 |
       |
|
|
PROTOZOAL COLITIS AS THE AETIOLOGYOF GASTRO-OESOPHAGEAL REFLUX DISEASE
JC PATEL*, SV JOSHI**, HL DHAR***
*Former Hon. Physician; **Technical Officer; ***Director, Medical Research Centre, Bombay Hospital Trust,Mumbai 400 020.
Forty four cases attending OPD of Bombay Hospital had symptoms resembling Gastro-oesophageal reflux disease (GORD). On questioning and examination, it was found that they were having symptoms of colitis which was a possible cause of symptoms like that of GORD. Anti-protozoal treatment given for about four to six weeks gave complete relief. From this observation, it was presumed that protozoal colitis was the cause of symptoms simulating GORD in Mumbai and possibly elsewhere in tropics where protozoal infection is prevalent.
It is suggested that those presenting GORD like symptoms should also be investigated and treated not only by upper endoscopy but also for protozoal infection. Our experience shows that treatment for protozoal infection should be for about four to six weeks.
INTRODUCTION
Gastro-oesophageal reflux disease (GORD) is a well recognised syndrome observed in the population all over the world. Commonly the symptoms of GORD are retrosternal burning, regurgitation or pain in chest. In the West it is investigated by endoscopy routinely which shows erosion in the lower oeosphagus in about 30% of patients due to reflux of gastric contents while in India, treatment is planned according to clinical symptoms in most of the cases. It is associated with those who consume fatty food and indulge in smoking. Peptic ulcer is common with variable prevalence all over the world. In India, prevalence of the peptic ulcer is recognised in all states but the actual rate of peptic ulcer prevalence is not known. Gastro-oesophageal reflux disease (GORD) is a multifaceted disease with multiple presentations that affects 30 to 40% of population is West in their lifetime.[1] GORD is described as the clinical manifestations of regurgitation of gastric contents. Classical symptoms as described are : Post prandial reflux of gastric contents in oesophagus, heart burn, pain in lower chest and upper abdomen, nausea, flatulence and fullness of stomach.
The aim of the study is to bring to the notice of clinicians hitherto unreported cause of GORD in patients attending out patient department of Bombay Hospital.
MATERIAL AND METHODS
Patients attend out-patient department for relief of symptoms. Out of 3000 patients attending out patient department (OPD) of one of the authors, 44 cases simulating GORD who did not get relief with usual treatment of GORD by their family physician and some of them who had undergone upper GI endoscopy are presented in this study. Other examination and investigations include their clinical history, basic parameters viz. pulse, blood pressure, weight and blood count and stool examination in cooperative patients. These cases were analysed for the gastrointestinal symptom suggesting GORD and its management.
RESULTS
Out of 3000 cases, attending Bombay Hospital out patient department in a period of two years, 44 persons were found to have symptoms resembling GORD i.e. post-prandial reflux of gastric contents in oesophagus, heart burn, pain in lower chest and/or in upper abdomen, nausea, flatulence, fullness of stomach and dysphagia. Diagnosis of GORD was clinical. Three of them had undergone upper GI endoscopy before attending OPD which was normal or negative. All (forty persons) previously had treatment with antacids and H2 blockers without relief. We considered that these symptoms simulating GORD might be more likely due to chronic infection of colon caused by protozoa and parasitic infection. Most of them, on questioning gave previous history of attacks of loose motions associated with tenesmus at times. Protozoal infection in the colon is known to change bacterial flora of the whole gastrointestinal tract from duodenum to colon. As a result these patients complained fullness of abdomen whole day, more after food. Gastrocolic reflex occurring within half an hour, heartburn and what they described as acidity were observed in all of our OPD GORD patients treatment given by us was that of protozoal infection of colon. Their symptoms were completely relieved with anti-protozoal (metronodazole) treatment. It may be mentioned that most of them had symptoms of nutritional deficiency i.e. glossitis, paraesthesia and general debility probably due to vitamin deficiency caused by lack of absorption of nutrients in duodenum and upper jejunum.
Our OPD patients mentioned above presented with symptoms viz in their own words acidity, heart burn, pain in chest or upper abdomen of varying duration within 30 minutes after food which are described as "GORD". This is termed by us as "Pseudogord". Symptoms are similar to classical GORD but are dissimilar in many ways, both have post-prandial heartburn but time of occurrence is different, oesophageal regurgitation, upper abdominal or lower chest pain etc. However, the time difference of pain is a distinguishing feature as it is within about 30 minutes after meals while in true GORD is about two or three hours after food. Both the conditions include pain in epigastrium, upper abdomen but pseudogord symptoms appear within 10-30 minutes after food while in GORD it is one or two hours or later after food i.e. that of peptic ulcer (Table 1).
