A CLINICOPATHOLOGIC STUDY ON PATIENTS SUFFERING FROM"CHRONIC DYSENTERY"

A. K. Azad Khan, M. N. Alam and K. M. Nazrul Islam

Department of Medicine and Department of Pathology,Institute of Post-Graduate Medicine and Research, Dacca-2.

Patients with symptoms of constipation or diarrhoea, passage of mucus and

pain abdomen most of1en relieved by opening the bowel are commonly encountered

in the medical practice in -Bangladesh. The patients generally present themselveswith the saying that they are suffering from "chronic dysentery." They are com-monly treated with antiamoebic drugs, sometimes with apparent relief. We have

failed to come across reports on the aetiology and pathology of this condition.

In the present paper we are reporting the sigmoidoscopic and histologicappearances of the rectal mucosa of a group of these patients.

PATIENTS AND METHODS

Adult patients of both sexes with the above complaints were selected at random

for the study. A few of them also complained of occasionally passing blood with

faeces' All the subjects were attending as outpatients at the time of the study.Microscopic examination of faeces f'om these patients were made on three con-

secutive days by one microscopist. The patients were then subjected to sigmoi-doscopic examinations within three days of the collection of the last faecal sam-

ples. The sigmoidoscopic appearances were recorded and a rectal biopsy taken,

usually from the posterior wall at about 10-15 em. from the anal margin.

In cases where rectal mucosa appeared abnormal, the biopsy was taken from,the suspected area. These biopsy specimens were immediately placed in 10%formalin and were later on studied under light microscope after haematoxylin andeosin staining.

The clinician who took thl;;} history, examined the patients and performed the

sigmoidoscopic examinations, the microscopist examining the faecal samples andthe histopathologist reporting on the rectal biospy specimens were unware of eachother's findings while recording them.

RESULTS

Fifty patients completed the study. Their sigmoidoscopic findings are shownin table I.

The histologic findings of these patients are shown in table II.

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TABLE - II

Histological finding

Normal or mild increase innumbers of round cells in I Moderate proctocolotis

the lamina propriaSevere proctocolitis

45 I 1 4

Of the 50 patients 10 presented with Entamoeba histolytica (E.h.) cyst and onlyone had trophozoites of E.h. in the faeces. For the present study other parasi-ticisms wire not considered.

Correlation: Sigmoidoscopic vs. histologic appearances - Of the 44 caseswhich were sigmoidoscopically normal most of them had mild increase in thenumbers of round cells in the lamina propria. One patient however showed mo-

derate increase in the number of round cells in the lamina propria of the rectalmucosa although sigmoidoscopically it appeared normal. The surface epithelium,

goblet cell population and the glands of all these rectal biopsy specimens weremorphologically unremarka ble.

Two patients on sigmoidoscopy appeared to have mild or patchy inflammation.

Their rectal biopsy specimens showed only mild increase in the numbers of roundcells in the lamina propria with normal surface epithelium, goblet cells and glands.

Four patients on sigmoidoscopy appeared to have moderate to severe inflam-

mation. This was also confirmed by histology.

Faecal findings vs. sigmoidoscopic and histologic appearances - In the presentstudy only the presence of Entamoeba histolytica (E.h.) in the faecal sample,swas

Vol IV No. 2 CHRONIC DYSENTERY-KHAN, ALAM & ISLAM

TABLE

Sigmoidoscopic findings--

Infla mmationNormaI

Moderate to severe \ Mild or patchy_._--- I

44 I 4 I 2

BMRC. BULLETIN Dec., 1978

considered for the correlations. Eleven patients showed E.h. in their faecal sam.

pies. Only one of them passed trophozoites of E.h. A1 the time he was havingbloody diarrhoeea. The sigmoidoscopy revealed diffuse inflammation and markedoedema compatiable with ulcerative colitis. The histopathology of the biopsyspecimen also showed features of severe ulcerative colitis. No atr.oeba could beseen in the biopsy sample. The remain!ng ten patients showed E.h. cysts in thefaeces and their sigmoidoscopic appearances were normal. Save for a mild in-crease in the numbers of round cells in the lamina propria, their biopsy spet:.imenswere unremarkable.

