Dysentery

Definition: The term "dysentery" means frequent passage of loose stools with blood, pus and mucus associated with tenesmus [Tenesmus refers especially to ineffectual(নিষ্ফল) and painful straining(জড়াইয়া ধরা, জাপটাইয়া ধরা, জোরে টানা) for an extended time. Straining to defecate (মলত্যাগ করা) is called rectal tenesmus; straining to urinate is called vesicaltenesmus.]

Classification:
A. Bacillary dysentery (Shigellosis: Sh.dysenteriae, flexneri, boydii, sonnei)
B. Amoebic dysentery(Entamoeba histolytica)

A. Bacillary dysentery (Shigellosis: Sh.dysenteriae, flexneri, boydii, sonnei):
Aetiology:

1. Incubation period: 1-7 days
2. Causative agents the Shigellae are classified into four subgroups A, B, C and D due to their different antigenic and biohemical properties. 
3. However, the four important species are Sh. Dysenteriae, Sh.Flexneri, Sh.Sonnei. 
4. There are 40 serotypes for 4 species. 
5. All these liberate endotoxin[a toxin that is present inside a bacterial cell and is released when the cell disintegrates(ভাঙ্গা). It is sometimes responsible for the characteristic symptoms of a disease, e.g., in botulism.], but Sh.dysenteriae, Sh. sonnei and Sh.flexneri liberate(মুক্ত করা) exotixin(a toxin released by a living bacterial cell into its surroundings) in addition. This exotoxin has neuroenterotoxic properties. Sh.dysenteriae is the gravest type and type I is the commonest offending agent. 
6. Contamination(দূষণ) of food by careless handling is the main source of infection. The infective dose is 10^2-10³ organisms.

Clinical feature:

Symptoms:

1. Onset(সূত্রপাত) is acute usually but there may be very mild diarrhoea with gradual onset
2. Patient passes loose stool (diarrhoea) for first few days and then loose stool is mixed up with blood, pus and mucus
3. There is marked tenesmus and colicky abdominal pain with nausea and vomiting
4. There is moderate high fever, weakness and patient complains of thirst and dryness of tongue, oliguria at times anuria. 
5.  In severe cases there may be intense headach due to meningismus, backache, muscle pain and sometimes coma and convulsion are present

Complication:

1. Severe haemorrhage and anemia
2. Perforation
3. Pritonitis
4. Rectal prolapse
5. Temporary disaccharidase deficiency
6. Peripheral circulatory failure
7. Toxic carditis
8. Renal failure, haemolytic uraemic syndrome
9. Peripheral neuritis, Guillian-Barre syndrome
10. Pneumonia, Pleurisy
11. Toxic non suppurative arthritis usually involving the weight bearing joints
12. Conjunctivitis and iritis
13. Electrolyte imbalance
14. Cutaneous haemorrhages
15. Meningitis
16. Reiter's syndrome

Management:

1. On examination:
   a) Patient is toxic, pulse shows tachycardia, BP is low, temperature is raised, eyes are sunken due to dehydration. Pallor(বিবর্ণতা, ) is present.
   b) Alimentary system: tongue and mouth are dry, abdomen shows diffuse tenderness, particularly over the whole of colon. The pelvic colon is very tender. Rarely there is splenomegaly. Auscultation reveals hyperperistaltic sound. It is usually a self limited disease. Peripheral neuritis (type-I), Guillain-Barre syndrome (S.boydii), septicaemia may also develop. Chest pain, cough, sputum and pleurisy, Reiter;s syndrome with arthritis, conjunctivitis and urethritis may be presnt. Rarely haemolytic uraemic syndrome may take place associated with leukaemoid reaction. Sigmoidoscopic examination reveals generalised inflammed congested mucosa with punctate ulcers.
2. Special Investigation:
   a) Leucocytosis with increased neutrophils
   b) Serum electrolyte test(it may be low due to loss of fluid)
   c) Stool R/M/E (Colour is pinkish red or frank blood may be present, mucus is present. All these give an appearance of so called Red current jelly. Faecal matter is scanty or nil. Stool is alkaline in reaction. Microscopic examination shows RBCs, pus cells, macrophage cells and pleanty of bacteria with shreds of mucus.)
   d) Culture (Culture should be done from freshly passed stool which is to be immediately incubated in MacConkey or Shigella-Salmonella SS or Xyloselysine deoxycholate XLD agar or enriched broth)
3. General:
   a) Rest in bed
   d) To combat dehydration 5% dextrose in normal saline IV drip may be given according to the necessity.
   c) Potassium replacement may also be done
   Orally reconstituted electrolyte powders may be given in the form of drink called oral rehydration solution (ORS-recommended by WHO) as below:

   Sodium Chloride	3.5 gm
   Sodium Bicarbonate	2.5 gm
   Potassium Chloride	1.5 gm
   Glucose or Sucrose	20 gm or 40 gm

4. Medicine:
   a) Merc-C: 
   In dysentery there is more violence; copious bleeding; great anxiety, can scarcely leave the stool a second, great tenesmus of rectum and bladder; urging to urination and stool is constant; great burning in the rectum. It is a violent case of dysentery. I would prefer Merc. in ordinary Merc. cases, but if this patient is not relieved he will not live, and Merc. cor. is needed here.
   
