Gut: first published as 10.1136/gut.7.5.438 on 1 October 1966. Downloaded from Gut, 1966, 7, 438

Ulcerative post-dysenteric

S. J. POWELL AND A. J. WILMOT From the Research Unit' and the Department ofMedicine, University ofNatal, Durban, South Africa

EDITORIAL COMMENT Better treatment is resulting in more severe cases of amoebic colitis surviving and these patients may have severe residual damage to the bowel resulting in ulcerative post-dysenteric colitis. This is considered to be a distinct entity.

The term 'post-dysenteric colonic irritability' was thousand patients who attend this hospital annually introduced by Sir Arthur Hurst (1943) to describe with acute amoebic complications are persistent irritability of the bowel following an acute common and we have had the opportunity to study attack of bacillary or amoebic dysentery. The early them (Wilmot, 1962). It is from this material that we symptoms were attributed to a non-specific chronic have based the following report of ulcerative post- colitis occurring after the specific infection had died dysenteric colitis in 33 African patients observed in out, but in the later stages were thought to be due to recent years. 'functional irritability' of the colon. Stewart (1950) found that post-dysenteric colitis was more common- CLINICAL FINDINGS ly a sequel to acute amoebic dysentery and was able All patients presented initially with severe amoebic to recognize two forms in his patients: 1 Those with dysentery, sigmoidoscopic examination showing a mild symptoms and no colonic ulceration, which he congested, oedematous mucosa with extensive rectal named 'functional post-dysenteric colitis', and (2)

ulcers the surfaces of which were covered by sloughs http://gut.bmj.com/ Those with colonic ulceration and more severe and exudate. In all instances culture for bacterial symptoms, which he termed 'ulcerative post- was negative but haematophagous tropho- dysenteric colitis'. zoites of histolytica were present in the The form with mild symptoms accords with dysenteric stools and ulcer scrapings. Apart from Hurst's (1943) description of post-dysenteric colonic being more severe than average the initial picture irritability and comprises one group of patients was typical of acute amoebic dysentery. forming part of the 'irritable colon syndrome' In dysenteric amoebiasis of average severity appro- (Chaudhary and Truelove, 1962). However, there are priate amoebicidal therapy almost invariably results on October 1, 2021 by guest. Protected copyright. few descriptions of patients with ulcerative post- in the cessation of symptoms and disappearance ofE. dysenteric colitis. The condition is omitted from many histolytica from the stools and ulcer scrapings within modern textbooks of and, apart approximately five days. Complete healing of ulcers from a brief account by Wilmot (1958), the more takes a little longer but by the tenth day of treatment recent literature has not enlarged on Stewart's (1950) the rectal ulcers, if not entirely healed, are clean and observations. Yet, to judge from requests for free of exudate, some degree of epithelialization is information, confusion exists concerning the distinc- present, and the intervening mucosa is no longer tion between post-dysenteric colonic irritability, congested. However, in the patients under study, on ulcerative post-dysenteric colitis, and chronic, non- the tenth day dysentery persisted, despite intensive specific . amoebicidal therapy consisting of emetine hydro- Among Africans in Durban both bacillary and chloride or dehydroemetine in full doses combined acute amoebic dysentery are common. The former with and either tetracycline condition is usually self-limiting, responds readily to or penicillin and phthalysulphathiazole. Although E. treatment and, in our experience, presents few histolytica could no longer be found there was little problems. On the other hand, among the several change in the mucosal picture apart from some 'The Amoebiasis Research Unit is sponsored by the South African lessening of exudate on the ulcers. In 12 patients Council for Scientific and Industrial Research, the Natal Provincial Administration, the University of Natal, and the United States Public supervened within the first 10 days but, Health Service (grant Al 01592). after successful treatment by conservative measures, 438 Gut: first published as 10.1136/gut.7.5.438 on 1 October 1966. Downloaded from

A B C FIG. 1. Radiograph ofleft transverse colon, splenicflexure, descending andsigmoid colon in different degrees ofdistension with barium. A,fully distended colon; B, after partial evacuation; C, afterfurther evacuation. Note constancy and rigidity ofstrictures. http://gut.bmj.com/ on October 1, 2021 by guest. Protected copyright.

