Granuloma of the cecum due to amebas

Granuloma

of the Cecum

COL. FRANK H. VAN WAGONER,

Due

to Amebas

Fort Belvoir, Virginia, AND ROY E. CAMPBELL, M.D., St. Augustine, Florida

M.c.,

From tlJe Surgical Service, 97th General Hospital, Frank-

episodes of diarrhea or constipation. There had been a weight Ioss of approximateIy 23 pounds during the previous six months. She had spent 1947 and 1948 in Europe and had been there again in September, 1953. Aside from these visits, she had remained in

furt, Germany.

T

HE probIems of amebiasis are not confined to the epidemic or even the endemic areas. It has been estimated by Faust’ that as many as 20 per cent of the popuIation of the United States are infected by amebas. Ochsner and DeBakey2 estimate the number of infected peopIe to be between 20 and 23 miIIion. Since a great many persons have recentIy returned from Korea where amebiasis is sometimes epidemic in proportion, it seems IikeIy that this number may even increase. The pathoIogy and symptomatology produced by amebiasis approach syphiIis in variation, and the compIications of amebic infection require a great variety of surgicaI procedures. AIthough onIy a few of the chronic cases of amebiasis show spread outside the intestina1 tract, it is beheved that a report of two cases presenting one of the Iess frequent forms of the disease shouId be worth whiIe. GranuIomas of the Iarge bowe1 caused by amebic infection have been reported infrequentIy since 1900 when KartuIis and NothinageI3 first recorded having seen one in which the Iarge bowe1 waI1 was 22 cm. thick. KIeitsch4 reported three such Iesions in a series of IOO consecutive patients admitted with some compIication of amebiasis, and Freeman and CIiveb reported three simiIar cases in their series of parenchyma1 amebiasis.

FIG. I. Case I. Preoperative barium enema. (Taken by U. S. Army Medical Dept.) the

United

States,

Iiving

in CaIifornia

from

1948 to 1953. On physica examination she weighed 116 pounds; her temperature, puIse and bIood pressure were normaI. She was thin and seemed to be chronicaIIy iI1. Positive physica findings were limited to the abdomen where an iI defined, sIightIy tender mass couId be palpated in the right Iower quadrant just IateraI to the umbiIicus. It was freeIy movable and was approximateIy 3 by 6 cm. in size. P. P. D., was I pIus. A seroIogy test was negative and urinaIysis was normal. Six stoo1 examinations were negative for ova and para-

CASE REPORTS

CASE I. A thirty-five year oId housewife was admitted to the hospita1 on February IO, 1954, with a chief compIaint of intermittent abdomina1 pain of severa years’ duration with gradua1 increase in frequency and severity. nausea and vomiting AbdominaI soreness, were sometimes associated with the pain. On the day prior to admission the pain was IocaIized in the right upper quadrant with some radiation to the back. The patient noted no change in bow-e1 habits, nor had she had any 1027

American

Journal

of Surgery,

Volume

00, December,

195,~

Van Wagoner

FIG. 2. Case I. Gross appearance MedicaI Dept.)

and CampbelI

of operative specimen. (Taken by U. S. Army

sites. HemogIobin, serum bilirubin, non-protein nitrogen, total protein and A/G ratio were normaI. Repeated white bIood counts reveaIed with 4 to Ieukocytosis of 14,000 to 13,000 3 per cent eosinophiIs. A barium enema (Fig. I) reveaIed a markedIy deformed cecum with Ioss of mucosa1 pattern which aIso extended several centimeters up the ascending coIon and distorted the mucosa in the termina12 or 3 cm. of iIeum. It was the opinion of the roentgenoIogist that this was an inflammatory process; however, maIignancy couId not be excIuded. Chest x-ray, gaIIbIadder series and intravenous pyeIogram were norma.1. On February 26, under spina procaine anesthesia, exploratory Iaparotomy reveaIed a movabIe, 7 cm. mass invoIving the cecum and termina1 iIeum and invading the mesentery. On paIpation it was hard and noduIar, with retraction in some areas. A smaI1 sateIIite noduIe on the anterior surface was biopsied and frozen section done, with a resutting report of hyperpIasia. The cIinica1 opinion was adenocarcinoma. Therefore right coIectomy with iIiotransverse coIostomy was performed. The postoperative course was uneventfu1. PathoIogic section reveaIed the Iesion to be an amebic granuloma with numerous amebas found in the specimen. Emetine hydrochIoride was administered immediately and continued

