PARASITOGENIC SURGICAL DISEASES

About 150 kinds of worms and their germs can parasitize in a person’s organism. Only some of them have value in surgical practice.

Echinococcosis is a disease of animals and people, caused by echinococcus. In home animals — sheep, goats, cows, pigs — it parasitizes as a blister form, and dogs, wolves, jackals, foxes that eat these animals, are infected and become a source of infection for people. Echinococcosis is spread in zones of intensive animal industry.

The worms’ eggs, after they have got into the person’s intestines, release from their membrane, which ejects the germ and penetrates the intestinal wall, and later — the blood and lymphatic vessels. By the v. porte system, it is brought to the liver, where up to 60–70% of the parasites start to develop. Others penetrate into the large blood circulation and lungs where up to 10–15% of the germs are held. Less often the parasite gets in the left auricle and ventricle, then again in the large blood circulation where the germs can be taken to any organ: kidneys, spleen, muscles, thyroid gland, the genitals, etc. Thus, the liver is most often damaged — 75%, lungs — 15%, less often other organs and tissues.

At the fixation place the germ looses its hook and starts to develop in a new form — hydatidosus, or blister. Echinococcus blister is a cystomic hollow formation. The cyst has a chitinous membrane filled with a transparent white or opalesced liquid. The blister grows slowly — in 1 month the diameter increases by 1 mm. The cyst can reach enormous sizes. Increasing, it compresses and atrophies the surrounding tissues, which, in its turn, causes aseptic productive inflammation and the formation of a fibrous capsule.

On the internal surface of the chitinous membrane, in a so-called germinal layer, new (daughter) blisters and scolex are formed. In the daughter blisters new generations of scolex — daughter blisters develop. The formation of daughter blisters can occur on the external surface of the chitinous membrane by their budding and the formation of a new cyst. Each of the numerous blisters and isolated scolex are potentially dangerous concerning infection. If during an operation the contents of the blister get on tissue, it is necessary to expect the spread of the process. Independent destruction of echinococcus is seldom marked — suppuration of the cyst, calcareousness of its capsule.

There are no pathological signs of an echinococcus cyst, frequently it reaches enormous sizes asymptomatically, grows very slowly for 10–20 and even almost 40 years.

The clinical course of echinococcus disease has three stages:

Asymptomatic — begins with the larva (oncosphere) gettinginto tissue and till the occurrence of the first clinical displays.

Stage of clinical displays — predetermined by the pressure ofthe cyst on the surrounding tissues and organs.

Stage of complicated echinococcosis: perforation, breaking ofthe cyst into the hollow organs, abdominal cavity, pleural cavity. All this is accompanied by the pain syndrome. In case of suppuration of the echinococcus cyst, at the site of swelling the pain amplifies, fever, intoxication, disgusting sweating are observed.

If the cyst compresses vital organs ascites, mechanical jaundice, parasthesia can occur. With the breaking of the cyst into the bronchial tube — a lot of sputum is released containing echinococcus blisters and fragments of the chitinous membrane. With damage to the bones pathological fractures, dislocations, infringements of joint functions, formation of fistulae are observed.

Diagnosis. Isotopes accumulation defects in the zone where the cyst is located are determined on the scanning image. Radiologically one or multichamber formations, sometimes with a level of liquid or site of calcification in the damaged zone appear. Auxiliary displays are enlargement, shift, and deformation of the organ.

Angiographically the vascular pattern becomes vague till the avascular zones is observed. During ultrasonic exam the formation, filled with liquid, is determined. During the computer exam — cyst formations in the organ.

Laboratory: eosinophilia is revealed in the blood, positive specific skin allergic test — the Casoni’s test (0.2 ml diagnosticum are entered). However, in 10–20% of the patients this reaction is absent.

Recently the Casoni’s test is not used because of pronounced sensitization of an organism (it can even cause anaphylactic shock) and low diagnostic value (in 20% of the cases there can be erroneous results). Today in diagnosis, the agglutination reaction (the Fisherman’s reaction), safe and informative, is applied.