A B FIG. 2. A, air-barium contrast demonstrating rigidity ofstrictures. B, mucosal relieffilm demonstrating mucosal irregu- larity (pseudo-polypoid appearance) and evidence of ulceration, best seen at junction of descending and sigmoid colons. Gut: first published as 10.1136/gut.7.5.438 on 1 October 1966. Downloaded from 440 S. J. Powell and A. J. Wilmot

FIG. 3

FIG. 5 http://gut.bmj.com/

FIG. 3. Section of colon showing surface ulceration with loss ofmuscle layers on left side x 25. on October 1, 2021 by guest. Protected copyright.

FIG. 4. Higher power ofa relatively normal area ofbowel with post-mortem autolysis ofsurface. Muscle layers intact x 60.

FIG. 5. Higherpower ofan ulcerated area showing disrup- tion ofmucosal surface, endarteritis ofa vessel, destruction ofmuscle layer, and a rather mild inflammatory infiltrate of plasma cells and lymphocytes x 60.

FIG. 4 Gut: first published as 10.1136/gut.7.5.438 on 1 October 1966. Downloaded from Ulcerative post-dysenteric colitis 441 dysenteric symptoms continued. It is also noteworthy three months. In one patient there was prompt im- that in many patients during the initial, acute provement but relapse occurred on two occasions episode of dysentery large sloughs of necrotic bowel when the dosage was reduced below 60 mg. daily. It mucosa were passed and, when sigmoidoscopic was only possible to discontinue steroids after examination could be done, extensive, raw, bleeding several weeks but cure, when achieved, appeared areas were visible at the site of separation. permanent. A second patient responded more slowly The subsequent course of the condition appeared to 30 mg. daily of prednisolone and, after a month, to depend on the degree of damage to the bowel. was able to return home although the rectal mucosa Although repeated search failed to reveal amoebae remained grossly abnormal and strictures were after initial treament, all patients received some form present. He returned to hospital six months later with of additional amoebicidal therapy at the tenth day a recurrence of diarrhoea. The sigmoidoscopic without much symptomatic response. However, the appearance was unchanged and barium enema on least severe cases began to show a progressive reduc- two occasions showed persistent multiple strictures. tion of dysentery and by approximately the 30th day The course and findings in this patient were in- in 13 patients the stools had become normal. Except distinguishable from those of chronic, non-specific for some granularity and hyperaemia at the site of ulcerative colitis. previous ulcers the rectal mucosa returned to normal. In the remaining four patients there was little or no Thereafter these patients remained free of symptoms. response to prednisolone, and one followed a steady This group may be summarized as showing moder- downhill course until he died three months after the ately delayed healing and occupies an intermediate initial attack of dysentery. Necropsy showed exten- position between those patients with typical acute sive ulceration throughout the colon but amoebae amoebic dysentery responding readily and complete- were absent. The final three patients were also given ly to amoebicidial therapy and those who develop hydrocortisone enemas without effect. In one a chronic colitis. rectosigmoid fistula, demonstrated by barium enema, The remaining 20 patients formed the latter group, was probably responsible for persisting symptoms. in whom dysentery continued, in some instances for Two of these patients eventually discharged them- over nine months, with little tendency for the rectal selves from hospital although they were not free of ulcers to heal. , anaemia, leucocytosis, and diarrhoea. The last patient, who has shown little elevation of the erythrocyte sedimentation rate response to any form of treatment, remains extremely persisted and the problem in management became ill and the outcome is doubtful. http://gut.bmj.com/ one of maintaining the patient despite intractable In 10 patients barium studies were done after the dysentery. Antispasmodics and non-specific diarr- acute attack had settled down. In seven severe hoeal remedies had little effect but courses of damage to the colon, loss of haustrations, and insoluble sulphonamides seemed of value in allevi- multiple strictures were demonstrable. ating symptoms. transfusion was frequently We have little follow-up information but, of the necessary to correct anaemia, and in some patients nine patients who have attended again at periods of severe protein, fluid, and loss required one month to one year after discharge, in seven the correction by intravenous infusions. In 14 of these disease has remained quiescent