Amoebic toxic colitis: analysis of factors related to mortality.

BACKGROUND: Toxic or fulminant colitis due to Entamoeba histolytica infrequently presents but is very serious. Unfortunately, there are numerous contradictory factors related to mortality. METHODS: We analyzed several cases of E. histolytica infection to determine the factors related to mortality. We included patients >15 years of age who were histopathologically diagnosed with amoebic toxic colitis and treated from January 2000 through December 2006. We evaluated demographic, clinical, laboratorial, surgical, and histopathological characteristics. RESULTS: We examined 24 patients and recorded 12 deaths (50%). Twenty patients underwent surgery within a mean time of 24 hours (range: 8-120 hours). Tenesmus and intestinal perforation were determined to be statistically significant (P<0·05) by univariate analysis. Three models of logistic regression were able to determine three statistically significant factors that affected mortality: (1) tenesmus and a lymphocyte count <1·5×10(3) cell/µl; 2) depth of invasion beyond the mucosa and a lymphocyte count <1·5×10(3) cell/µl; 3) time spent with symptoms and perforation. CONCLUSIONS: The mortality rate determined in this study is similar to previously reported series. A low lymphocyte count, significant depth of invasion, and intestinal perforation were determined to be the factors related to increased mortality, while tenesmus and limited amount of time spent with symptoms were associated with survival. Quick diagnosis and appropriate treatment are important factors that reduce mortality.

[Diarrhea from the infectologist's point of view]. / Hasmenések az infektológus szemszögébôl.

Gastroenteritis is a nonspecific term for various pathologic states of the gastrointestinal tract. Gastroenteritis causing pathogens are the second leading cause of morbidity and mortality worldwide. In the developed countries diarrhea is the most common reason for missing work, while in the developing world, it is a leading cause of death. Internationally, the mortality rate is 5-10 million deaths each year. "Traveller's diarrhea" is a polyetiologic common health problem of international travellers which affects travellers generally for days, but it can result in chronic postinfectious irritable bowel syndrome as well. Infectious agents usually cause acute gastroenteritis either by adherence of the intestinal mucosa, or by mucosal invasion, enterotoxin production, and/or cytotoxin production. The incubation period can often suggest the cause of etiology. When symptoms occur within 6 hours of eating, ingestion of preformed toxin of S. aureus or Bacillus cereus should be suspected. The incidence of hypervirulent C. difficile associated colitis is an emerging problem as a healthcare system associated infection. While infectious agents do not commonly cause chronic diarrhea, those that do include C. difficile, Giardia lamblia, Entamoeba histolytica, Cryptosporidium, Aeromonas and Yersinia . Amoebiasis is the second to malaria as a protozoal cause of death. Infection with HIV is also a common cause of diarrhea.

Fulminant amebic colitis: analysis of 55 cases.

UNLABELLED: Fulminant amebic colitis is a rare disease with high morbidity and mortality. PURPOSE: This study was designed to identify the most frequent clinical and histopathologic features of fulminant amebic colitis and to analyze results of surgical treatment and the existence of risk factors for mortality. MATERIALS AND METHODS: A retrospective analysis was conducted of clinical and histopathologic data of 55 patients with fulminant amebic colitis. Data were obtained from the files of autopsies and surgical operations that had been performed at a referral center in Mexico from 1943 through 1994. RESULTS: Median age was 52 (range, 18-79) years. There were 34 men (62 percent) and 21 women (38 percent). Diabetes mellitus and chronic alcoholism were the most frequent diseases in association with fulminant amebic colitis (40 and 31 percent, respectively). The most frequent clinical manifestations were abdominal pain, diarrhea, rectal bleeding, and fever. There was a coexistent amebic liver abscess in 54 percent of patients. The main histopathologic characteristics were necrosis, presence of trophozoites, and acute and/or chronic inflammation. Of 25 patients who underwent surgery, only six survived (operative mortality, 76 percent; overall mortality, 89 percent). The variables that correlated with mortality were longer duration of symptoms, lower count of leukocytes, nonsurgical treatment, nonresective surgical procedure, hospital admission before 1971, and invasion of trophozoites into or through the muscularis. CONCLUSIONS: The results may help to obtain an earlier diagnosis and establish proper treatment of fulminant amebic colitis.