   
   b) Nux-V:Constipation, with frequent ineffectual urging, incomplete and unsatisfactory; feeling as if part remained unexpelled. Constriction of rectum. Irregular, peristaltic action; hence frequent ineffectual desire, or passing but small quantities at each attempt. Absence of all desire for defecation is a contra-indication. Alternate constipation and diarrhśa-after abuse of purgatives. Urging to stool felt throughout abdomen. Itching, blind hćmorrhoids, with ineffectual urging to stool; very painful; after drastic drugs. Diarrhśa after a debauch; worse, morning. Frequent small evacuations. Scanty stool, with much urging. Dysentery; stools relieve pains for a time. Constant uneasiness in rectum. Diarrhśa, with jaundice (Dig).
   c) Canth: This remedy, which produces such an intense vesical tenesmus, also produces a like condition in the rectum. Its characteristics are bloody and slimy discharges which look like the scrapings of the intestines, which are nothing but the fibrous exudations from the disease. Tenesmus is marked, and always with Cantharis there is a painful urination, and there is present a colic-like pain doubling the patient up, being here similar to Colocynth, which has a number of the same symptoms. Thus both have the above symptom of being doubled up by pain, both have slimy and bloody stools, worse from eating or drinking; but under Colocynth the pains cease after stool and the patient is relieved by bending double. Cantharis has more inflammation, Colocynth more nervous symptoms. Colchicum is also similar, the tenesmus and constriction of anus following stool is more tormenting than the urging during stool; tympany also strongly indicates Colchicum. Kali bichromicum follows Cantharis when the scrapings become jelly-like. The thirst with Cantharis is unquenchable.
   d) Caps:Capsicum has frequent small stools attended with tenesmus and burning in the rectum, but to have Capsicum well indicated the symptoms of shivering when the patient drinks should be present.
   e) Coloc
   f)  Phos
   g) Rhus-t
   h) Sulph: For persistent or chronic cases of dysentery Sulphur is the remedy; the tenesmus continues, in fact there is a sort of tenesums all the time, the stools are slimy and there is frequent sudden urging to stool. Sometimes this condition is present without the tenesums. In Nux the tenesums ceases after stool and the pains are relieved for a short time; it is similar to Sulphur in its frequent urging, the stools are bloody, slimy, scanty and watery,and the patient is worse in the morning. Tearing pains down the thighs as an accompaniment of dysentery would indicate Rhus toxicodendron. Great offensiveness of stools and constriction of the anus would suggest Lachesis. Baptisia is useful where there is tenesums but no pain which indicates vital depression, offensive discharges are also present. It is especially useful in dysentery of old people with fevers.
   i)  Acon: In the first stages of dysentery Aconite has proved a useful remedy, and it comes in especially well when the days are warm and the nights are cold. ,The stools are frequent and scanty with tenesmus, the skin is hot and dry and general Aconite symptoms are present. Ferrum phosphoricum comes in cases less acute than Aconite; there is more blood with the stool, but tenesmus contra-indicates the remedy. Mercurius follows both well. Belladonna is especially suitable to the dysentery of children and plethoric young persons. Cowperthwaite recommends the 3X.
   j)  aloe: Aloes is also a useful remedy in dysentery. The stools are of a jelly-like mucus, and covered with blood and accompanied by griping in the epigastric region, the amount of mucus expelled is large, and, like Sulphur,it is useful in chronic cases. It is also a splendid remedy in purely inflammatory dysentery and follows Aconite well. Ipecac may be useful in cases where large quantities of mucus are expelled. In haemorrhoidal dysentery, which is really a phlebitis of the haemorrhoidal veins, Aloes and Hamamelis are the remedies.
   k) ars: Arsenicum is a valuable remedy in dysentery. There are scanty stools, burning in the rectum, thirst, and after the stool there is great prostration, but there is not the tympanitic distention of the abdomen found under Lycopodium and Carbo vegetabilis; though the patient is restless and thirsty, water is borne badly. Stools which are undigested, slimy and bloody, indicate Arsenicum. Blackish brown, horribly offensive stools also indicate well the remedy. The tenesmus and burning of the anus and rectum continue after stool. If Arsenicum be well indicated its characteristic thirst and restlessness must be present.
   l)  carb-v
   m) Coloch
   n) gels
   o) ham
   p) ip
   q) Mag-c
   r) Merc: Mercurius solubilis corresponds more to sporadic cases, and is seldom indicated in malignant types, and in mild cases Mercurius dulcis is an excellent remedy where tenesmus and pain are slight.
   s) Staph
   t) If there is marked anemia as a result of severe bleeding blood transfusion may be given
   u) If there is shock and collapse, circulatory stimulants such as Dopamine in the drip along   with steroids particularly Hydrocortisone haemisuccinate may be givenand continues to maintain an effective systolic blood pressure
   v) For severe colicky pain Atropine, Atropine. These drugs are better avoided.
   w) For vomiting, Phenothiazine derivatives, Domperidone, etc. may be given
   x) If extrarenal uraemia develops it should be treated accodingly
5. Specific:
   a) Co-trimoxazole (double strength, containing Trimethoprim 160 mg and Sulphamethoxazole 800 mg) may be given twice or trhice daily for about 5-7 days.
   b) New drugs like Ciprofloxacin, 750 mg twice daily
   c) Norfloxacin 500 mg daily for 3-5 days may also be helpful
   d) Ciprofloxacin and Levofloxacin are contraindicated in pregnancy
   e) It is to be remembered that so long culture report is not available, Co-trimoxazole may be      started first.
   f) Recently few resistant strains are also observerd against this important anti bacterial agent
   g) One should be very cautious in using these drugs as drug resistance of different characters may develop very often
   h) this drug resistance is seen to be mediated by a cytoplasmic DNA Particle (R factor) which replicates and may be transferred among various gram-negative bacilli of the intestine
   i) In very mild cases, sometimes, specific drugs are not required