Perforated colonic ulcer as a complication of amebic colitis: a case report

¹Surgery Department, Red Sea University and Portsudan Teaching Hospital, Portsudan, Sudan, ²Central Laboratory Histopatholgy Department, Ministry of Health, Portsudan, Sudan, ³Surgery Department, Port Sudan Teaching Hospital, Portsudan, Sudan, ⁴Medicine Department, Red Sea University, Portsudan, Sudan

^&Corresponding author
Amar Yahia Ibrahim, Surgery Department, Red Sea University and Portsudan Teaching Hospital, Portsudan, Sudan

Introduction    

Necrotizing amoebic colitis is a rare complication associated with colon amebiases [1]. Only a few cases of this condition have been published and reported in the literature [2]. It has a high mortality rate and poor outcomes [1-4]. Death may happen in two-thirds of patients with this condition [5]. The causative organism for amoebiasis is the entamoeba histolytica which is an enteric protozoan [1]. Untreated amoebiasis may complicate into a fulminant amoebic ulcer [6]. This complication cause spontaneous colonic perforation [6]. It causes generalized peritonitis [6]. It mimics other causes of acute abdomen, specially perforated duodenal ulcer and acute appendicitis [7]. It is related mainly to low-income countries [6,7]. Early diagnosis and management of this condition are required due to the fatal anticipated outcome [2,8].

Patient and observation     

Patient information: we present a case of a male 20 years old free worker of low socioeconomic class. He presented to the emergency unit with generalized abdominal pain and fever for 10 days. The condition started with central sudden severe abdominal pain that progressed to generalized abdominal pain in a few hours. The pain was dull aching in nature, not relieved nor aggravated by anything. The pain was not shifted to any other site. The pain was associated with high-grade fever that is continuous all over that day, more at night and associated with rigors. Three days before admission patient developed vomiting three times per day, greenish in color, a large amount. The condition was associated with loss of appetite but no significant weight loss. On the day of admission, the patient passed a small amount of stool normal in color, and also passed flatus. No jaundice no marked abdominal distention no hematemesis no melena. Past medical history, and drug and family histories were not significant.

Clinical findings: on general examination the patient was of average build, he was irritable, looked ill, not pale, jaundiced, or cyanosed. Vital signs: PR 110 per minute, BP 110/60, Temp 38°c, RR 35. There was tenderness all over the abdomen with guarding, the maximum tenderness was in the right iliac fossa and right side of the abdomen. There were no bowel sounds. In per rectal examination, the rectum was empty.

Timeline of current episode: the condition started at home with central sudden severe abdominal pain on 23/6/2022. The patient developed vomiting on 30/6/2022. He was presented to the emergency unit with generalized abdominal pain and fever on 3/7/2022. He underwent an urgent laparotomy, perforation detected and right hemicolectomy was done on 3/7/2022. On 8/7/2022, the patient developed discharge from the wound of the infected fluid. A diagnosis of intra-abdominal sepsis and pus collection was done. On the same day, the patient underwent exploration laparotomy. After the Intraoperative there was pus collection in the pelvic, the patient developed shortness of breath, cough and he died. On 12/7/2022 the histopathology result came back. Areas of bacterial colonies were noticed along with amoebiasis-like structures. The final diagnosis of the perforated amoebic ulcer was made.

Diagnostic assessment: lab investigations presented in Table 1. The other blood investigations were within normal limits. Erect abdominal X-ray showed a large amount of air under both hemidiaphragm (Figure 1).

Clinical diagnosis: perforated viscus is most likely a perforated duodenal ulcer.

Therapeutic intervention: after recusation, the patient underwent an urgent laparotomy. At the opening of the peritoneum, there was a gush of a large amount of fluid mixed with fecal materials. The estimated amount was two litres. The abdomen was washed with normal saline, then the site of perforation at the hepatic flexure of the colon was identified. The perforation was transversed, about five cm in length. Also, there were multiple adhesions and difficult anatomy at the site of perforation due to the prolonged inflammatory process. Right hemicolectomy was done, and the specimen was sent to histopathology. Specimen of the right hemicolectomy and site of perforation is shown in (Figure 2).

Follow-up and outcomes: on day one postoperative patient was still febrile RR 35, PR 104, BP 150/80, Temp 39.7°C abdominal tenderness confined to the area of the midline incision. On day 5 post-operative, the patient developed discharge from the wound of infected fluid. A diagnosis of intraabdominal sepsis and pus collection was done. So, the patient underwent exploration laparotomy. Intraoperative there was pus collection in the pelvic, subphrenic, and subhepatic spaces and the right paracolic gutter. Intra-abdominal wash with normal saline was done. Two days post-operative, the patient developed shortness of breath and cough and he died. After 10 days the histopathology result came showing multiple areas of perforation with granulation tissues and an inflammatory process extending to the surrounding bowel structures. Areas of bacterial colonies were noticed along with amoebiasis-like structures (Figure 3, Figure 4). The final diagnosis of the perforated amoebic ulcer was made.

Patient perspective: after arrival to hospital and recusation, the patient temporarily improved. He was pleased about the hospital care and the interventions. The patient and the family were surprised by the amount of pus that came out from the patient abdomen. After patient died they were grateful to the hospital staff for efforts to save patient life.

Informed consent: an informed written consent was obtained from the patient's father to publish this work after the patient died.

Discussion     

Fulminant necrotizing amoebic colitis is a fatal rare disease that is associated with large bowel perforation and late presentation. The patient in this study was presented late to the hospital due to his poor socioeconomic class. This delayed presentation has a direct impact on the outcome. The presenting complaint of our patient was matched with peritonitis secondary to intra-abdominal sepsis. The diagnosis was confused with that of other causes of generalized peritonitis. This confusion in diagnosis is commonly seen in cases of NFAC. R. A. Lubynski et al. had seen 6 patients with amoebic bowel perforation in 1981 at Baragwanath Hospital. He stated that the disease duration was short, and the diagnosis was made pre-operative only in two cases [9]. Intraoperative, the perforation was found in the splenic flexure in our case. Our histopathological specimen showed multiple perforations, which is a common finding in amebic colitis. B. Yue et al. reviewed data on perforated amoebic colitis in Beijing Friendship Hospital retrospectively for five years starting from 2020. He studied data of 16 patients with amoebic colitis. He found that the cecum and rectum were the common sites of involvement (68.75%) [10]. Also they found that multiple ulcers and erosions were present in all patients (100%) which is the same finding addressed by Lubynski RA et al. [9]. Despite early and good resuscitation, our patient died on day seven post-operative. Courbil LJ et al. described seven cases in Dakar in 1970, the author suggests early intervention and intensive care admission but despite these measures, the outcome remains poor [5].

Conclusion     

Perforating amoebic ulcers should be considered a differential diagnosis in all patients with acute peritonitis, especially those with a history of symptoms resembling colitis or those with comorbidity. Early management is crucial in these cases.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

All the authors have read and agreed to the final manuscript.

Table and figures     

Table 1: the lab investigations of the case

Figure 1: erect abdominal X-ray showing a large amount of air under both hemidiaphragm

Figure 2: specimen of the right hemicolectomy

Figure 3: H&E stain entamoeba species ×10

Figure 4: H&E stain entqmoeba species ×40

References