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6I4 Postgrad Med J: first published as 10.1136/pgmj.36.420.614 on 1 October 1960. Downloaded from

THE PATTERN OF CERTAIN GASTRO-INTESTINAL DISEASES IN B. J. VAKIL, M.D.(BOM.) Hon. Assistant Physician, J.J. Group of Hospitals, and Clinical Tutor, Grant Medical College, Bombay From the Department of , Central Middlesex Hospital, London, N. W. io

The incidence and clinical pattern of diseases The incidence of peptic ulcer is highest in differ in different parts of the world and even vary coastal areas. This area along the coast is often from area to area in the same country. Several described as the peptic ulcer belt. The maximum factors contribute to these differences. Racial incidence is in the South-West coastal areas fol- and hereditary factors, climatic conditions, socio- lowed by South-East and Eastern coastal areas. economical factors, dietetic habits and mode of West coast areas are conspicuous in their low living are some of the important factors involved incidence. A small strip of area (Coimbatore in the genesis of these variations. district) in the South between the two coastal The pattern of gastro-intestinal disease in India areas of heavy incidence have a significantly low differs considerably from that of the Western incidence. The central and northern plains of World. Some of the gastro-intestinal conditions the country are relatively free from the disease. which are common in India are rarely seen in The highest incidence of peptic uker is betweenProtected by copyright. Western countries and vice versa. This review the ages of 20 and 35 years. The mean age for will be concerned primarily with the differences in peptic ulcer is reported to be 3I years for males patterns of the more common gastro-intestinal and 25 years for females, gastric ulcer occurring conditions. more in younger age groups than duodenal ulcer.6 In spite of keeping in mind the smaller attend- Peptic Ulcer ance and fewer beds for women in hospital, one is It is doubtful if the claim that peptic ulcer is a still impressed by the relative rarity of peptic disease of modern civilization is correct. Its ulcer in females, the ratio ofmales to females being incidenceloa, be,C14 has been reported from the 8: i. Incidence is higher in Hindus than remote parts of Africa and India where the in- Moslems.6 19 There is fair evidence that poor fluence of modern civilization could hardly be seen. communities have a higher incidence of peptic Peptic ulcer is distributed unevenly throughout ulcer than the well-to-do classes.6. 1a, b. c, 15 Several b, C, 18, 19 re- India. authorslOa, have Agreement is lacking on the relative incidencehttp://pmj.bmj.com/ ported that the incidence is highest in the South. of gastric ulcer to duodenal ulcer. However, all The incidence in different parts of the country authors agree on higher incidence of duodenal is shown in Table i and Fig. i. ulcer. Table 2 shows the ratio of G.U.: D.U. as reported by various authors. TABLE I It is suggested that two types of peptic ulcer SHOWING INCIDENCE OF PEPTIC ULCER IN DIFFERENT exist in India in PARTS OF INDIA BASED ON DOGRA'SlaSb, C WORK AND differing aetiology, clinical ADAPTED FROM KONSTAM'S ARTICLE features and prognosis.'5 For want of proper on September 28, 2021 by guest. Incidence Area Population, No. of per IOO,OOO TABLE 2 1931 Cases Population SHOWING RATIO OF INCIDENCE OF DUODENAL ULCER TO GASTRIC ULCER IN DIFFERENT PARTS OF INDIA Assam .. 9,247,857 926 TO Bengal .. 5 i,087,338 x6,976 33 Ratio of Bihar .. 23,676,o28 8,85I 37 Author Area D.U.: G.U. Bombay .. 26,398,997 2,099 7 Punjab .. 23,580,852 2,131 9 Menon'8 South India 20: I Madhya Sommervell25 Travancore 36.7: I Pradest 17,990,937 2,327 12 Dogra10 Madras 48 : I United Dogra10 South India 24: I Provinces 49,614,833 4,460 I I Antia2 Bombay 8.7 :I Madras .. 46,760,028 57,397 143 Chaterjee6 Bengal I1.1 :I Orissa .. I8,653,555 4,132 29 Narsingh Rao' Calcutta 6.5: I October I960 VAKIL: The Pattern of Certain Gastro-intestinal Diseases in India Postgrad Med J: first published as 10.1136/pgmj.36.420.614 on 1 October 1960. Downloaded from

