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21 a b e tuberculosis is often endemic in people from

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21. A, B, ETuberculosis is often endemic in people from developing countries with poor socio-economicbackground. There is often a co-existent pulmonary tuberculosis. While tuberculosis may affectmultiple sites of the intestine, ‘skip lesions’ are characteristic of Crohn’s disease. Narrowing ofthe terminal ileum on a barium study is present in Crohn’s disease as in tuberculosis. However,because of intense fibrosis of the intestine and around draining lymph nodes, the caecum intuberculosis often gets pulled up into the subhepatic position.22. ETuberculosis affects various sites and amounts of the intestine, and therefore all the notedsurgical procedures may be carried out for a patient with intestinal tuberculosis.23. B, DFor patients from developing countries and with poor socioeconomic background, a high index ofsuspicion for tubercular perforation needs to be maintained. Rarely, patients present with featuresof peritonitis and, because of a localised perforation due to adhesions, gas under the diaphragmis often absent. These patients often present very late. While laparotomy is almost alwaysindicated, resection and anastomosis may not be feasible in a septic, undernourished patient withsevere adhesions. In these individuals, resection and exteriorisation as a first step is followed byrestoration of bowel continuity after completion of antituberculous chemotherapy.Amoebiasis24. A, D, EThe disease is common in the Indian subcontinent, Africa and parts of Central and South America.The majority produce no symptoms and amoebic liver abscess occurs in less than 10 per centof patients affected with amoebiasis. The mode of infection is via the faeco-oral route throughcontaminated food or water.25. B, C, DThe cysts hatch in the small intestine and large numbers of trophozoites are released andcarried to the colon. Here they attach themselves to the mucosa and may penetrate to cause
PRINCIPLES52flask-shaped ulcers, or invade the portal vein to be carried to the liver. Here they affect the rightlobe in 80 per cent of cases, the left lobe in 10 per cent and the rest are multiple. A large numberin the intestine form cysts which are passed in stool that can infect other humans as well.26. A, B, D, EThe clinical features are all those of an amoebic liver abscess. The CT scan features of ahypodense lesion with irregular walls showing peripheral enhancement are characteristic ofan abscess. The fluid is chocolate-coloured, odourless and ‘anchovy sauce’-like fluid, a mixtureof blood and necrotic liver tissue. This fluid becomes smelly when secondarily infected. Theabscess is usually high in the diaphragmatic surface of the right lobe. This may cause pulmonarysymptoms. Untreated abscesses are likely to rupture.

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