although there has on October 1, 2021 by guest. Protected copyright. patients symptoms slowly abated. Repeated sig- been little, if any, change in the degree of stricture moidoscopy throughout their long illnesses showed a visible at sigmoidoscopy. One patient, previously slow tendency towards healing of the ulcers and a mentioned, had a recurrence of symptoms and the gradual reduction in mucosal fragility but, at sites condition now shows great similarity to chronic non- where ulceration had been deep or sloughing had specific ulcerative colitis. A further patient returned occurred, some narrowing of the bowel lumen was with a recurrence of dysentery several months after common, and in 11 instances final healing was discharge. Despite intensive amoebicidal therapy on accompanied by scarring and stricture formation. A the previous occasion he was shown to have suffered common site was at the recto-sigmoid junction. In a recurrence of amoebic dysentery on his second these patients the mucosa eventually became admission. This again responded to amoebicides. abnormally pale and avascular but, although in most Although the rectal ulcers healed the strictures the strictures were sufficient to prevent the passage of persisted unchanged and have produced mild a sigmoidoscope, symptoms ofobstruction developed obstructive symptoms. in only one instance. These were mild and have recurred during the past six months but it has not DISCUSSION been necessary to resort to surgery. Oral prednisolone was given to the remaining six The term 'post-dysenteric colonic irritability' is more patients after dysentery had persisted for two to accurate than 'functional post-dysenteric colitis', as Gut: first published as 10.1136/gut.7.5.438 on 1 October 1966. Downloaded from 442 S. J. Powell and A. J. Wilmot Chaudhary and Truelove (1962) have shown that Africans, reports of the latter condition have inflammatory changes are absent in this condition. appeared recently (Billinghurst, 1964; Pillay, 1964), This distinguishes it and all other forms of the irrit- and we have observed such cases. More frequent are able colon syndrome from both ulcerative post- patients in whom the aetiology of the initial attack dysenteric colitis and chronic, non-specific ulcerative was assumed to be amoebic and, following amoebi- colitis. A further distinction is that, in contrast to the cidal therapy, it has not been possible to distinguish predominantly functional nature of all forms of the the two conditions with certainty. In such instances irritable colon syndrome, the origin and course of the general clinical picture, sigmoidoscopic and ulcerative post-dysenteric colitis is associated with radiographic findings may be identical to chronic, structural changes in the bowel. In our experience it non-specific ulcerative colitis. Nevertheless, in most has been confined to patients with severe amoebic patients with the post-dysenteric form the disease is dysentery, in some cases complicated by peritonitis. not characterized by a sequence of remissions and The colitis was an immediate sequel to invasion by relapses. The local complications of the two condi- E. histolytica and its duration ranged from mere tions are similar although it is our impression that prolongation of the normal healing time of amoebic whereas fibrous stricture is more common in ulcera- dysentery to a protracted course of more than nine tive post-dysenteric colitis, carcinoma is rare. How- months. Strictures were common in the more severe ever, the latter observation may merely be a reflec- cases and in one instance persistent symptoms were tion of the infrequency of carcinoma of the large probably due to the development of a recto-sigmoid bowel in general among Africans. The remote fistula. Such intestinal fistulae are a recognized, complications of chronic, non-specific ulcerative although rare, complication of severe amoebic colitis such as conjunctivitis, iritis, skin eruptions, dysentery (Dinner and Bader, 1961). arthritis, and erythema nodosum were not seen in In our series the severity and degree of post- our patients. dysenteric colitis appeared to be related to the sever- It has been shown that antibodies against E. ity and extent of the initial damage to the bowel histolytica are detectable by the gel-diffusion tech- mucosa during the original infection. With two nique in approximately 90 % of cases of acute exceptions there was slow, at times exceedingly slow, amoebic dysentery (Maddison, Powell, and Elsdon- improvement, but, despite residual scarring and Dew, 1965; Powell, Maddison, Hodgson, and strictures, once the rectal ulcers had healed relapse Elsdon-Dew, 1966) and they were demonstrable in