DISCUSSION

In the present study mo~t of the patients had normal sigmoidoscopic appearan-ces. The histopathology revealed only mild increase in the numbers of chronicinflammatory cells in the lamina propria. There was no apparent correlation be-tween the presence of E.h. cysts in the faecal samples and the increase in the num-bers of round cells in the lamina propria of the biopsy samples. It appears thatmild increase in the numbers of chronic inflammatory cells in the lamina propriaof the rectal biopsy specimens in comparison to those of the European population(Whitehead, 1973) may be normal for the locals. Although it was not possiblefor us to make a quantitative assessment of the number of cells (Dunnill and White-head, 1972) nevel theless, there was some increase in the numbers of round cellsin the lamina propria of these rectal biopsy specimens. Although much has beenwritten concerning the racial or geographic variations in the morphology of thejejunal mucosa (Sprinz et ai, 1962; Baker et ai, 1962; Banwell et ai, 1964;Colwell et ai, 1968; Brunser et ai, 1970), there is little in the literatureconcerning the colon and rectum in this respect. Preliminary studies with rectalmucosa from the apparently normal local population have shown mild increasein the number of round cells in the lamina propria and a larger study is in progress.

Our patients presented with the self-diagnosis of "chronic dysentery." Theincreased cellularity in their rectal mucosa mayor may not be related to the sym-ptoms. We believe that the latter proposition is more likely and most of thesepatients were suffering from irritable bowel syndrome where the sigmoidoscopicappearances and histology of the rectal mucosa are essentialy normal (Trueloveand Reynell, 1972).

In the present study there was no apparent difference in the sigmoidoscopicand histologic appearances of the rectal mucosa from those who passed the cysts

of E,h. in the faeces and those who did not. It might be pertinent to ask whether

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Vol. IV No. 2 CHRONIC DYSETERY-KHAN, ALAM & ISLAM

the cyst passers from endemic areas should be treated with antiamoebic drugsbecause Entamoeba histolytica may not be related to the symptoms. Finding outthe prevalence of cyst passers in the apparently normal population may help tosettle the issue.

The patient who showed E.h. trophozoite in the faeces was suffering from acuteamoebic dysentery. The sigmoidoscopic and histologic appearances of his rectalmucosa were like those of severe ulcerative colitis. We failed to show amoeba

in the biopsy sample. The patient was treated with injections of €,metine hydroch-loride with dramatic response. These findings are in agreement with those ofPittman et al (1973). These authors also failed to demonstrate amoeba in sevenout of 12 rectal biopsy specimens from patients with amoebic colitis. Theirsigmoidoscopic and histologic appearances were like those of active ulcerativecolitis. Prathap and Gilman (1970) did not find crypt abscess in the rectal biopsyspecimens from patients with amoebic colitis. Our patients had a few crypt abscessalthough they were few and far between. We want to emphasize that amoebiccolitis may mimic ulcerative colitis and failure to c'.emonstrate amoeba in the tissue

section does not excluce the diagnosis of amoebic colitis.

From the present study it seems that ulcerative colitis is not a commoncause for colonic symptoms ("chronic dysentery") in this country. Alam et al

(1975) reported a relatively high incidence of ulcerative colitis amongst a similargroup of patients. These authors based their diagnosis from the clinical sysmptomsand the histological evidence of increased numbers of round cells in the lamina

propria. However we believe that increased numbers of these cells in the laminapropria of rectal biopsy specimens may be normal for the local populetion.

SUMMARYFifty adult patients with the self diagnosis of "chronic dysentery" were studied.

Their faeces were examined mcroscopically; they were sigmoidoscoped and theirrectal mucosa were examined histologically. Most of them had irritable bowelsyndrome. Their sigmoidoscopic appearances were normal and the histologyshowed only mild increase in the numbers of round cells in the lamina propria.This was regarded as normal for the local population. Ten patients showed cystsof Entamoeba histolytica in the faeces. This was thought to be unrelated to thesymptoms. Only four patients had sigmoidoscopic as well as histologic evidenceof moderate to severe proctocolitis. One of them was proven to be a case of amoe-bic colitis. These fidings have been discussed.

ACKNOWLEDGEMENTS

We would like to acknowledge thes ervices of Messers A. Zafar, Md. F. HossainMiah and Dr. Badrul Islam for this study.

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BMRC. BULLETIN Dec., 1978

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