Evolution of surgical treatment of amebiasis-associated colon perforation

Giant Amoebic Liver Abscess: A Rare Diagnosis in a Rural Setting of Sub-Saharan Africa

Background

Extraintestinal amoebiasis is an uncommon complication of Entamoeba histolytica infection, occurring in about 5-10% of patient. Prompt diagnosis and management is essential to prevent complications. However, diagnosis and management in resource-limited settings is very challenging owing to limited diagnostic tools and nonspecific clinical symptoms. Therefore, our case report underscores the role of incisive clinical evaluation, basic investigation, and nonsurgical management of giant amoebic abscess in resource-limited settings. Case Presentation. A 13-year-old female Cameroonian presented with subacute onset of upper abdominal pain, high fever, and chest pain for one week. Before presentation, she had been on treatment at a local traditional practitioner during which her symptoms worsen. After clinical evaluation and basic investigation, she was diagnosed with a giant amoebic liver abscess. She was resuscitated and placed on nonsurgical management. Follow-up after 1 month was significant for complete recovery.

Conclusion

Amoebic liver abscess is a rare complication of Entamoeba histolytica infection with devastating complications. The diagnosis of this disease requires high index of suspicion in resource-limited settings. Good clinical evaluation and timely nonsurgical therapy can provide recovery to some patients.

Lethal multiple colon necrosis and perforation due to fulminant amoebic colitis: a surgical case report and literature review

Background

Amoebiasis caused by the protozoan species Entamoeba histolytica rarely develops into fulminant amoebic colitis (FAC), but when it does, it shows an aggressive clinical course including colonic perforation, necrotizing colitis, and high mortality. Surgical treatment for FAC patients should be carried out urgently. However, even after surgery, the mortality rate can be 40–50%. Although FAC is one of the most unfavorable surgical diseases with a poor prognosis, there are a few reports on the perioperative diagnosis and management of FAC based on autopsy findings. We herein report the surgical case of a 64-year-old man who developed multiple colon necrosis and perforation due to FAC. A detailed autopsy revealed FAC as the cause of death. Additionally, we reviewed the existing literature on FAC patients who underwent surgery and followed their perioperative diagnosis and management.

Case presentation

A 64-year-old man presented with anorexia, diarrhea, and altered consciousness on arrival to our hospital. Computed tomography revealed a large mass in the upper right lobe of his lung, and the patient was admitted for close investigation. Bloody diarrhea, lower abdominal pain, and hypotension were observed soon after admission. Urgent abdominal contrast-enhanced computed tomography scan revealed extensive intestinal ischemia, intestinal pneumatosis, and free intra-abdominal gas. The preoperative diagnosis was bowel necrosis and perforation with intussusception of the small intestinal tumor. Emergency subtotal colectomy and enterectomy were performed soon after the contrast-enhanced computed tomography. He was taken to an intensive care unit after surgery. However, he could not recover from sepsis and died with disseminated intravascular coagulation and multiple organ failure on the 10th-day post-surgery. A histopathological examination of the resected colon showed transmural necrosis and massive amoebae invasion. He was diagnosed with FAC. An autopsy revealed that he had developed pulmonary large cell carcinoma with small intestinal metastasis. The death was caused by intestinal ischemia, necrosis and the perforation of the residual bowel caused by amoebae invasion.

Conclusions

Since FAC is a lethal disease with a high mortality rate and antibiotic therapies except metronidazole are ineffective, preoperative serological testing and perioperative metronidazole therapy in FAC patients can dramatically improve their survival rates.

Spectrum of CT findings in amebic colitis

Entamoeba histolytica is distributed throughout the world. Invasive amebiasis affects millions of people globally, and the associated complications cause 40,000-100,000 deaths per year. In countries where fecal-oral transmission is unusual, amebic colitis is not common, and the infection may be seen in travelers to and emigrants from endemic areas. Without adequate treatment, amebic colitis may develop into fulminant and become rapidly fatal. With the current increase in global mobility, amebic colitis should be suspected even in patients not in the endemic areas. CT plays an important role in the diagnosis of amebic colitis by demonstrating the presence of colitis with the typical involvement of the cecum and rectum. Pathological features of atypical involvement are also demonstrated. Since preoperative diagnosis can reduce the mortality associated with necrotizing colitis, radiologists need to recognize the typical as well as atypical CT findings of amebic colitis. Considering this requirement, this paper aims to describe the histopathologic features of amebic colitis and to illustrate the spectrum of corresponding CT findings.