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FIG. I terminology we would call them the tropical type and B2 are responsible factors. Ogilvie2' con- and the Western type. The tropical type is the sidered chillies (red pepper) to be the most most prevalent form of the disease. It seems to be probable cause of peptic ulcer. primarily a disease of poor communities residing It is not clear how far protein malnutrition in rural areas near the coast and whose diets are exists in India. Average protein requirement for http://pmj.bmj.com/ poor in quality. Clinically the disease is charac- Indians is estimated to be 45 g., whereas average terized by chronicity and its tendency to fibrosis intake is 63 g. Food is grossly deficient in animal and stenosis. It is the experience of the surgeons proteins, average intake being io g. Kwashiorkor is in the South that major complications like per- infrequently seen amongst children but very rarely foration and haemorrhage are rarely met in these amongst adults." People residingin the peptic ulcer patients, whereas fibrosis and stenosis are fre- belt are poor and their diet is more likely to be in- quently observed. This is in sharp contrast to adequate. i shows Fig. various food habits of on September 28, 2021 by guest. reported complication rates from many Western different areas. The staple diet of people in the countries. In central, northern and western coastal areas is rice. People of the South-East areas, the clinical picture of peptic ulcer is very like eat more spices. These facts point in favour of that observed in Western countries. All social malnutrition and spices being causative factors. classes are reported to be involved and haemor- However, similar conditions exist in many other rhage and perforation are the most frequent parts ofthe country where the incidence is low; for complications. example people residing in West Coast areas also Several factors have been suggested in causation eat mainly rice and indulge freely in spices yet they of peptic ulcer in India. Nissen20 and Konstaml5 suffer infrequently from peptic ulcer. The low believe that protein deficiency is the causative incidence of peptic ulcer in areas where the staple factor. Sommervell25 has suggested that de- diet is wheat, and meat is consumed more freely, is ficiency of vitamins and particularly Vitamin A impressive. Peptic ulcer is reported to be un- D2 6i6 POSTGRADUATE MEDICAL JOURNAL October I96o Postgrad Med J: first published as 10.1136/pgmj.36.420.614 on 1 October 1960. Downloaded from known amongst the fishermen of the South whose amongst vegetarians. There is no conclusive diet is fairly adequate in proteins.25 The low evidence in favour of this view. incidence of the disease in Coimbatore is attributed Clinically the disease tends to be milder in the to the higher consumption of milk in that area. local population. The full-blown picture of Because of the higher incidence of hookworm sprue as seen in a foreigner is rarely met with. infection in the South, this is often considered a This, coupled with a higher incidence of chronic responsible factor in the genesis of duodenal ulcer. , makes diagnosis difficult. The disease Chandler8' 9 reported a parallelism between ulcer has a tendency to natural remissions and relapses. incidence and but others have The exact incidence of non- in been unable to find a higher incidence of duodenal India is not known. It is believed that its in- ulcer in areas where hookworm is especially cidence is substantially lower than that in Western prevalent. countries. Obviously a few cases of non-tropical sprue must be mistaken for tropical sprue. Primary Syndrome Abdominal Tuberculosis There is fair evidence that the indigenous This is a fairly common condition. Glandular, population suffer from tropical sprue. Clinically peritoneal and intestinal varieties are all met with. the disease tends to be of a milder and more Generally these conditions are secondary complica- chronic nature in Indians than in foreigners tions of a primary lesion. Its incidence used suffering from it. The disease is widely dis- to be as high as 95 per cent. in advanced cases of tributed throughout the country. The true in- pulmonary tuberculosis but recent years have seen cidence in different parts is not known but the a steady The incidence in army units stationed in different parts decline. commonest secondary suggest it is higher in Assam, Bengal and form of tuberculosis is the ulcerative type of Bihar.12' 13, 16 Southern and Western regions intestinal lesion.