Symptoms GORD Peptic ulcer Pseudogord Colitis Heartburn + + Pain in upper abdomen + + Cause of pain Due to increased Acid reflux Due to lienteric colic in colon -after food gastrocolic reflex producing movement in colon-relieved by antispasmodic drugs or treatment for colitis. Time 2 or more hours after food 20 to 40 minutes after food Endoscopy Erosion of lower end of oesophagus Normal, regular or mild inflammation of oesophagus Effective Treatment Antacids and/or H2 blockers Antiprotozoal drugs for longer period
DISCUSSION
In the present study, heartburn, a cardinal symptom was observed in 44 cases. In literature, it is reported in 7-31%[2,3] after consumption of spicy food and in our OPD patients, citrus fruits was similar to that in case of GORD (acid peptic disease) but with the time, cause and treatment difference. Other symptoms included gastric symptoms like nausea, flatulence, epigastric chest pain and gas production.[4-6]
The food is not properly digested and passes on to large intestine - colon. It is the colon where water absorption occurs and the residue of food is passed as stool but the bacterial fermentation continues and causes gas formation which results in bloating of colon particularly that of the transverse and descending. Such distended colon presses upon the post meal full stomach and left dome of the diaphragm causing oesophageal regurgitation after 15-20 minutes of meal which is being reported by our Indian patients as the symptom of acidity - like that of GORD. Occasionally, such person complains of pain in epigastrium which can be explained by movement of inflamed colon producing colicky pain occurring in upper abdomen and is mistakenly believed by many of us as pain of peptic ulcer. In a small number of patients, stool examination was positive but negative in others for protozoal infection viz. Entamoeba histolytica, Giardia lamblia and Trichomonas hominis.
We assumed the symptoms simulating GORD were due to protozoal infection of colon as evidenced by tenderness on palpation mostly all parts and occasionally a part of colon. The treatment given to these patients was mentronidazole in the dose of 200 mg three times a day for a period of one month or more. It was associated with Cotrimoxazole as oral antibacterial preparation to eliminate susceptible bacteria which are considered to be the food of protozoa. In addition, an antispasmodic drug to relieve colic was also given for first seven days. The reason for longer than text book advocated administration of metronidazole, 'in our opinion' is that the infection is of chronic nature and previous intermittent and inadequate treatment. However, the text book published from the 'West' advocates the treatment of protozoal infection colitis by metronidazole for a period of 5 to 10 days. This is based on trials carried out in Western countries where the hygienic conditions are different from the city of Mumbai and in India. In the city of Mumbai most people have their meal and particularly, lunch meals from vendors, hotels, canteens or restaurants with poor hygienic conditions and the servants may also carry infection.
In the past, one of the authors had examined the stools of boys of a canteen of a multinational company where NRIs often had GI infections. Eighty per cent of the staff had stools positive for protozoal infection. They were treated resulting in improvement of GI disturbances (unreported).
The risk of infection and re-infections is high. The prolonged treatment with metronidazole gave relief to all our patients. On this basis, it was considered that the symptoms of GORD associated with hyperacidity and symptoms like peptic ulcer cannot be applied to the patients from the city of Mumbai. Such a syndrome prevalent in this country was named by us as "Pseudogord" and the treatment for this condition should be that of chronic protozoal colitis and not with antacids and H2 blockers.
In this study, a number of patients who had negative endoscopy and were treated with H2 receptors had no relief. However, they responded adequately to protozoal treatment.
CONCLUSION
A novel concept of "Pseudogord" is put forth in this paper with radical difference in management of symptoms resembling "GORD" in which treatment is directed towards protozoal colitis and not against non-existing hyperacidity, peptic ulcer or acid regurgitation.
ACKNOWLEDGEMENTS
We thank the chairman of Bombay Hospital Trust, Mr. Bharat Taparia and Medical Director, Dr. DP Vyas for allowing us to work in out patient department of the hospital. We also thank the OPD staff, nurses and others for assistance and the patients.
REFERENCES
1.Gastroesophageal reflux disease. Gastroenterology clinics of North America. Ed Katz PO. WB Saunders Co. Philadelphia. 1999; 28 (4) : 809-30.
2.Nebel OT, Fornes MF, Castell DO. Symptomatic gastroesophageal reflux : Incidence and precipitating factors. Dig Dis Sci 1976; 21 : 953 (Quoted in reference No. 1)
3.Klauser AG, Scindlbeck NE, Muller-Lissner SA. Symptoms in gastroesophageal reflux disease. Lancet 1990; 335 : 205-8.
4.Hewson EG, Sinclair JW, Dalton CB, et al. 24 hour esophageal pH monitoring : The most useful test for evaluating non-cardiac chest pain. Am J Med 1991; 90 : 376 (Quoted in reference No. 1)
5.Jacob P, Kahrilas PJ, Vanaguna A. Peristaltic dysfunction associated with non-obstructive dysphagia in reflux disease. Dig Dis Sci 1990; 35 : 939 (Quoted in reference No. 1)
6.Small PK, Loudon MA, Waldron B, et al. Importance of reflux symptoms in functional dyspepsia. Gut 1995; 36 : 189-92.
 |