for eight days. During this time the patient remained asymptomatic. ChIoroquine and carbarsone@ were given for a fifteen-day course. StooIs were again checked for amebas, and in one specimen of four obtained whiIe the patient was on amebicide, Endamoeba histoIytica cysts were found. The patient was discharged from the hospita1 on March 12th and has remained weI1. Figure 2 shows the gross specimen removed at surgery. CASE II. A twenty-seven year oId white man was admitted on September 17, 1933, with a two-day history of generaIized abdomina1 pain and anorexia. The pain was cramp-like and intermittent but became Iocalized in the right Iower quadrant. There was no nausea or vomiting. Past history was significant in that the patient had miId diarrhea of one week’s duration whiIe in Korea in 1950; this had responded to antibiotics. On physica examination the patient’s temperature was 99O~. There was tenderness in the right Iower quadrant of the abdomen with muscIe guarding, but no rebound or referred tenderness. Recta1 tenderness was present on the right. AI1 other physica findings were within norma Iimits. The white bIood count was 17,950 with 75 per cent polymorphonucIears, 17 per cent Iymphocytes, 3 per cent eosinophiIs and 3 per cent stab forms. Hemo1028

GranuIoma

of Cecum

globin was 14.4 gm. A seroIogy test was negative and urinaIysis was normal. It was believed that the patient had acute appendicitis. However, at operation shortIy after admission a cecaI mass measuring approximateIy 8 by 6 cm. was found which extended into the mesentery. It was impossibIe for the operator to teI1 whether this was an inflammatory or a neopIastic Iesion. The appendix seemed norma and so was not removed. Preparation of the Iarge bowel was started and a barium enema given which showed changes suggestive of an inflammatory Iesion in the termina1 iIeum and the ceca1 area. (Fig. 3.) MaIignancy couId not be excIuded. The patient was again expIored and a mass, which appeared grossIy to be inflammatory, was found attached to the cecum and ascending coIon. It was fixed to the posterior waI1 of the bowe1 and extended into the IateraI peritonea1 reff ection and into the mesentery of the coIon where severa large, firm nodes were paIpated. A part of the Iesion was excised from the waI1 of the cecum aIong with the appendix. FoIIowing operation the patient’s condition was satisfactory except that he had Iost a tota of 20 pounds since the onset of his iIIness. The pathoIogic report reveaIed findings consistent with a non-specific infIammatory process showing acute and chronic infIammation, with eosinophiIs being particuIarIy conspicuous. Repeated stoo1 examinations were negative for ova or parasites. GastrointestinaI series, eIectrocardiogram and proctoscopic examinations were normaI, as were Iiver function tests. On October I Ith he began to compIain of vague right upper quadrant pain which occasionaIIy radiated to the shoulders and became increasingI?; severe. His temperature ranged between 100” to 103~~. and the white Chest x-ray and blood count was 17,150. fluoroscopy were negative. On examination there were marked tenderness and rebound tenderness in the right upper quadrant of the abdomen. On October 13th an abscess in the superior surface of the right Iobe of the Iiver was drained through the right flank. The pus contained amebas. In addition, subsequent stoo1 specimens aIso reveaIed E. histoIytica. Chloroquine was therefore administered, and Iater vioform with emetine hydrochIoride irrigation of the Iiver abscess. After a stormy postoperative course he recovered enough to be returned to the Zone of Interior. On foIIow-up report made December 5th the patient was 1029

Due to Amebas

FIG. 3. Case II. Preoperative barium by U. S. Army MedicaI Dept.)

enema.