was infrequent. In most the course progresses to- the 11 patients in whom they were sought in our http://gut.bmj.com/ wards lasting recovery but some progress equally series. In one instance there was a reduction and steadily downhill, and occasional cases may follow a eventual disappearance of antibodies over a period course indistinguishable from that of chronic, non- of six months although the colitis was still active, so specific ulcerative colitis. In the latter instance it is that it is probable that negative results will be obtain- important to exclude relapse or reinfection by E. ed in some longstanding cases of ulcerative post- histolytica. dysenteric colitis. As sera from patients with chronic, Although some degree of selection in our series non-specific ulcerative colitis have failed to show may have favoured investigation of the more severe precipitins against E. histolytica (Maddison, 1965; on October 1, 2021 by guest. Protected copyright. cases it is noteworthy that no instances of the milder Powell et al., 1966), serological methods may be of condition of post-dysenteric colonic irritability were value in diagnosis, at least in the earlier stages of the seen during the period of observation. Moreover no post-dysenteric form. sequelae to were observed. Our limited experience with steroids in ulcerative Functional disturbance of the is post-dysenteric colitis is similar to that reported by infrequently diagnosed in the local African popula- Rankin, Goulston, Boden, and Morrow (1960) in tion but it is not known if this is a true reflection of fulminating ulcerative colitis, and response to this its incidence as the Africans are reticent about minor form of treatment cannot be used to distinguish the disturbances of function. However, there is no doubt conditions. Most patients with the post-dysenteric that our African medical students, who are not form do not require steroids but, in view of the typically representative of the general African prompt improvement in one patient, they warrant a population, are just as subject to nervous diarrhoea cautious trial when other measures have failed and under examination stress as students elsewhere. the patient is deteriorating. We have not used Whereas, in the patients we have seen, distinction sulphasalazine but we feel that it deserves a trial. from post-dysenteric colonic irritability can be Improved methods of treatment have resulted in readily made, it is more difficult to differentiate increased survival in acute amoebic dysentery, in- ulcerative post-dysenteric colitis from chronic non- cluding those patients in whom peritonitis has super- specific ulcerative colitis. Although apparently rare in vened (Powell and Wilmot, 1966). Recent experience Ulcerative post-dysenteric colitis 443 Gut: first published as 10.1136/gut.7.5.438 on 1 October 1966. Downloaded from suggests that consequently more patients are now of the radiographs and to Dr. S. Kallichurum for provid- seen in whom there is severe residual damage to the ing and interpreting the histological sections. bowel resulting in ulcerative post-dysenteric colitis. REFERENCES The condition therefore deserves more widespread Billinghurst, J. R. (1964). Ulcerative colitis in the African. Rep. of 11th recognition than it has attained in the past. Ann. Meeting of Ass. of Physicians of East Africa. Brit. med. J., 2, 117. Chaudhary, N. A., and Truelove, S. C. (1962). The irritable colon SUMMARY syndrome. Quart. J. Med., 31, 307-322. Dinner, M., and Bader, E. (1961). Internal intestinal fistulae caused by amoebiasis. S. Afr. med. J., 35, 808-811. The findings in 33 patients with ulcerative post- Hurst, A. (1943). Medical Diseases of War, 3rd ed. Arnold, London. dysenteric colitis are reported. The condition was a Maddison, S. E. (1965). Characterization of antigen antibody reaction by gel diffusion. Exp. Parasit., 16, direct sequel to severe amoebic dysentery and its 224-235. severity was related to the degree and extent of Powell, S. J., and Elsdon-Dew, R. (1965). Application of serology to the epidemiology of amoebiasis. Amer. J. trop. Med. Hyg., damage to the bowel mucosa caused by the initial 14, 554-557. infection. The distinction from post-dysenteric Pillay, V. K. G. (1964). Ulcerative colitis in the African. Brit. med. J., 2, 689. colonic irritability and chronic, non-specific ulcera- Powell, S. J., Maddison, S. E., Hodgson, R. G., and Elsdon-Dew, R. tive colitis is discussed. With increased survival from (1966). Amoebic gel-diffusion precipition-test. Clinical evalua- severe amoebic dysentery the condition may be tion in acute amoebic dysentery. Lancet, 1, 566-567. and Wilmot, A. J. (1966). Prognosis in peritonitis complicating recognized more frequently. severe amoebic dysentery. Trans. Roy Soc. Trop. Med. Hyg., 60, 544. Rankin, J. G., Goulston, S. J. M., Boden, R. W., and Morrow, A. W. We wish to thank Professor E. B. Adams for access to (1960). Fulminant ulcerative colitis. Quart. J. Med., 29, 375-390. patients under his care, and are grateful to Dr. R. Nupen, Stewart, G. T. (1950). Post-dysenteric colitis. Brit. med. J., 1, 405-409. formerly acting medical superintendent, King Edward Wilmot, A. J. (1958). Some results of severe amoebiasis. (Proc. 6th Int. Congr. trop. Med. Mal., vol. 3.) An. Inst. med. trop. VIII Hospital, Durban, for facilities. We are indebted to (Lisboa), 16, suppl. 7. Dr. H. Engelbrecht for the interpretation and illustrations (1962). Clinical Amoebiasis. Blackwell, Oxford. http://gut.bmj.com/ on October 1, 2021 by guest. Protected copyright.