage is the treatment of choice for amoebic perforation of the colon.

Perforation of the colon in unsuspected amebic colitis: report of two cases

Two cases of amebic colitis that resulted in perforation of the colon, an ominous complication, are presented. The first was diagnosed preoperatively as acute ulcerative colitis with toxic megacolon, and the second as peritonitis complicating acute cholecystitis. In both instances the correct diagnosis was made after operation. The first patient recovered after colectomy and antiamebic therapy, but the second patient died in the early postoperative period, in septic shock. Amebic colitis occurs infrequently in the United States, and the diagnosis is rarely considered. In most cases an initial diagnosis of ulcerative or granulomatous colitis is made and the true diagnosis is recognized only after operation for colonic perforation or hepatic abscess. It is suggested that amebic colitis should be considered more frequently in cases of patients who have diarrhea. Stool examination for ova and parasites is often negative in amebic colitis. The IHA is usually positive in emebiasis, and should be performed early in casesof patients who have bloody diarrhea or other clinical symptons when amebiasis is suspected. Rectal biopsy is also a useful diagnostic approach, but failed to reveal amebae in one of our cases. Finally, it is suggested that operation be performed urgently when fulminating amebic colitis is not reversed by antiamebic therapy, when peritonitis occurs even with antiamebic treatment in progess, and for colonic perforation or toxic megacolon even when antiamebic therapy has not been indicated.

Amoebic perforation of the intestine in children

Three cases of small children with perforations of the large intestine due to Entamoeba histolytica who subsequently died are presented. They highlight the misleading symptomatology and the severe prognosis.

The surgical management of amoebiasis in children

Five children with severe complications of acute amoebic dysentery are described. The results of a simple defunctioning proximal ileostomy are encouraging. Prior administration of anti-amoebic therapy and postoperative intensive medical care are mandatory for a successful outcome.