It is disputed if primary tuberculosis of theProtected by copyright. follow them. The incidence is lowest in North intestine exists. Some authors feel that there is and Central India. The areas where sprue is nothing like primary tuberculosis of intestines and common are the areas of higher humidity and such cases are variants of Crohn's disease. Even heavy rainfall.12 13 The incidence of sprue is after applying the strictest criteria of diagnosis, maximum in summer and monsoon months, namely presence of tubercle bacilli and/or positive namely between March and September, a period animal inoculation, there is substantial evi- during which the incidence of and 3, 23 malaria is also high. The distribution of sprue dence', to suggest that primary tuberculosis and its seasonal incidence overlap those of dysen- of the intestine is a definite entity. Ukil and tery. As a result of this and the high percentage Tribedi found a post-mortem incidence of about of people suffering from both the diseases, several 5 per cent. of primary intestinal tuberculosis. authors have tried to link the two. Manson Bahr17 Several authors1' 3, 23 have described well-proved found a history of dysentery in 40 per cent. of his cases of primary disease. sprue cases. Keele and Bound13 reported that The human strain of tubercle bacilli is thought to be responsible for this type of lesion. Ukil28 http://pmj.bmj.com/ there is no relation between the two diseases. and Anand' found the human strain in all their Malaria is thought by some authors to exaggerate cases of intestinal tuberculosis. The habit of the sprue syndrome. Recent control of malaria spitting and the use of ash and earth to clean should provide an answer to this problematic utensils accounts for this higher incidence of relationship. infection with the human strain. Milk is generally There is fair evidence in favour of the infection boiled before using, which explains the absence of theory of tropical sprue. The incidence of infection with the bovine strain. tropical sprue is highest during the period when Clinically these cases are mostly of the hyper- on September 28, 2021 by guest. flies breed. It is a common experience that trophic variety and rarely of ulcerative type. change of house or locality or town results in a Ileo-caecal is the commonest site of involvement spontaneous cure. Certain towns, areas and even but occasionally other parts of the intestinal tract houses are notoriously known as ' sprue-areas', may be involved. Pain in the abdomen, low as people staying in these areas often suffer from , loss of weight, diarrhoea or , the disease. Further, it is the experience of many anorexia, haemorrhage and flatulent dyspepsia physicians that chemotherapeutic drugs used in are the commonest symptoms. Locally, a tender treatment of dysentery help patients with sprue. mass is felt in large numbers of patients. Low protein intake is yet another factor in the The clinical picture is very akin to that of causation of tropical sprue.26 This has been Crohn's disease and mistakes in diagnosis on either supported by the finding that sprue is common side are likely to occur. -Even histology is not October I960 VAKIL: The Pattern of Certain Gastro-intestinal Diseases in India 617 Postgrad Med J: first published as 10.1136/pgmj.36.420.614 on 1 October 1960. Downloaded from reliable as shown by Banerjee3 who found the FIG. 2. picture of tubercle granuloma changing to chronic granuloma very similar to that seen in Crohn's SHOWING TYPES AND CAUSE OF AMOEBIASIS disease, on exhibition of anti-tubercular treatment. ON EXPOSURE Anand' has shown that in some cases typical FULMINATING4 HEALTHY PERSON - ) CARRFI DYSENTERY j JJT changes of tuberculosis may not be seen in the ACUTE AMOEBIC DYSENTERY -*ACUTE intestine but may be evident in lymph nodes. DEATH / RELAPSING / 1TYPE The clinical course of hypertrophic tuberculosis CHRONIC TYPE is quite distinct from that of Crohn's. Most of the RECOVERY cases recover completely with successful treatment or deteriorate and succumb to it. Remissions and The post-dysenteric syndrome is a common relapses are not commonly seen. Crohn's disease sequel of amoebic dysentery. It is manifested by is characterized by natural remissions and post- recurrent , persistent diarrhoea and operative