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.

Global variation in anastomosis and end colostomy formation following left-sided colorectal resection

BACKGROUND

End colostomy rates following colorectal resection vary across institutions in high-income settings, being influenced by patient, disease, surgeon and system factors. This study aimed to assess global variation in end colostomy rates after left-sided colorectal resection.

METHODS

This study comprised an analysis of GlobalSurg-1 and -2 international, prospective, observational cohort studies (2014, 2016), including consecutive adult patients undergoing elective or emergency left-sided colorectal resection within discrete 2-week windows. Countries were grouped into high-, middle- and low-income tertiles according to the United Nations Human Development Index (HDI). Factors associated with colostomy formation versus primary anastomosis were explored using a multilevel, multivariable logistic regression model.

RESULTS

In total, 1635 patients from 242 hospitals in 57 countries undergoing left-sided colorectal resection were included: 113 (6·9 per cent) from low-HDI, 254 (15·5 per cent) from middle-HDI and 1268 (77·6 per cent) from high-HDI countries. There was a higher proportion of patients with perforated disease (57·5, 40·9 and 35·4 per cent; P < 0·001) and subsequent use of end colostomy (52·2, 24·8 and 18·9 per cent; P < 0·001) in low- compared with middle- and high-HDI settings. The association with colostomy use in low-HDI settings persisted (odds ratio (OR) 3·20, 95 per cent c.i. 1·35 to 7·57; P = 0·008) after risk adjustment for malignant disease (OR 2·34, 1·65 to 3·32; P < 0·001), emergency surgery (OR 4·08, 2·73 to 6·10; P < 0·001), time to operation at least 48 h (OR 1·99, 1·28 to 3·09; P = 0·002) and disease perforation (OR 4·00, 2·81 to 5·69; P < 0·001).

CONCLUSION

Global differences existed in the proportion of patients receiving end stomas after left-sided colorectal resection based on income, which went beyond case mix alone.

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.

Primary cecal pathologies presenting as acute abdomen and critical appraisal of their current management strategies in emergency settings with review of literature

Background:

The importance of cecal pathologies lie in the fact that being the first part of the large intestine, any disease involving the cecum affects the overall functioning of the large bowel. Primary cecal pathologies presenting as acute abdomen have not been described in any previous study in terms of presentation, management, and outcome.

Objectives:

The objective of this study was to identify the reported causes of primary cecal pathologies presenting as acute abdomen and the various causes presenting in our setting, the to discuss morbidity and mortality associated with cecal pathologies, and to critically analyze the various management modalities employed in an emergency setting.

Materials and Methods:

This is a retrospective analysis of a prospectively collected data of all adult patients admitted to our unit in the last 10 years for acute abdomen, in whom cecal pathology was identified as the primary offending agent.

Results:

Our analysis of 43 patients revealed cecal perforation secondary to amebic colitis along with the simultaneous presence of liver abscess to be the most common primary cecal entity met in practice as acute abdomen. Other pathologies that were encountered included volvulus, diverticulitis, and idiopathic typhlitis. Primary acute cecal pathologies are associated with high mortality rates (≈42%). Delay in diagnosis seems to be the most important factor contributing to high mortality as these conditions are commonly misdiagnosed as appendicular pathology. Most of our patients were managed by conservative colonic resection with proximal diversion. This seems to be a more plausible option in current practice in an emergency setting (mortality rate ≈ 36%) as hemicolectomy is associated with proportionately higher mortality rates (67%).

Conclusion:

A high index of suspicion, timely and adequate pre-operative workup, optimal resuscitation, and surgical conservatism with proximal diversion might help in early accurate identification of these conditions and possibly improved outcome.

Fulminant Amebic Colitis after Corticosteroid Therapy: A Systematic Review

BACKGROUND

Amebic colitis, caused by intestinal infection with the parasite, Entamoeba histolytica, is a common cause of diarrhea worldwide. Fulminant amebic colitis is the most devastating complication of this infection, associated with both high mortality and morbidity. We conducted a review of the English literature to describe cases of fulminant amebic colitis associated with exposure to corticosteroid medications in order to identify the risk factors for poor outcome and determine difficulties in diagnosis and treatment.

