2 English reference amoebic colitis
3 Overview Amebic colitis is caused by Entamoeba histolytica parasitic in human colon. Patients may have abdominal pain, diarrhea, deformities or loose stools, mixed with mucus and undigested food, and have a strong odor. The incubation period is different, 1 ~ 2? Weeks or months or more. Different clinical manifestations may occur due to the different number of ingested cysts, pathogenicity and physical resistance. Chronic patients may be anaemic and malnourished. In addition, the damage of intestinal wall tissue in acute and chronic stages is different, which can cause various complications. With the improvement of nutrition and sanitary conditions, the infection rate decreased obviously.
4 disease name amebic colitis
5 English name amebic colitis
6 classification of gastroenterology >; Intestinal diseases > colorectal diseases
7 ICD number K63.8
According to Giboda, the positive rate of Entamoeba histolytica in the feces of Czech 1982- 1987 international students was 3.9%, and the positive rate of serum antibody was 7.9%. According to the statistics of the World Health Organization and the US Centers for Disease Control 1992, there are about 400-500 million people infected with this disease in the world, and tropical, subtropical and developing countries and regions are the high incidence areas, with the infection rate as high as 10%-30%. With the development of international tourism, the infection rate of this disease in developed countries will increase again. For example 1988 After an Italian tour group visited Thailand, amebic colitis and liver abscess broke out. Amebic colitis is rare in northern China. However, it still happens in South China. According to the "Disease Surveillance" of the Ministry of Health, 4,583 cases were reported in 196, 3,583 more than in 195. 197 The number of cases in the first four months was 7 16, 459 more than the same period last year.
9 Etiology In recent years, it has been reported that a part of Entamoeba histolytica is non-pathogenic and can live in the intestines of some people for a long time without causing symptoms. Non-virulent strain and virulent strain have different surface antigen components, and do not produce proteolytic enzymes, and host blood does not produce corresponding antibodies.
The pathogenic mechanism of 10 Entamoeba histolytica has two different forms in its life history: trophoblast and cyst stage. After being ingested, the cyst can pass through the stomach and the upper part of the small intestine without injury, and be digested by trypsin in the lower part of the small intestine. Mature tetranuclear cysts can be detached and become small trophozoites (diameter 7 ~ 20? M), parasitic in intestinal cavity, feeding on bacteria, without damaging intestinal wall tissue, both of them divide and reproduce, and grow well in anoxic ileum. When the body's resistance is insufficient or the local intestinal mucosa is damaged, the small trophozoite can become a large trophozoite (diameter 20 ~ 40? M), can secrete tissue-dissolving enzyme to destroy intestinal wall tissue, invade intestinal mucosa and submucosa, multiply in large numbers, and form localized submucosal abscess, the contents of which are mainly necrotic substances, and the abscess ruptures to form flask-like ulcer. The mucosa between ulcers is basically normal, which is obviously different from bacillary dysentery. When the body's resistance is enhanced, large trophozoites can become small trophozoites, and can further become cysts (diameter 10? M or so), excreted with feces. It can survive for 2 ~ 4 weeks in a cool and humid environment and 6 ~ 7 weeks in a refrigerator, but it is not heat-resistant, and it will die at 50℃ for 5 minutes. Only mature 4-nucleated cysts are contagious, and immature 1 ~ 2 cysts are not contagious, but they can develop into 4-nucleated cysts in suitable external environment. If the large and small trophozoites are excreted, they all die quickly. If the course of disease is prolonged, the destruction of intestinal wall tissue and the proliferation of connective tissue are carried out at the same time, which can cause intestinal wall hypertrophy and intestinal cavity stenosis, and occasionally "amoeba tumor" can be formed due to excessive proliferation of connective tissue.
1 1 Clinical manifestations of amoebic colitis The incubation period of amoebic colitis varies from 1 to 2 weeks or more. Different clinical manifestations may occur due to the different number of ingested cysts, pathogenicity and physical resistance.
1 1. 1 asymptomatic type mainly refers to the carrier of amoeba cyst, which is often ignored by patients because of its mild symptoms. The epidemic prevention station in Maanshan reported amoeba positive cases 1 166 cases, of which 22.7% were asymptomatic. These patients are an important source of infection of this disease.
