Gut: first published as 10.1136/gut.7.5.438 on 1 October 1966. Downloaded from Gut, 1966, 7, 438 Ulcerative post-dysenteric colitis S. J. POWELL AND A. J. WILMOT From the Amoebiasis 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 dysentery 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- pathogens was negative but haematophagous tropho- dysenteric colitis'. zoites of Entamoeba 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 gastroenterology 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 ulcerative colitis. 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 diiodohydroxyquinoline 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 peritonitis 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. Fever, 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. Blood 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 electrolyte loss required one month to one year after discharge, in seven the correction by intravenous infusions. In 14 of