[The diagnosis and surgical treatment of intestinal amebiasis]. / Diagnostika i khirurgicheskoe lechenie kishechnogo amebiaza.

Ninety-one patients with intestinal amebiasis (IA) were studied. All had been long suffering from IA due to the fact that it had not been diagnosed in time. Indications for emergency surgery were profuse hemorrhage, perforation of amebic ulcers, gangrene, and toxic dilatation of the large intestine. Planned operations were made in pseudopolyposis, strictures of the large intestine. Surgical treatment was performed along with specific therapy. Seven patients died due to late diagnosis, ineffective therapy and profound systemic and regional changes caused by these factors. It is necessary to differentiate ulcerative colitis, polyposis, and tumors of the large intestine with IA.

Risk factors associated with fulminant amebic colitis.

Amebic colitis is associated with serious complications and a high fatality rate if it progresses to its fulminant form. The purpose of this retrospective study was to determine the risk factors associated with fulminant amebic colitis. From February 1978 to February 1993, 60 adults were diagnosed with intestinal amebiasis at Chang Gung Memorial Hospital. Sixteen patients with massive bloody diarrhea, persistent systemic toxicity or signs of peritonitis were classified as having fulminant colitis, five of whom progressed to fulminant colitis after admission to the hospital. Forty-four patients with good responses to amebicides and without complications were classified as having moderate colitis. There was no amebiasis-related mortality among patients with moderate colitis. In contrast, five patients with fulminant colitis died. Early diagnosis and surgical treatment significantly decreased mortality when compared with conservative treatment. Significant factors associated with the development of fulminant intestinal amebiasis in univariate analyses were being male, age over 60 years, having an associated liver abscess, progressive abdominal pain, signs of peritonitis, leukocytosis, hyponatremia, hypokalemia and hypoalbuminemia. Only the factors of being over 60 years of age and hypokalemia were important in multivariate analyses. We conclude that early and extensive surgical treatment is mandatory for patients with typical presentations of fulminant amebic colitis on admission to the hospital, such as progression to peritonitis, persistent systemic toxemia and explosive bloody diarrhea. For other patients, especially the elderly and those with low serum potassium levels, close monitoring and observation for signs of fulminant colitis is important.

Fulminant amebic colitis.

Amebiasis is the acute and chronic disease produced by Entamoeba histolytica, an entity which occurs in endemic fashion in many of the tropical and subtropical areas of the world, capable of affecting diverse organs of the body, especially the colon. Amebiasis has different clinical forms of presentation, varying from the asymptomatic carrier state to severe, although not frequent, fulminant or necrotizing colitis, characteristically associated with high morbidity and mortality. We hereby report a series of 50 adult patients with fulminating amebic colitis managed at our institution between January, 1971 and July, 1989, with a global mortality of 60%. Early diagnosis, treatment with effective antiamebic agents--specifically metronidazole--and opportune aggressive surgical intervention have resulted in better survival rates. We had no survivors prior to 1970; our current survival rate is still a dismal 40%, indicating the very severe nature of the disease.

Role of intraoperative prograde colonic lavage and a decompressive loop ileostomy in the management of transmural amoebic colitis.

A prospective analysis is presented of a selected group of 45 consecutive patients with transmural amoebic colitis treated by laparotomy, colonic lavage and ileostomy (phase 1 surgery) over 3 years. The diagnosis of amoebic colitis and amoebic perforation of the bowel were difficult and therefore all patients with 'acute abdomen' had proctosigmoidoscopy and a trial of metronidazole for 24-48 h before laparotomy. At laparotomy, adhesive wraps were present in all patients; 13 perforations were exposed by inadvertent disturbance of adhesive wraps but were successfully closed by suture to any available organ in close proximity, such as the omentum or small bowel. Four patients (9 per cent) died after phase 1 surgery. After 6 weeks when the acute disease had healed, 33 of the remaining 41 patients (80 per cent) required closure of ileostomy only, five had resection of stricture and three (7 per cent) needed stricturoplasty (phase 2 surgery). Two patients (5 per cent) died after phase 2 surgery. Thus, in surgery for transmural amoebic colitis adhesive wraps should not be disturbed as they mechanically protect the peritoneal cavity from faecal soiling when perforation occurs. The colon should be emptied by lavage and the faecal stream diverted to avoid secondary bacterial effects.

