GASTROENTEROLOGY Co py r i~h t
© 1971 by The Williams & Wilkin s Co.
Vol. 61. No.6 Printed in U.SA.
CASE REPORT
EXTENSIVE STENOSIS OF THE COLON AND FISTULA FORMATION FOLLOWING AMOEBIC DYSENTERY G. DouGLAS CAIN, M.D., FRED J. WoLMA, JR., M.D., AND MARCEL PATIERSON, M.D. Division of Gastroenterology, Department of M edicine, and Department of General Surgery, University of Texas M edical Branch, Galveston, Texas
Amoebic dysentery with fibrotic stenosis and fistula formation is unusual. This case illustrates severe stenoses of the colon and fistula formation after prolonged therapy for amoebic dysentery. Surgical intervention was necessary. Early diagnosis and prompt therapy might have prevented these complications.
Case Report
nent findings were a slightly distended and exquisitely tender abdomen with very few M. S. is a 27-year-old white housewife. In February, 1970 she had the sudden onset of bowel sounds. At proctoscopy, the colon was bloody diarrhea. There were no prior gastroin- friable and edematous with no normal-aptestinal symptoms and she had not traveled pearing mucosa. Aspirates from the surface outside Texas for many years. An aunt and revealed active trophozoites of Entamoeba hisuncle, returning from Mexico, had visited her tolytica . A rectal biopsy showed amoebae. Admission laboratory data revealed a hemoin January and were ill with diarrhea that subglobin of 10.9 g per 100 ml and a hematocrit of sided spontaneously. The diarrhea increased to 12 stools daily and 32%. The total white count was 24,000 with she lost 25 lb. She saw her family physician and 10% neutrophils, 75 % stabs, 8% lymphocytes, in June, 1970 had an exploratory laparotomy. and 2% monocytes. Blood chemistries, liver The colon was found to be markedly dilated function tests, and scan were normal. Serum from the cecum to the splenic flexure with a protein electrophoresis revealed an albumin of purulent exudate oozing from the surface. She 1.28 g per 100 ml with normal globulins. Stool had a simple closure and was referred to our cultures were negative for pathogens. An im munodiffusion test for amoebiasis was positive.' hospital. On admission, she was dehydrated, ob- (The control serum, K-3205, and antigen lot tunded, and had a constant foul-smelling 12-A was kindly supplied by Dr. George R. bloody rectal discharge. She had a fever of 101 Healy of the Parasitology Section, CommuniF, a blood pressure of 90/60, a regular pulse of cable Disease Center in Atlanta.) Flat and 130 per min, and weighed 110 lb. Other perti- erect abdominal films revealed a markedly dilated colon with some small bowel dilation that improved during her hospital stay. She was Received April 8, 1971. Accepted June 26, 1971. treated with emetine hydrochloride subcutaneThis work was supported in part by the Depart- ously for 5 days, and chloroquine hydrochloride ment of Health, Education, and Welfare Institutional and diiodohydroxyquin (Diodoquin) were given Grant 1801 FR 05427 09. by mouth. Address request reprints to: Dr. Marcel Patterson, She improved rapidly and was discharged Department of Medicine, University of Texas Med- July 13 to take diiodohydroxyquin and chloroical Branch, Galveston, Texas 77550. quine for 2 weeks. The authors wish to thank the CDC in Atlanta for She failed to keep her follow-up appointment supplying the amoeba antigen for the immunodiffu- but returned in September with the complaint sion tests and for performing the hemagglutination of occasional right lower quadrant pain. She test. weighed 113 lb . Abdominal films, stools, and 898
December 1971
CASE REPORT
blood studies were normal aside from a serum albumin of 2.5 g per 100 ml. She returned on October 16 with increasingly right lower quadrant cramping discomfort associated with a "knot" in this area that would disappear resulting in relief of pain. At proctoscopy, a tight stricture 4 em from the anal verge was seen. The mucosa was normal. A barium enema showed a stricture in this area along with stenosis of the transverse colon and two strictures in the upper descending colon. (fig. 1). She was readmitted to the hospital. Laboratory studies were normal aside from a serum albumin of 2. 7 g per 100 ml. Repeated stools for parasites were negative. The amoeba immunodiffusion test remained positive and a rectal biopsy showed amoebae. She was discharged on diiodohydroxyquin and chloroquine for 3 more weeks and tetracycline for 10 days. A 2-week course of metronidazole (Flagyl) was added on the basis of reports of its usefulness in amoebiasis, 2 although this drug is not approved for this disease in the United States. She was seen again on December 4 with little improvement in her symptoms except that she had her first menses since the onset of her ill-
FIG.
1. Extensive stenosis of the entire transverse
colon and two stenotic areas in the upper descending colon are present (arrows).