1 1.2 Amebic enteritis is similar to common enteritis. Patients may have abdominal pain, diarrhea, shapeless or loose stools, mixed with mucus and undigested food, and have a strong odor.
1 1.3 Amebic dysentery is similar to bacillary dysentery, but the poisoning symptoms are mild. The patient can have a fever of about 38℃, abdominal pain and diarrhea, which can reach 10 times a day. The stool is bloody mucus stool, or the stool is separated from blood, and sometimes it can be completely bloody stool. If the frequency is not much, the feces are dark red or jam-like, which has a strange smell.
12 Complications of chronic patients with amebic colitis may include anemia and malnutrition. In addition, intestinal wall tissue is damaged differently in acute and chronic stages, which can cause the following complications.
12. 1 peritonitis caused by intestinal perforation 254 cases of amebic dysentery were reported, and 9 cases were confirmed by operation and autopsy, accounting for 7.48%. Adams reported that 97 out of 30 13 cases had peritonitis (3.2%). Although the incidence is not high, the prognosis is poor.
12.2 Clark reports 186 40% of patients with amoeba suffered from appendicitis in autopsy. Criag reported that 26.67% of 60 cases were complicated with appendicitis. The incidence rate is really high. Therefore, in areas with high incidence of amoebiasis, many acute abdomen are caused by amoebic appendicitis or perforation of amoebic appendix.
12.3 chronic amoebic colitis with intestinal stenosis, intestinal wall hyperplasia and hypertrophy, amoebic granuloma formation, leading to stenosis. A few patients even form intestinal obstruction and need surgical treatment.
Adams reported 30 13 cases of amoeba tumor, of which 15 cases developed amoeba tumor (0.5%).
12.5 The amoeba of nonspecific ulcerative colitis has been completely eliminated and transformed into nonspecific ulcerative colitis. According to Adams statistics, there are 2 1 case (0.7%).
In addition, there are rare intestinal bleeding, intestinal polyps and intussusception.
13 laboratory examination and stool examination are important basis for diagnosis. Non-pathogenic amoeba needs to be identified after the pathogen is found. At present, serological examination is developing rapidly, which is the key experiment to diagnose amoebiasis. About 90% of patients' serum can be detected by ELISA, indirect hemagglutination and indirect immunofluorescence. PCR diagnosis technology is a very effective, sensitive and specific method.
The WHO Committee suggested that the cysts with four nuclei found under the microscope should be identified as Entamoeba histolytica or Entamoeba dispersa; The trophozoite containing red blood cells was detected in feces, which should be highly suspected to be Entamoeba histolytica; Serological examination showed high titer positive, which should be highly suspected of entamoeba histolytica infection. Amoebiasis is only caused by Entamoeba histolytica.
14 auxiliary examination 14. 1 colonoscopy is feasible for those cases with high clinical suspicion that microscopy, serology and PCR have no positive results. About 2/3 of the symptomatic cases, scattered ulcers of different sizes can be seen in the mucosa of rectum and sigmoid colon, the surface is covered with yellow pus, the edge is slightly prominent, slightly congested, and the mucosa between ulcers is normal. There are more chances to find trophozoites by scraping materials from ulcer surface under microscope.
14.2 x-ray barium * * * examination showed that the lesions were filling defect, spasm and congestion. Although this discovery is not specific, it is helpful to distinguish amoeba from intestinal cancer.
15 diagnosis The patient's fresh feces, especially bloody mucus, are carefully searched for amoeba, and once the active amoeba histolytica trophozoite that devours red blood cells is found, the diagnosis can be made. If you don't find it once, you should check it many times and try to cultivate bacteria and amoeba. Attention should be paid to heat preservation during microscopic examination, otherwise the amoeba trophozoites are inactive and difficult to distinguish from macrophages. Colonoscopy is very helpful for diagnosis, especially for differential diagnosis. In acute stage, flask-like ulcer can be seen, and the mucosa between ulcers is normal. Intestinal mucosal hyperplasia, granuloma and polyps can be seen in the chronic stage, and the living tissue can be taken out from the lesion for pathological examination to further determine its properties.