Colectomy for necrotizing amebic pancolitis in early childhood with survival.

A case of necrotizing amebic pancolitis in a 6-year-old boy with asplenia, partial situs inversus, and cyanotic congenital heart disease is reported and the literature is reviewed briefly. Our patient was managed successfully by prompt colectomy, ileostomy, a Stamm gastrostomy, and extensive drainage of the peritoneal cavity with administration of metronidazole postoperatively and prolonged jugular vein Broviac catheter hyperalimentation. This child may be the first survivor of total colonic amebic necrosis in childhood. Necrotizing amebic colitis appears to be more hazardous in infancy and childhood than in adult years. Malnutrition and additional illnesses and malformations may produce greater immunocompromise in the very young, placing them at greater risk for the ultimate of amebic intestinal complications, total colonic necrosis and disintegration.

[Amebiasis in Transcaucasia and in mountainous desert locales]. / Amebiaz v Zakavkaz'e i v usloviiakh gorno-pustynnoi mestnosti.

The history of the amebiasis investigation in Transcaucasia is presented. 16 cases of amebiasis are described. Data for 1982-1988 on the amebiasis in the moorland are given (41 fatal case).

Colitis amibiana necrotizante: reporte de 6 casos / Necrotizing amebic colitis. Report of 6 cases

Se describen 6 casos de colitis amibiana necrotizante que ingresaron al hospital Vargas de Caracas durante los años 1981 a 1988. Todos los pacientes eran del sexo masculino con edades comprendidas entre los 14 y 68 años. Los signos y síntomas más frecuentes fueron, dolor abdominal, fiebre y diarrea, esta última con moco y sangre en tres de ellos. La distensión y la irritación peritoneal estuvo presente en la totalidad de los casos. En 4 pacientes la leucocitosis fue mayor de 20.000/mm cubicos, con desviación a la izquierda y cayados. En sólo dos casos se sospechó el diagnóstico durante el acto operatorio al evidenciarse un colon inflamado, friable, con áreas isquémicas y multiples perforaciones, indicándose tratamiento con metronidazol, sobreviviendo tan solo uno de ellos. Los procedimientos quirúrgicos empleados fueron la colectomía total con ileoetomía, la hemicolectomía derecha con anastomosis ileotransversa y la hemicolectomía izquierda con operación de Hartman. La mortalidad en esta serie alcanzó el 83%. Debe resaltarse la importancia de sospechar el diagnóstico en todo abdomen agudo con síndrome disentérico, agotándose todos los metodos diagnósticos y tener presente los hallazgos operatorios a fin de iniciar tratamiento antiamibiano y lograr así disminuir la mortalidad

Epidemiologic and clinical features of invasive amebiasis in Bangladesh: a case-control comparison with other diarrheal diseases and postmortem findings.

To describe the epidemiologic and clinical features associated with invasive amebiasis in Bangladesh, 85 hospitalized diarrheal patients with hematophagous trophozoites of Entamoeba histolytica in their stools were compared to a control group of 84 hospitalized diarrheal patients without amebiasis. Postmortem examinations were carried out in 22 deaths due to amebiasis. For the patients with amebiasis, there was a bimodal age distribution with peaks at 2-3 years and greater than 40 years, whereas the control patients had a unimodal distribution with the peak at 0-1 year. The sex distribution was equal in childhood but young adults were predominantly female and older adults predominantly male. The clinical features significantly associated with amebiasis were prolonged dysentery, prior measles rash, malnutrition, hyponatremia, hypokalemia, and hypoproteinemia (all P less than 0.05). The case fatality rate in amebiasis was 29%, which was significantly higher than 11% for the controls (P less than 0.05). Postmortem findings included extensive colitis with deep ulcers and complications, including colonic perforation in 2 cases, peritonitis in 4 cases, pneumonia in 9 cases, and septicemia in 5 cases. These results indicate that invasive amebiasis in this population differs from other diarrheal diseases, affecting mainly children greater than 2 years and adults and causing severe and fatal illness characterized by extensive colitis with diverse systemic consequences.