relapses. Unlike Crohn's, obstructive the passage of mucus. Abuse of drugs and complications are frequent whereas fistulae are psychological factors are considered to play an extremely rare. important role in its genesis. Peritoneal tuberculosis is a common condition Both acute and chronic are and is manifested in two varieties; namely ascitic widespread throughout the country and claim a and fibro-caseous. high percentage of mortality and morbidity. Although the true incidence of Crohn's disease is not known, it is considered to be an extremely Ulcerative rare condition in India. In contrast to specific colitis, is a rarity. Undoubtedly a few of the chronic Dysentery dysentery cases must be ulcerative colitis. Amoebiasis is the biggest gastro-intestinal Protected by copyright. problem in India. The incidence is high. Intestinal Parasites Reports22 24 suggest that 2o to 43 per cent. of the Intestinal parasitic infestation is common and healthy population are cyst carriers; 35 to 58 per forms a pxoblem second to amoebiasis in incidence cent. of patients with abdominal complaints show and diversity of abdominal complaints. the presence of amoebae or cysts in their stools. Ascaris lumbricoides and Enterobium vermicularis It would be no exaggeration to say that the average are the commonest parasitic infestations. Chil- person in India has suffered, is suffering or will dren are more prone to these infestations. Infes- suffer from amoebiasis. Fig. 2 depicts the various tation with ascaris, enterobius, trichuris and anky- types and course of the disease. Chronic dysen- lostomiasis are cosmopolitan in their distribution. tery is the commonest type met in practice. The Trichinella and Taenia solium infestation-are seen unfortunate sufferer is never completely free from in non-Moslems, whereas infestation with Taenia the disease and gets exacerbations from time to saginata is seen amongst non-Hindus due to par-

time. The morbidity rate is high; complete cure ticular food habits.- Infestation with Taenia http://pmj.bmj.com/ a rarity. echinococcus occurs occasionally. Schistosomiasis Endameba Histolytica is often a causative and flukes are extremely rare and are local- organism of . This type of appendi- ized to small zones. Hook-worm is reported to citis responds promptly to anti-amoebic treatment. be very prevalent in the South. It declines in Occasionally manifestations of acute abdomen may Eastern and Northern regions.8 9, 22 be present in a fulminating case. Perforation and is widely spread and the or- are rare complications. ganism is commonly found in stools. According Chronic granuloma of caecum and due to Shrivastava4 11.5 per cent. of healthy popula- on September 28, 2021 by guest. to amoebic infection is occasionally met with and tion show the presence of giardia in their stools, needs to be differentiated from malignancy and whereas 21.5 per cent. of people with abdominal tuberculosis of these organs. complaints have these parasites. Their patho- Amoebic is the commonest complica- genicity is disputed but it is believed by many tion. An autopsy survey suggested that 39 per physicians that they are often responsible for cent. of patients dying with intestinal amoebic symptoms such as flatulent dyspepsia, upper lesions have liver involvement; 5 to io per cent. of abdominal pain, diarrhoea, steatorrhoea, urticaria, people with amoebic dysentery are reported to nervousness and dysentery. develop hepatitis; 20 to 30 per cent. of patients with amoebic hepatitis may not give any history Portal of dysentery or may not show any evidence of Portal cirrhosis is widely prevalent in India, intestinal involvement. The clinical picture is very much that of the post- 6i8 POSTGRADUATE MEDICAL JOURNAL October I960 Postgrad Med J: first published as 10.1136/pgmj.36.420.614 on 1 October 1960. Downloaded from necrotic variety, though wasting and malnourish- Summary ment are marked associated features. In more The incidence and clinical picture of gastro- than 6o per cent. of patients it is difficult to intestinal diseases in India differ considerably from ascertain a cause for their cirrhosis. They have those in other parts of the world. An attempt has never been jaundiced, give no history of hepatitis been made to describe some of these differences and have not been taking alcohol in any significant and discuss the local factors in aetiology and quantity. Malnutrition and parasitic infestations prognosis. Some problems of gastro-intestinal are blamed for the cirrhosis. Recent work on disease have been outlined. Kwashiorkor in India and elsewhere has seriously thrown doubts on protein deficiency as a cause of cirrhosis. The prognosis of the Indian cirrhotic REFERENCES is poorer than his counterpart in Western countries I. ANAND, S. S. (ig56), Ann. roy. Coll. Surg. Engl., 19, 205. 