16 amebic colitis should be differentiated from acute and chronic enteritis, acute and chronic bacillary dysentery, nonspecific ulcerative colitis and colon cancer. The most important thing is stool examination and sigmoidoscopy. It should also be differentiated from enteritis caused by other parasites. For example, patients with schistosomiasis may have symptoms of abdominal pain and diarrhea, small yellow particles scattered on intestinal mucosa can be seen by B-ultrasound, and schistosome eggs can be found by taking live tissue. Giardia parasitizes the small intestine and can cause abdominal pain and diarrhea. The cysts and trophozoites of Giardia langbianensis can be found in feces. If duodenal drainage is performed, the positive rate of drainage fluid will be higher. In the past years, it was thought that Entamoeba fragilis parasitized in human colon was not pathogenic, but in recent years, it was suggested that Entamoeba fragilis could cause gastrointestinal symptoms in some people, especially abdominal pain and diarrhea. The stool is pasty or formable 2 ~ 4 times a day, and there is no obvious lesion in the colon mucosa. So far, it has not been confirmed that it has cysts, so the route of infection is still unclear. Some people think that it may be an infection of pinworm eggs or larvae. This problem deserves further study in the future. The trophozoite of fragile binuclear amoeba is small, with a diameter of 3.5 ~ 12? M, hematoxylin staining can see that there are two nuclei, which are not difficult to distinguish from the trophozoites of Entamoeba histolytica.
17 the principle of treating amebic colitis with anti-amoeba drugs is to eliminate both symptoms (trophozoites) and infectivity (cysts), so as to completely cure the patient and eliminate the source of infection. In the past, the combination therapy of ipecacine (ipecacine) and Kuiiodine prescription (or carbaarsenic) was commonly used, and it is still applicable now. In recent 10 years, some new drugs have been used in clinic with good curative effect and low toxicity.
1. metronidazole (metronidazole, metronidazole)? It is effective on the trophozoites and cysts of amoeba and has little toxic effect, so it has been widely used at home and abroad. The dosage is 3 times /d, 800mg each time, 5 ~ 10 day, and the curative effect can reach about 90%. Some treatments are not effective, which may be related to the small dose, which makes the intestinal cavity unable to reach the effective concentration.
2. Tinidazole (metronidazole) can kill the trophozoite of amoeba, and has a certain effect on cysts. The dosage is 1g, twice a day for 3 ~ 5 days, and the curative effect is over 90%. The side effects are abdominal discomfort, nausea, vomiting, constipation or diarrhea, but the incidence is low and mild. It has no adverse effects on heart, liver, kidney and blood.
3. Diclofenac furoate is effective for intestinal trophozoites and cysts. Three times a day, 500mg each time, 10 day, the curative effect is about 80%. Side effects may include flatulence. No toxic effects were observed.
4. The characteristic of etoposide is that it is not absorbed by oral administration, and its insecticidal effect is higher than metronidazole. Oral administration of 20mg/kg per day can achieve about 80% curative effect, but there are few reports on clinical application at present.
18 patients with uncomplicated amebic colitis have a good prognosis. According to Adams' statistics, the mortality rate is 0.5%, mainly due to severe water loss and electrolyte imbalance. If there are complications, it will obviously affect the prognosis. The mortality rate of peritonitis complicated with intestinal perforation can be as high as 40.2%. Therefore, we should strive for early diagnosis and early treatment. Severe patients should be seriously and actively treated with anti-amoeba and symptomatic treatment. Once perforation occurs, emergency surgical treatment should be given.
19 prevention of amebic colitis drinking water must be boiled, and lettuce should not be eaten to prevent the diet from being polluted. Prevent flies from breeding and kill flies. Check and treat patients with cyst pus and chronic diseases engaged in catering industry, and change jobs during treatment. Pay attention to personal hygiene such as washing hands before and after meals.
Related drugs: trypsin, oxygen, emetine, Tugen, Kuiiodine prescription, metronidazole, tinidazole and dichlorophenol.
2 1 related test trypsin
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