Tratamiento quirúrgico de las formas de amibiasis intestinal / Surgical treatment of severe intestinal amebiasis

Aunque la ambiasis intestinal puede cursar completamente asintomática, existen formas de amibiasis invasora que pueden ocasionar la muerte del pacientes en poco tiempo. Entre las formas graves de amibiasis intestinal han sido descritas la colitis fulminante, el ameboma y la apendicitis amibiana. Se revisaron retrospectivamente los expedientes clínicos de aquellos pacientes sometidos a tratamiento quirúrgico para formas graves de amibiasis intestinal de 1947 a 1985 en el Instituto Nacional de la Nutrición. Se estudiaron 33 pacientes. Viente tuvieron colitis fulminante, 7 ameboma y 6 apendicitis amibiana. La principales manifestaciones fueron dolor abdominal, fiebre y masa abdominal palpable. Once pacientes tuvieron también absceso hepático amibiano. Sesenta y tres por ciento de los pacientes tenían alguna perforación al momento de la cirugía. La mortalidad operatoria fue de 60% y la morbilidad operatoria de 62%. Las formas graves de amibiasis intestinal son complicaciones raras de la amibiasis intestinal con cifras altas de morbilidad y mortalidad. Su sospecha y diagnóstico tempranos permitirian al paciente una mejor evolución

Necrotizing amebic colitis: a frequently fatal complication.

Acute necrotizing amebic colitis is an uncommon but life threatening development with a high mortality rate, even when properly diagnosed and treated. We report six cases of acute necrotizing amebic colitis, none of which were diagnosed preoperatively. At operation, five of the six patients had friable, necrotic, and gangrenous colon. A right hemicolectomy with ileostomy was performed in two patients and a subtotal colectomy with ileostomy was performed in four patients. Five of the six patients died within 4 weeks of operation. The sole survivor was the patient who had received metronidazole preoperatively. Only after histologic examination of the surgical specimen was the diagnosis made in all cases. If the diagnosis can be made preoperatively and antiamebic therapy instituted, surgical resection may decrease the high mortality rate of this disease.

Fulminant amebic colitis.

Nine patients with fulminating amebic colitis who were treated surgically from 1975 to 1982 are presented. Only those who had bowel resections with exteriorization of the cut ends survived. The pertinent literature is reviewed briefly.

[Intestinal amoebiasis in Zaire children (author's transl)]. / Amibiase intestinale de l'enfant en milieu Zairois.

A study of 385 cases of acute intestinal amoebiasis observed from 1960 to 1978 in the clinic of pediatrics of Kinshasa university. The epidemiologic, diagnostic aspects and the evolution are considered. The disease is responsible for 1,6 p. 100 of the admissions in the clinic of pediatrics for the considered period, with most cases (75 p. 100) in children under six years. Diagnosis, easily suspected if a dysenteric syndrome is obvious, is then confirmed by the detection of hematophagous amoebas in the stools. In children affected by malnutrition, incidence of complications and a lethal rate are both high.

[Shock during necrotic amoebic colitis (author's transl)]. / L'état de choc au cours de l'amibiase colique nécrosante.

Two varieties of conditions of shock may be isolated during necrotic amoebic colitis (13 cases). Eight patients present a simple hypovolemic shock secondary to wastage by diarrhea and perilesional oedema with globular, protein, alcaline and potassic deficiency. Its prognosis is relatively good, after vascular infilling and corrections of metabolic disorders. Five other patients present real toxi-infectious shock resulting from widespread tissue necrosis with auto-intoxication associated with septicemic complications. Its prognosis is frankly bad. The treatment is far more difficult. The use of cardiovascular analeptics, such as dopamine, after an infilling failure, is not always sufficient to re-establish the situation. The exeresis of necrotic tissues is an indispensable condition to remove the cause of the shock before septicaemic generalisation.