2. ANTIA, F. P., BHATNAGA, S. M., and VYAS, M. C., and few patients survive more than two years. 'Proceedings of World Congress of Gastro-Enterology'. Malnutrition and parasitic infections may be Baltimore: The Williams and Wilkins Co. factors contributing to the adverse prognosis. 3. BANERJEE, B. N. (1950), IndianjY. Surg., 12, 33. 4. BRAMWELL-COOK, A. (1944), Indian med. Gaz., 79, 429. 5. BOCKUS, H. L. (I944), 'Gastro-Enterology'. Philadelphia: Infantile Cirrhosis W. B. Saunders & Co. 6. CHATERJEE, S. C., DAS, D. C., and SENGUPTA, S. N. Infantile cirrhosis is a peculiar disease of India. (I958), J. Indian med. Ass., 30, 35. The disease is widely spread but is heaviest in the 7. CHAUDHARI, R. N., and RAI CHAUDHARI, M. N. (I944), South. Children of middle-class Hindu families Indian med. Gaz., 79, 404. 8. CHANDLER, A. C. (1928), Indian YT. med. Res., I4, I85. between 6 months and 2 years are usually affected. 9. CHANDLER, A. C. (1929), Ibid., 15, 143. The disease is characterized by an acute phase 0oa. DOGRA, J. R. (94I), Ibid., 28, I45. during which the child becomes ill, runs a mild iob. DOGRA, J. R. (I94I), Ibid., 28, 481. fever and develops hepato-splenomegaly. Ioc. DOGRA, J. R. (I94I), Ibid., 29, 665. iI. GOPOLAN, C., and RAMALINGASWAN, V. (I955), Ibid.,Protected by copyright. Jaundice, ascites and oedema follow in due course. 43, 751- A small percentage of cases deteriorate rapidly, 12. KEELE, K. D. (1946), Brit. med. Y., iii, iIi. becoming cholaemic in two to four weeks and 13. KEELE, K. D., and BOUND, J. P. (I946), Ibid., i, 77. 14. KONSTAM, P. G. (1954), Lancet, ii, 1039. succumbing to it. But a large percentage pro- IS. KONSTAM, P. G. (i959), Indian Y. med. Sci., 13, 480. gresses to a chronic stage which ultimately ends in i6. LEISHMAN, A. W. D. (I945), Lancet, ii, 813. cirrhosis. Pathologically the disease is charac- 17. MANSON-BAHR, P. (194I), Trans. roy. Soc. trop. Med. Hyg., 34, 347. terized by obliterative lesions of terminal and some I8. MENON, C. V. P., cited by Konstam, P. G. (I959). of the bigger divisions of hepatic venous trees, I9. NARSING RAO, M. (1938), Indian med. Gaz., 73, 454. necrosis of liver cells with poor attempt at re- 20. NISSEN, R. (1945), 'Duodenal and Jejunal Peptic Ulcer'. New York: Grune and Stratton. generation and connective tissue proliferation. 2I. OGILVIE, H. (1953), Lancet, ii, g5S. Protein malnutrition, virus infection and in- 22. PATEL, J. C. (i9s4), Indian J. med. Res., 42, 279. testinal toxaemia have been suggested as aetio- 23. PAUSTIEN, F. F., and BOCKUS, H. L. (1959), Amer. Y. logical factors. The clinical and pathological Med., 27, 509. picture is very much like that of veno-occlusive 24. SHRIVASAVA, J. B. (1953), Indian 3'. med. Res., 41, 397. 25. SOMMERVELL, T. H. (1942), Brit. J. Surg., 30, 113. http://pmj.bmj.com/ disease with the major differences that the former 26. STEFANINI, M. (I949), Acta med. scand., 133, II3. 27. TRIBEDI, B. P., and GUPTA, D. M., cited by Ukil, A. C. involves only children and in the majority of cases (1942). no plant extracts could be held responsible. 28. UKIL, A. C. (r942), Indian med. Gaz., 77, 6I3. on September 28, 2021 by guest. NOTICE OF SPECIAL INTEREST TO SUBSCRIBERS: WY N ,WHY NOT HAVE YOUR COPIES OF THIS JOURNAL BOUND INTO YEARLY VOLUMES?' HAVE You can have your twelve monthly issues fully bound in dark green pin head doth. lettered in gilt on spine with name of Journal, Volume Number and year, complete with index at front, for 22s. 6d. post free. A limited number of out of Ifl print journals ariavailable to bind into volumes nd mtke your library complute. RN Prie on application giving det ils of iouues required to complete back volumes. THE FELLOWSHIP OF POSTGRADUATE MEDICINE. BOU 60 PORTLAND PLACE. LONDON, W.1 1