LETTERS TO THE EDITOR

 

Chagas disease in the differential diagnosis of megacolon

Enfermedad de Chagas en el diagnóstico diferencial del megacolon

 

 

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Key words: Chagas disease. Fecaloma. Megacolon. Surgical treatment.

Palabras clave: Enfermedad de Chagas. Megacolon. Fecaloma. Tratamiento quirúrgico.

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Dear Editor,

Chagas disease (CHD) is endemic in the Americas but due to increased immigration is becoming increasingly common in our country. It is caused by Trypanosoma cruzi (1) that is transmitted by blood-sucking insects, blood transfusions or fetal transmission (1,2). The CHD has three phases: an acute (non-specific symptoms) (3), one asymptomatic (antibody positive) and a significant chronic cardiac disease (leading cause of death) (4) and formation of digestive megavisceras such as megaesophagus and megacolon (5). The diagnosis depends on the stage of the disease and treatment is applicable only in the acute phase.

 

Case report

We report a case of a patient 41 years old, from Argentina, who went to the emergency room with abdominal pain and constipation. On examination, she presented lower abdominal discomfort with feeling lower abdominal mass. Gynecological pathology was ruled out and was done Rx abdomen showing abundant fecal material. The blood test with tumor markers was normal and an abdominal CT objectived fecal and recto-sigmoid colon dilation (Fig. 1). Cleansing enemas are effective and fibrocolonoscopy was normal. During admission the patient was interrogated again and in her family history stands out the death of his mother for cardiac disease at the age of 45. CHD serology was performed being positive. The patient underwent conservative treatment with good evolution and was discharged without surgical intervention.

 

Discussion

Megacolon is an abnormal dilation of the colon that can be caused by several factors: primary, by alterations of ganglion cells of Auerbach and Meissner plexus, congenital (Hirschsprung disease) or secondary to diverse neurological, metabolic, infectious, connective tissue connective psychogenic and medicines (4). The pathophysiology of CHD is not entirely known. Treatment of megacolon secondary to CHD should be to prevent surgical complications. Conservative treatment is reserved for patients oligosymptomatic or with surgical contraindications (5). Most patients with CHD have some type of heart disease, so they tend to be high risk for surgery (6). Because of the morbidity involving the preservation of the affected colon segment, is reflected in the literature a tendency to prefer resection techniques for the derivative. Currently the two most accepted are the Duhamel-Haddad technique (6,7), which takes place two times and has the disadvantage of carrying a temporary perineal colostomy. The other is the Habr-Gama technique that causes the posterior colorectal anastomosis, immediately, with acceptable results (8). Subsequently, new variations have been postulated as the rectosigmoidectomy with ileal interposition, with good results and decreased recurrence (9,10). Although CHD is a tropical disease we have to think about it, in front of patients, especially from South America, who come to our clinic presenting symptoms secondary to the presence of digestive megavísceras.

 

Anna Pallisera¹, Luis Ortiz-de-Zárate¹, Antonio Moral², Francisco Rey¹,
Sergio López¹, María Clara-López¹, Ruth Ribas¹, Núria Farreras¹ and Rosa Jorba¹
Department of General Surgery and Digestive Disease.
¹Hospital General de Hospitalet. Hospitalet de Llobregat. Barcelona, Spain.
²Hospital de Sant Pau i la Santa Creu. Barcelona, Spain

 

References

1. De Oliveira RB, Troncon LE, Dantas RO, et al. Gastrointestinal manifestations of Chagas' disease. Am J Gastroenterol 1998;93:884-9.         [ Links ]

2. Duran I, Díaz JM, Vázquez JM, et al. Dolicosigma y estreñimiento crónico secundarios a enfermedad de Chagas. Rev Esp Enferm Dig 2005;97:292-3.         [ Links ]

3. Iantorno G, Bassotti G, Kogan Z, et al. The enteric nervous system in chagasic and idiopathic megacolon. Am J Surg Pathol 2007;31;460-8.         [ Links ]

4. Bannura G, Contreras J, Barrera A, et al. Tratamiento quirúrgico del megacolon del adulto: análisis de 62 pacientes. Rev Chilena de Cirugía 2004;56(3):248-54.         [ Links ]

5. Garcia RL, Matos BM, Feres O, Rocha JJ. Surgical treatment of Chagas megacolon. Critical analysis of outcome in operative methods. Acta Cir Bras 2008;23 suppl,1:83-92.         [ Links ]

6. Cutait DE, Cutait R. Surgery of Chagasic megacolon. World J Surg 1991 15 188-97.         [ Links ]

7. Teixeira FV, Netinho JG. Surgical treatment of Chagasic Megacolon: Duhamel-Haddad Procedure is also a good option. Dis Colon Rectum 2003;46(11)1576-78.         [ Links ]

8. Nahas SC, Pinto RA, Dias AR, et al. Long term follow-up of abdominal rectosigmoidectomy with posterior end-to-side stapled anastomosis for chagas megacolon. Colorectal Dis 2009. Nov 10. [Epub ahead of print]         [ Links ]

9. Araujo SE, Dumarco RB, Bocchini SF, et al. Recurrrrence of chagasic megacolon after surgical treatment: clinical, radiological, and funcional evaluation. Clinics 2007;62:89-92        [ Links ]

10. Nethino JG, Cunrath GS, Ronchi LS. Rectosigmoidectomy with Ileal Loop Interposition. A new surgical method for the treatment of chagasic megacolon. Dis Colon Rectum 2002;45:1387-92.         [ Links ]