899
ness. Laboratory studies were normal. A barium enema showed little change. A rectal biopsy revealed chronic inflammation. The above amoebicidal regimen was repeated. On December 25, she was admitted as an emergency with severe abdominal pain. On examination she was acutely ill and doubled with abdominal cramping. The abdomen was tender but no rigidity or rebound was present. Flat and erect films of her abdomen were normal. A barium enema showed the same areas of stenoses as before and an enterocolic fistula was seen at the midtransverse colon (fig. 2). Laboratory studies were normal. The immunodiffusion test for amoebiasis was positive and the amoeba hemagglutination test was positive to a dilution of 1: 1024. On December 29, she had a exploratory laparotomy with lysis of adhesions, repair of the enterocolic fistula, and resection of the colon from the terminal ileum to the midsigmoid. A permanent ileostomy was constructed. Her postoperative course was uneventful. At discharge, she weighed 99 lb. The resected colon had ulcerations of the mucosa and diffuse submucosal fibrosis involving the muscularis. Amoebae were seen in
FIG. 2. An enterocolic fistula has developed in the midtransverse colon. The rectal stenosis is apparent (arrows) . The strictures in the transverse and upper descending colon have not changed.
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Vol. 61, No.6
CASE REPORT
the ulcerated areas. The transverse colon was a fibrotic tube with the lumen measuring 1.5 em. One month after discharge, she had gained 17 lb and had no complaints. On physical examination it was noted that the rectal strictute was more pliable. The immunodiffusion test for amoebiasis was negative. Three months later she continued asymptomatic and had gained another 28 lb.
Comments In 1955, Holguin and Patterson 3 observed that E. histolytica infestations were decreasing in Texas probably as a result of a more urban population with better sanitation. A prospective analysis of 268 stools revealed an incidence of 2.7%. From November 1968 to January 1971, 5305 stools were examined at this institution. E. histolytica was found in only 17, an incidence of 0.32%. Even this figure is false since some stools were duplicates. The lack of reports in recent literature suggests that stricture and fistula formation following amoebic dysentery is rare. Stein and Bank• reported fibrotic stenosis of the rectum 1 month after partial colectomy and amoebicidal drugs. Also, an enterorectal fistula occurred but cleared while on antibiotics. Bassler 5 observed stricture formation in the sigmoid colon of a patient with amoebic dysentery. Eventually the stricture resolved after 3-year treatment. Gelfand 6 described amoebic dysentery in Europeans and Africans living in Rhodesia. He noted thickening of the mucosa as a result of edema, but no fistulas or stenosis. Tchang 7 performed barium enemas on 26 patients with amoebic colitis and found no strictures or fistulas. Amebomas may present as a stenosing lesion. 8 • 9 Reeder and Hamilton 10 reviewed their barium enema examinations in 25 patients with amoebiasis. Fifteen had amebomas and all had ulcerations. Amebomas may simulate carcinoma but are usually longer than a carcinoma. Kark et al. 11 found 24 anorectal strictures associated with amoebiasis. These strictures usually occurred 6 to 10 em from the anal
verge. None of these lesions were as diffuse or extensive as the fibrotic stenoses seen in our patient. Complications of amoebic dysentery include metastatic disease, toxic megacolon, bowel obstruction with amebomas, perforation leading to peritonitis or sinus tracts and fistulae , intussusception, 10 and, with our case, severe extensive fibrotic stenoses. Our unusual case fortifies the adage that persons with gastrointestinal complaints should be examined for parasites. Additionally, this patient illustrates the value of proctoscopy, rectal biopsy, and the necessity of a barium enema even though stools become negative for E. histolytica. Long term amoebicidal therapy is planned for this patient with the hope that the stenosis in the rectum will be relieved and an ileocolon anastomosis can be done. 5 REFERENCES 1. Katcher E, Miranda M, de Salgado VG: Correlation of clinical, parasitological, and serological data of individuals infected with Entamoeba histolytica . Gastroenterology 58:388-391, 1970 2. Powell SJ, MacLeod I, Wilmot AJ, et a!: Metronidazole in amoebic dysentery and amoebic liver abscess. Lancet 2:1329-31, 1966 3. Holguin AH, Patterson M: A survey for internal parasites at Galveston, Texas. Med Rec Ann 51 : 887-888, 1959 4. Stein D, BankS : Surgery in amoebic colitis. Gut 11:941-946, 1970 5. Bassler A: Intestinal obstruction due to amebiasis. JAMA 106:1965-1968, 1936 6. Gelfand M: The clinical features of E. histolytica infection in Europeans and Africans in Rhodesia. Cent Afr J Med 16:180-184, 1970 7. Tchang S: Amebiasis in Northern Saskatchewan: radiological aspects. Canad Med Ass J 99:688695, 1968 8. Ruiz-Moreno F: Amebic granulomas of the colon and rectum. Dis Colon Rectum 6:201-205, 1963 9. Levine SM, Stover JF, Warren JG, et a! : Ameboma, the forgotten granuloma. JAMA 215:14611464, 1971 10. Reeder MM , Hamilton LC : Tropical diseases of the colon. Sem Roentgen 3:62-80, 1968 11. Kark AE, Epstein AE, Chapman DS : Nonmalignant anorectal strictures. Surg Gynec Obstet 109: 333-343, 1959