Treatment of echinococcosis is mainly surgical — radical echinococcectomy, removal of the cyst with the capsule or with a part of the organ. If it is impossible to remove the parasite, an open echinococcectomy, preventing the spread scolex into the tissue, is conducted. The contents are deleted; the chitinous membrane and a part of the fibrous membrane are incised. The cavity is processed with antiseptics having a specific action (formalin, hypertonic solution of sodium chloride with hydrogen peroxide) and drainage. In order to reduce the cavity, the capsule is sometimes sutured.

Human alveococcosis is a disease with primary damage of the liver by larva (alveolar or multichamber echinococcosis).

Basic hosts for the helminth — arctic fox, fox, dog, cat (the intestines are parasitized by the stitch helminth).

The larval stage takes place in the organism of rodents (mice, muskrats) and humans. Arctic foxes, foxes, dogs, cats are infected when eating mice containing the parasite in their intestines; the parasite reaches sexual maturation and release oncospheres. A person is infected by using foods and water, while removing infected animal’s skin, as well as during contact with pets — dogs, cats. From the intestines, the larvas get into the liver where they grow. Metastasing occurs in the lungs and brain. By their appearance, the nodes remind porous cheese, and small cavities with putriform contents are observed in their layer. In case of suppuration abscesses in the liver, cholangitis arise. The disease develops for a long time. Primary signs of the disease can be cholangitis, mechanical jaundice, metastasises of alveococcosis in the lungs and brain. Tumourous formations in the liver can reach significant sizes therefore the liver increases, becomes dense, but pain is not present. In order to establish the diagnosis allergic tests are taken into account (eosinophilia, the Casoni’s test and hemagglutination with latex, which yields positive results in 70–75% of patients).

For diagnosis roentgenography, angiography, tomography, radionuclide scanning, echography, computer tomography, as well as roentgenography of the thorax and neurologic examination are used.

Treatment: hepatic resection together with the node is conducted, other tissue is infiltrated with antiparasitic solutions (0.1% solution of trypaflavin — 20 ml). Levamisol, mebendazol are used in antiparasitic therapy.

Preventive measures of echinococcosis, alveococcosis consist in strict following the epidemiological mode, the infected organs of animals should be eliminated. It is necessary to prevent contact with dogs, especially for children who do not understand the danger of infection and the consequences. Veterinary supervision for service dogs is important.

Ascariasis is intestinal helminthiasis. The causative agent: round ascaride helminth; source of infection — people. The worms’ eggs, excreted with excrements, mature in the ground. With polluted vegetables, fruit, dirt they enter the digestive tract. Through the mucous membranes of the small intestines the larvae go deep into v. porta and penetrate the liver and further get to the lesser circulation. In the lungs the larvae leave the vessels, go deep into the bronchioles, then into the bronchial tubes, pharynx, with sputum enter the stomach and intestines where they reach sexual maturity. Ascariasis can lead to complications, which require surgical treatment.

Intestinal impassability develops with the obstruction of the intestinal orifice by parasites. The clinical picture is similar to obturation obstruction. In case of inefficiency of conservative treatment, surgical intervention is conducted: they separate the ball of ascaride and move them to the orifice of the large intestine with following dehelminthization.

Ascariasis of appendicitis has no specific displays. Ascarides in the appendix are an operational find.

Ascariasis of the liver and biliary ways is observed seldom, the parasite gets through the papilla and cause congestion of bile secretion. The clinical picture is characterized by mechanical jaundice, purulent cholangitis, hepatic abscesses. Retrogradic cholangiography, ultrasonic exam, computer tomography assist in determining the diagnosis.

Treatment is surgical: cholecystectomy, choledochotomy, removal of the ascarides and external drainage of the biliary ways, opening and draining the hepatic abscess.