(Taken

asymptomatic with continued improvement his genera1 condition.

in

COMMENTS

The two cases of amebic granuioma recorded herein demonstrate the diffIcuIty in diagnosing this disease. In each case the patient was expIored with a preoperative diagnosis of carcinoma. This has been the most common preoperative diagnosis in a11 cases recorded in the literature. Indeed, it is sometimes impossibIe to differentiate between the two when seeing the Iesions grossIy. In Case II the diagnosis wouId not have been made even from biopsy, had the patient not developed amebic abscess of the liver. Between surgical attacks the biopsy slides were repeatedIy reviewed and stoo1 examinations were done on numerous occasions without making the diagnosis. It is suspected that many non-specific granulomas of the coIon upon which surgery is performed are due to ameba, even though the organism may not be found. Freeman and CIive5 recommended that a trial of antiamebic therapy be carried out on a11 patients with masses of the coIon suspected of being parenchyma1 amebiasis. This poIicy may be dangerous when one considers the difficulty in suspecting ameboma in patients

Van Wagoner with no history of amebiasis and the danger of aIIowing carcinoma of the coIon to metastasize whiIe waiting for a chronic inflammatory mass to subside. Such a case was reported by Morgan.6 A patient who had amebic uIcers in the rectum and a mass in the cecum preoperativeIy diagnosed and treated as ameboma turned out to have carcinoma of the cecum. Some amebic granuIomas of the coIon do not disappear even on antiamebic therapy and require subsequent resection. Such cases have been reported by Gunn and Howard? Lindskog and WaIters,a and Hawee AIso, many carcinomas show some diminution in size and some improvement in x-ray findings after the secondary infection has been cleared. If the estimates of the number of ameba carriers is anywhere near correct, a Iarge number of carcinomas of the coIon wiII undoubtediy deveIop in peopIe who harbor amebas in their intestines; and this finding wouJd further Iead one astray. It is certainIy an important aid to know of the presence of amebas preoperativeIy, as the dangers of performing even an appendectomy upon a patient with amebiasis were repeatedIy pointed out after the Chicago epidemic in which a Iarge number of patients with amebiasis operated upon for appendicitis died. McCoy reports thirteen deaths in thirty-two patients with amebiasis upon whom appendectomy was performed. A logica course to foIIow wouId be always to suspect amebic granuIoma when deaIing with Iesions of the coton and to empIoy sigmoidoscopy and repeated stoo1 examinations for amebas. If amebas are found, antiamebic therapy couId be initiated immediately. However, in those patients in which the

and CampbeII differentia1 diagnosis cannot be made with certainty, surgery shouId not be delayed. The compIiment fixation test for amebiasis may be heIpfu1 in making the differential diagnosis but we have had no experience with it. SUMMARY

I. Two case histories of patients with amebic granuIomas of the cecum are presented. 2. The diffIcuIties of diagnosis and the importance of making differentia1 diagnosis between ameboma and carcinoma are pointed out. 3. EarIy surgery is recommended for Iesions of the colon in which differentia1 diagnosis cannot be made. REFERENCES

I. FAUST, E. C. The prevaIence of amebiasis in the western hemisphere. Am. J. Trap. Med., zz: 93, 1942. 2. OCHSNER, A. and DEBAKEY, M. Amebic hepatitis and hepatic abscess: an anatysis of 181 cases, with review of the literature. Surgery, 13: 460, 1943. 3. KARTULIS, S. and NOTHINAGEL, H. SpezieIIe PathoIogie und Therapie, vol. 5, p. I. Vienna, rgoo. Alfred Holder. 4. KLEITSCH, W. P. Amebiasis in surgica1 patients. Am. J. Surg., 79: 450-451, 1950. 5. FREEMAN, M. J. and CLIVE, E. A. Parenchymal amebiasis: a cIinica1 study. Am. J. M. SC., 224659, 1952. 6. MORGAN, C. N. Amebiasis: some diffrcuIties of diagnosis. Brit. M. J., 2: 721-723, 1944. 7. GUNN. H. and HOWARD. N. J. Amebic EranuIomas oftheIarge bowel. J. A. M. A., 97: 166170, 1931. 8. LINDSKOG,G. E. and WALTERS, W. SurgicaI aspects of amebic dysentery. J. A. M. A., 131: 92-4, r 946. g. HAWE, P. The surgica1 aspect of intestina1 amebiasis. Surg., Gynec. ti Obst., 81: 387-403.

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