A 4-year-old girl with chronic lower GI bleeding

Prepared by...................Nuthapong Ukarapol, M.D.
CC : A 4-year-old girl has had a history of chronic lower GI bleeding for 1 year.
PI : She has had dripping of fresh blood before and after defecation for 1 year. The rectal bleeding has been reported almost every bowel movement. There was a history of diarrhea from time to time. Neither constipation, fever, nor vomiting was noted. The patient also sometimes complained abdominal pain. There was no history of bleeding per rectum in the family.
Significant PE

Vital signs: T 37.3 C, RR 24/min, PR 100/min, BP 120/80 mmHg
Weight 17 Kg, Height 95 cm, Well-nourished child
Abdomen: normal, no mass, normal bowel sound, not tender
No hepatosplenomegaly
PR: fresh blood noted, no anal fissure, no mass or polyp
Clinical diagnosis: sigmoid polyp
Investigations:
CBC: Hb 11.5 gm/dl, Hct 32.2 %, WBC 7400 /cumm, Platelet 511,000 /cumm N 55 L 30 Eo 7 Mono 8 RC 1.4%
Stool examination: WBC 5-10/ HPF, many RBC, no parasite
Stool concentration x2 times: no parasite
Stool culture: negative for Salmonella and Shigella
PT 8 sec (12.1) PTT 24 (27.5)
ESR 6 mm at 1 hour
Colonoscopy: proctitis with multiple rectal shallow ulcers (Figure 1)
Figure 1. The colonoscopy revealed multiple colonic ulcers, predominantly at the rectosigmoid region.
Differential diagnosis:
1. Infections: eg. Amoebiasis, CMV infection, C. difficile, Salmonella, Shigella, Campylobacter jejuni
2. Inflammatory bowel disease: ulcerative colitis, indetermine colitis, Crohn's disease
3. Allergic proctocolitis/ Eosinophilic colitis
Histopathology:
There was evidence of colonic ulceration/ erosion with intense eosinophilic infiltrate. No evidence of crypt abscess, but mild cryptitis. At the ulcer edge, E. histolytica was noted. (Figure 2-3)
Figure 2 (10X)
Figure 3 (40X)
Final diagnosis: Chronic amoebic colitis
Additional investigations:
Serum IgE (total) 756.7 IU/ml (30-100)
Ameba titer in the serum: OD=0.861 (cut off 0.194) : positive
Treatment: Metronidazole 200 mg p.o.tid x 10 days
Brief review in Intestinal Amoebiasis
An ingested cyst is excystated by gastric acid in the stomach. The trophozoites later on colonize, multiply, invade, and encystate in the large intestine. The most preferable sites are the cecum and ascending colon, in which it ultimately leads to ulceration in the invasive form. The incubation period is approximately 7-12 days. In immunocompromised hosts, extraintestinal manifestations and disseminated amoebiasis can occur.
Clinical presentation of intestinal amoebiasis:
1. intermittent or mucus bloody diarrhea
2. tenesmus
3. anorexia and malaise
4. abdominal pain
Clinical forms of intestinal amoebiasis:
1. Acute amoebiasis; similar to shigellosis
2. Chronic amoebiasis; presenting with intermittent diarrhea and abdominal pain
3. Asymptomatic amoebiasis (cyst passer)
4. Amoeboma; need to be differentiated from colonic carcinoma
5. Amoebiasis with complications: e.g. toxic megacolon, peritonitis, extraintestinal manifestations, such as liver abscess
Diagnosis:
1. Stool examination; if suspected, stool examination should be repeated at least 3-6 times.
2. Stool culture with isoenzyme analysis to differentiate E. dispar from E. histolytica
3. Stool antigen (Gal/GalNAc lectin) detection assay
4. PRC for E. histolytica-specific DNA
5. Serology; more sensitive in amoebic liver abscess
6. Colonoscopy with biopsy at the ulcer edge and exudate
Treatment:
1. Metronidazole 10-15mg/kg TID to a maximum of 750 mg/day for 10 days or Tinidazole 50 MKD in 3 dividing doses to a maximum of 2 gm/day for 3 days (for invasive form and amoebic liver abscess)
2. Iodoquinol or paromomycin (luminal agents) for asymptomatic cyst passer
Diagnosis : Chronic Amoebic Colitis

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