Ascariasis of the pancreas develops when ascarides fill the bile excretion tract. It appears as chronic indurative or acute pancreatitis.

During ascaride perforation of the GIT organs the clinical picture of peritonitis develops.

Postoperative complications of ascariasis are predetermined by the migration of ascarides after the operation.

Taking into account the severity of surgical complications of ascariasis, inspection of patients on the eve of an elective operation is indicated; in case of revealing ascariasis dehelminthization is conducted.

Opisthorchosis is helminthiasis of the hepatobiliary systems and pancreas. The causative agent of opisthorchosis is siberian or feline opisthorchis. Basic hosts are people, cats, dogs, foxes, white foxes. The intermediate host is carp fish (ide, roach, bream, etc.).

Helminths’ eggs get in to water with excrements and are swallowed by mollusks, where they turn into larva which enter the water and actively get in the body of fish, where encyst in the muscles and the hypodermic tissue. The use of unthoroughly fried and salted fish that contain helminth germs, results in the infection of a person. In the liver the helminths cause the development of necrotic and dystrophic processes. The most often complications — purulent cholangitis with the formation of hepatic abscesses. Chronic opisthorchosis frequently results in liver cancer. Damage to the pancreas by opisthorchosis can entail acute pancreatitis, and chronic damage leads to pancreatic cancer. Pathological symptoms are not observed, therefore the diagnosis is determined on the basis of clinical and specific methods of examination, the presence of helminth eggs in the duodenal contents.

Treatment. Dehelminthization is conducted on the eve of the operation and after it. Chloxilum (chloroparaxinolum) is appointed according to a special scheme as an antihelmintic means.

Amebiasis is a disease caused by amoeba with prevailing ulcer damage to the large intestines, possible hematogenous dissemination of the agent into the internal organs (the liver, the lungs, the brain, etc.) with the development of abscesses. The disease is spread in tropical countries. The basic source of infection is people who excrete the cysts of amoebas with feces. The cysts of amoebas which get in the digestive tract result in the development of the disease. In the large intestine, the amoeba get in the submucous layer, necrosis (ulcers) develops around them. Through the vessels, the amoebas get in the blood and spread into other organs (liver, lungs, etc.) where they cause the formation of abscesses. Ulcers in the intestines can perforate causing peritonitis.

The clinical picture of amebiasis of the intestines is similar to the picture of bacterial dysentery; it is characterized by general symptoms of intoxication (fever, weakness, indisposition), often defecation with slime and blood.

The diagnosis is confirmed when amoebas are revealed in feces, and with the help of specific serological reaction. In case of intestinal perforation the diagnosis is determined on the basis of the clinical picture of peritonitis, but with severe intoxication symptoms of irritation of the peritoneum are pronounced poorly. With gangrene of the intestines they resort to its resection with the formation of colostoma. If the opening can be sutured, they do it and nothing more. Sometimes amoeboid colitis comes to an end with the development of amoebic granuloma — around the ulcer an inflammatory infiltration is formed. By the morphological structure this is chronic productive inflammation with eosinophilic infiltration and necrosis of cells. The cecum and the ascending colon are more often damaged. Colonoscopy and determining amoebas in stool play an important role in diagnosis. Amoebic granuloma results in obturation obstruction. Treatment is conservative. In case of inefficiency of conservative treatment and complications they resort to surgical treatment.

Appendicitis during amebiasis is predetermined by the development of specific ulcers. Characteristic attributes are not present.

The disease can have signs of intestinal bleeding.

Treatment is conservative with obligatory application of antiamebic preparations. Surgical treatment is introduced only with vital indications (in case of inefficiency of therapeutic means), as well as resection of the bleeding intestine is conducted.

Hepatic abscesses is the most often complications of amebiasis, observed in 2–10% of the cases. These abscesses do not have a pyogenic membrane because their contents irritate the tissue. The contents is pus with a haemorrhagic coloring without an odour. The accompanied secondary infection gives an odour to the purulent contents and change color. The clinical picture is similar to hepatic abscesses: intoxication, pain, enlargement of the liver, icterus. Radiological, radioisotope exam, ultrasonic and computer tomography, amoebas presence confirm the abscess diagnosis.

