DYSENTERY / MedUrgent

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DYSENTERY





 Dysentery is an acute inflammation of the large intestine characterized by diarrhea with blood and mucus in the stools.

Differential diagnosis of acute dysentery:

1. Acute amoebic dysentery: Has a slow insidious onset. No fever is present and the patient's condition is generally good (Walking dysentery). It is the bacillary dysentery which requires lying down. In the chronic cases, patients may even be normal. Abdominal pain if present is of a grumbling nature. Stools are offensive, watery and rather bulky. They give an acid reaction and may contain blood and mucus. Under the microscope, they are seen to contain RBC's, a few pus cells and the trophozoite form may be found. On sigmoidoscopy, the classical flask-shaped ulcer may be seen.

2- Food poisoning: The patient presents with vomiting, diarrhea and abdominal pain within 48 hours of intake of contaminated food. There may or may not be toxicity, body pains, fever or other systemic manifestations. The time at which the symptoms begin may help in giving an indication to the causative organism. Diagnosis is usually by culturing the stools or vomitus. In some severe cases, a blood culture may be required.

3- Dysenteric malaria: This is due to P. falciparum. It occurs with heavy infections and shows fever and rigors. A blood film will demonstrate the presence of heavy parasitaemia.

4. Shigella infections; these differ in severity, and may range from asymptomatic to total incapacitation. Patients may complain of diarrhea abdominal pain and tenesmus. Its diagnosis depends on the culture of the faeces. Fever is usually present. Microscopic stool examination demonstrates blood and pus cells.

 
Differential diagnosis of chronic dysentery:

1. Schistosomiasis: There is usually a history of residence in an endemic region or history of a previous infection. It manifests with central abdominal pain, splenomegaly, hepatomegaly, and the stools are usually bloody and mucoid. The diagnosis is confirmed by finding Schistosoma eggs in the stools and rectal snips. The patient does not look ill.

2. Ulcerative colitis: Signs include changes in the skin, involvement of the eyes and arthritis. There is a painless diarrhea, with bloody mucoid stools, but no organisms are found. A barium enema or rectal biopsy will show features of ulcerative colitis. Sigmoidoscopy, which is important, shows a gray ground appearance, shallow ulcers and a weeping mucosa that tends to easily bleed on touch.

3. Tuberculous colitis: This is often under-diagnosed. It can be due to ingestion of infected sputum, infected food or drinks like milk. It presents with fever, ill-health, and diarrhea with blood and mucous. Sigmoidoscopy and biopsy will demonstrate granulomatous lesions on histological examination.

4. Crohn's disease: The small bowel is usually affected, but lesions may cross the cecum to involve the large bowl. To demonstrate the step lesions and cobble-stone appearance, biopsies and barium enema studies are required.

TREATMENT

Supportive treatment is the most necessary in the acute stages, and this includes:

1. Rehydrating the patient by fluid replacement either orally or by IV Infusions, depending on the degree of dehydration and general condition of the patient. Care must be taken to keep the Na, K and bicarbonate within normal limits. Estimation of serum levels is important. 2. Food should be soft to prevent perforation and further complications. Symptomatic treatment: Anti-spasmodic for the abdominal pain. 2. Sedation. Anti-diarrhea drugs such as loperamide (Imodium) in adults which is a non-opiate preparation may be used. Opiates such as Codeine may also be used. These help by decreasing the propulsive intestinal movements, the number of motions and the pain. These are contraindicated in children as they lead to the retention of the causative organism, and cause undue complications. Loperamide in children has been reported to cause sudden death.

Specific drugs:

1) Sulphonamides (soluble Sulphadimidin + insoluble Sulphadiazine) were used in the past, but most Shigella species are now resistant to sulphanomides and thus they are no longer recommended.

 2) Metronidazole: effective against anaerobics, giardiasis, amoebiasis. Dose for adults is 500 mg 8 hourly for 5 days. For children the dose is 15-50 mg/kg/day in 3 divided doses for 5 days. 3)Ampicillin is a drug of choice. It is given as 500mg every 6 hrs for 5 days. A sensitivity test should be carried out. Another specific drug used is Penglobe (bacampicillin). This is long- acting and has a better bioavailability. It comes in the form of tablets of 900mg, and is given in a dose of one tablet, twice daily for 5 days.

4) Cotrimoxazole, which is given as two tablets twice daily for 5 days (adults).

5) Tetracycline may also be used at a dose of 600mg every 6 hrs for 5 days. It may also be given as a single oral dose of 2.5 grams daily instead (not used for children). In mild cases, drugs are not required. Kanamycin, Gentamycin and Streptomycin were found to be ineffective.

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