METHODOLOGY AND PRINCIPAL FINDINGS

Articles reporting severe and fulminant forms of amebic colitis between 1991 and 2016 were collected. 525 records were screened to identify 24 cases for qualitative analysis associated with corticosteroid use. Cases arose from areas of high endemicity or travel to such areas. Most cases (14 of 24, 58%) were given corticosteroids for initially misdiagnosed colitis, mainly inflammatory bowel, resulting in rapid progression of disease. Nearly half of all cases underwent surgical intervention, and 25% of cases died, despite all patients eventually receiving treatment with metronidazole. The odds of death did not differ significantly by prior misdiagnosis, co-morbidities, bowel perforation or need for surgery.

CONCLUSIONS AND SIGNIFICANCE

Infection with E. histolytica should be considered prior to the administration of corticosteroids, in particular for patients residing in endemic areas or those with appropriate travel history, especially prior to the diagnosis of inflammatory bowel disease. The development of preventative and treatment interventions are needed to improve outcomes of fulminant disease.

Development of perianal ulcer as a result of acute fulminant amoebic colitis

We report a case of acute fulminant amoebic colitis that resulted in the development of a perianal ulcer in a 29-year-old Japanese homosexual man with acquired immunodeficiency syndrome (AIDS). The patient was admitted to our hospital with a persistent perianal abscess that was refractory to antibiotic therapy administered at another hospital. On admission, we observed a giant ulcer in the perianal region. At first, cytomegalovirus colitis was suspected by blood investigations. Ganciclovir therapy was initiated; however, the patient developed necrosis of the skin around the anus during therapy. We only performed end-sigmoidostomy and necrotomy to avoid excessive surgical invasion. Histopathological examination of the surgical specimen revealed the presence of trophozoite amoebae, indicating a final diagnosis of acute fulminant amoebic colitis. The patient’s postoperative course was favorable, and proctectomy of the residual rectum was performed 11 mo later. Amoebic colitis is one of the most severe complications affecting patients with AIDS. Particularly, acute fulminant amoebic colitis may result in a poor prognosis; therefore, staged surgical therapy as a less invasive procedure should be considered as one of the treatment options for these patients.

Blastocystis spp., Cryptosporidium spp., and Entamoeba histolytica exhibit similar symptomatic and epidemiological patterns in healthcare-seeking patients in Karachi

In this study, we collected data on the incidence of enteric parasites in healthcare-seeking individuals along with their symptoms to quantify the potential roles of factors such as age, sex, and seasonality in infection. We performed analysis to identify factors which could help differentiate parasitic infection from other causes of gastrointestinal illness in a community. The size of the patient population (n = 339), patient selection methodology, collection methods, and statistical analysis followed approaches from similar studies in core clinical journals. Ethical approval was obtained from the University of Karachi's Ethical Review Board. Fecal specimens (n = 339) submitted by symptomatic patients were collected from two clinical laboratories, along with information about the patients' age, sex, and symptoms. We found that symptoms of fever, vomiting, and constipation were 100 % predictive of finding a parasitic infection, while diarrhea was 88 % predictive of a parasitic infection. Gastrointestinal parasite-positive patients reported diarrhea (~60 %), vomiting (~30 %), fever (~25 %) and constipation (~25 %), while parasite-negative patients exhibited a symptomatic profile without fever, vomiting, and constipation. The distribution of symptoms in parasite-positive patients remained relatively invariant regardless of the parasite identified. Blastocystis spp.-mono-infected patients reported a similar profile to patients positive for Entamoeba histolytica/Entamoeba dispar and Cryptosporidium spp. Most parasitic infections exhibited a strong seasonal pattern, with a peak incidence in summer months. Infection by Blastocystis spp. was the most prevalent, and it was the only infection mathematically correlated to rainfall by Pearson's method. We observed no increase in healthcare-seeking behavior following a stressful community event, namely, the attempted assassination of Benazir Bhutto in Karachi. The data suggest that parasitological testing would produce a high yield of positive results when performed on healthcare-seeking patients in Karachi in 2007 with symptoms of fever, vomiting, or constipation and a low yield when performed on patients noting only abdominal pain. Parasitological testing also produces a higher yield on patients seen in summer months.

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.