Treatment should be complex and include antiamebic, antibacterial and disintoxication therapy. The main method of treatment is punctuation with the removal of the contents and introduction of antibacterial and antiamebic preparations. With its inefficiency they resort to operative intervention (opening, drainage and corresponding conservative treatment).

Metastasing of amoebas to the lungs causes pneumonia and abscess of the lungs. The clinical picture is similar to that one for any microflora. To treat the abscess they apply bronchial sanation, with the absence of a positive effect, a puncture of the abscess with the aspiration of the pus with introduction of medical products is carried out.

Amoebic abscess of the brain is observed seldom. Treatment: antiamebic and antibacterial preparations, and removal of the abscess together with the capsule.

With the presence of all kinds of amebiasis complex treatment with obligatory application of antiamebic means is carried out: Emetinum, metronidazole (trichopol, flagyl), chingamin (delagil) according to certain schemes stated in the course of the infectious diseases. Preventive measures of surgical complications of amebiasis consists in general epidemic actions and active treatment of patients with amebiasis of the intestines.

Filariasis is the general name for helminthiasis caused by filaria. Wuchereriosis and brugiosis have got the greatest value in surgery. They are characterized by damage to the lymphatic system. Filariasis is widespread among the population of tropical countries: Africa, South America, Southern Asia. The helminthes parasitize the lymphatic vessels and nodes. Their larvas are in lymph and blood, source of invasion — sick person, monkey, dog, and cat. The larvae are transmitted by mosquitoes of the family Anophelex, Kulex, etc. The development of microfilariasis lasts for 8–35 days. The growth and development of the helminths in the lymphatic vessels results in infringement or full termination of lymph flow in vessels. Lymphostasis results in elephantiasis.

Clinical picture. Fever, headache, general weakness. Lymph nodes are dense, painful, lymphatic vessels look like dense cords of red color, painful during palpation.

Lymphangitis spreads from the proximal parts to the distal. The primary focus of inflammation is absent. Lymphangitis precedes the increase of the axillary and inguinal lymph nodes. At different sites of the body, a stratching rash like urticaria, appears. Gradually the inflammation decreases, and in some months or years renews. In 2– 7 years the secondary stage — lymph vessels varicosis, lymphostasis, ruptured vessels, lymphorrhea begin. The lymph nodes are sharply enlarged. The accompanied secondary infection results in the development of phlegmons, abscesses. The third stage of the disease is characterized by development of elephantiasis, more often on the legs, breast, and vulva.

The diagnosis is determined on the basis of the clinical picture and revealing microfilaria in the blood.

Treatment. During the initial stages: antiparasitic therapy — ditrasine citrate (baroside, tetrazine) a dose of 0.1 g three times a day for 7–10 days. The control over treatment is carried out if the microfilarias are found in the blood. If necessary, the treatment is repeated. With the presence of secondary infection antibacterial therapy is appointed. Abscesses, empyema pleuras, peritonitis are subject to surgical treatment. With elephantiasis the changed tissue is completely incised with following dermaplasty. Surgical treatment is necessary even if the parasites are not found in the blood. If they are revealed again, dehelminthization and then surgical treatment are conducted.

Paragonimiasis is a disease caused by helminths which damage mainly the lungs and brain of a person. It is observed in the Far East (China, Japan, Korea, Philippines), as well as in Africa, South America. The causative agent: trematode. Basic host: people, cats, dogs, pigs, tigers, mongoose. Additional hosts: fresh-water crabs and crayfish.

The eggs excrete with sputum, less often with excrements, get in to the water, in 4 weeks larva come out, penetrate into the body of mollusk and turn into cercaria. The cercaria leave the mollusk and penetrate the body of crabs or crayfish where encystment occurs. The usage of crabs or crayfish which are insufficiently thermally processed results in infection. In the small intestine immature paragonimuses leave metacercaria and, perforating the intestinal wall, penetrate into the free abdominal cavity, move towards the diaphragm and through it get into the lungs, where they settle and mature. Around the parasite inflammation takes place with growth of connective tissue cysts, filled with pus, parasites and their eggs. Retropulmonary forms of paragonimiasis result from hematogenous metastases from the lungs in case of destruction of pulmonary tissue and vessels. In the brain, multiple cysts are observed.

The clinical picture of paragonimiasis is determined by the period of deepening, migration and development of the parasite. First the abdominal syndrome is observed, characterized by enteritis, phenomena of acute stomach, acute hepatitis. The rooting of the parasite in the lungs has clinical displays, such as bronchopneumonia, acute bronchitis, haemorrhagic pleurisy. Later there are such symptoms as pain in the chest, paroxysmal cough in the morning with purulent sputum, pneumorrhagia, fever. During auscultation rattles are determined, more often wet. Frequently pulmonary bleedings, dyspnea occur. Intoxication causes tachycardia, dystrophic changes in the myocardium, neurologic semiology — headache, dizziness, fatigue.

Paragonimiasis of the brain appears as meningitis or meningoencephalitis which develops against a background of pulmonary paragonimiasis. The basic symptoms — significant headache, convulsive epileptic attacks with full or partial loss of consciousness, dizziness, narrowing of the visual field and decrease in visual acuity. Laparoscopic or during laparotomy haemorrhagic, fibrinous and fibrinopurulent effusion is marked; during microscopic exam immature forms of helminths are observed. It is necessary to take into consideration the anamnesis — the use of meat, crabs, crayfish, paragonimiasis dwelling in the epidemic place. These patients’ sputum has a chocolate or bright red color, viscous; microscopic exam reveals a congestion of parasites eggs. In the blood: eosinophilia, frequently lymphocytosis, hypochromic anemia. The intradermal test with special antigene is positive, great itching, lymphangitis. Radiological exam reveals more often small or large blister-like, linear, ring-shaped, diffuse shadows in the middle area of the lungs.

With paragonimiasis of the brain the clinical picture, brain symptoms, laboratory exam, epidemiological parameters allow to determine the correct diagnosis. The topographical diagnosis is determined on the basis of radiological and angiographic investigations.

Treatment is conservative — Bithiolum internally for 10 days in the dose of 30–40 mg/kg of weight a day 2–3 times. Inefficiency of conservative treatment, repeated pulmonary bleedings, progressing exhaustion, and constant pneumorrhagia are indications to surgical treatment (pulmonary resection). With damage to the brain, indications for surgical treatment (removal of the cyst) are increase in mental and neurologic symptoms, inefficiency of conservative treatment.Fascioliasis is helminthiasis with damage of the hepatobiliary system. It is observed in France, Cuba, in our country it is rare. The causative agent: fasciola hepatic. Constant host: people, big and small horned cattle, pigs, horses. Intermediate host: mollusk, small leaches. From the helminth’s eggs which are in water, larvae leave and penetrate the mollusk. The larva which develops in the mollusk’s body enters the water, where it encapsulates. From the reservoir the larva gets into an organism and locates in the biliary tract, the gallbladder, rarely in other organs. Fasciola hepatic which parasitizes in the biliary tract, damages the epithelium. Such conditions are favorable for the penetration of purulent microflora, which, in turn, causes cholecystitis, hepatic abscesses, cholangitis, mechanical jaundice, which require surgical treatment. Patients with fascioliasis display attributes of an inflammatory disease of the gallbladder and channels. During an operation on the biliary tract and in the cavity of an abscess it is possible to find fasciola hepatic. Surgical intervention is carried out traditionally, antiparasitic treatment is carried out with the help chloxil or emetine hydrochloride.