Chronic Diseases of the Colon

NZMJ, August 1923

Patients suffering from chronic diseases of the colon fall into two main groups:—(1) Those presenting local bowel symptoms only such as colic, diarrhœa, or constipation; (2) those in whom, in addition to local symptoms, general symptoms are also present, such as headaches, general malaise or joint pains.

PATHOLOGY

1. Lane’s Bands.—While some cases undoubtedly are due to abnormalities producing mechanical obstruction such as Lane describes, the majority show no such lesion.

2. Undue Mobility of Splenic and Hepatic Flexures.—In these cases a certain amount of obstruction arises, dependent to a large extent on posture, being most marked in the recumbent position.

3. Inflammatory Pericolitis.—This may follow appendicitis, duodenal ulcer, etc., and, by leading to adhesions, produce a greater or lesser degree of obstruction.

4. Ulceration of the Colon.—Most patients who have had ulcerative lesions of the colon give a clear account of experiencing a delayed peristalsis or “stoppage in the passage of wind” at the site of the old ulceration—the common sites which are indicated are the hepatic and splenic flexures and in the mid-line about the umbilicus. Even when this history is clear and local tenderness exists at these points X-ray examination often reveals no particular delay or stenosis of the bowel. As these cases frequently recover quickly it is probable that there is local inhibition of peristalsis, not necessarily dependent on gross destruction of tissue, a mild degree of inflammation being sufficient to produce it. On the other hand many of these patients, on normal palpation, present an easily thickening of the bowel which tends to disappear more or less completely under treatment.

Post-mortem examination in patients suffering from post-dysenteric ulceration of the colon reveals a tendency to heal with less thickening of the bowel than one would expect from the extent of the ulceration. In exceptional cases, however, where there has been great destruction of tissue, permanent narrowing of the lumen of the bowel results.

5. Disturbed Nervous Control.—Apart from local lesions peristalsis may be variously disturbed by interference with the nervous mechanism. The two most important types being (a) spastic contraction dependent on excessive vagus one, and (b) atony. Spastic contraction usually affects the descending colon and produces a form of constipation which is not associated with toxic symptoms. Atony of the bowel is much less common than formerly supposed, and is probably confined to cases or paralysis and old age. Atonic dilatation of the caecum which follows inflammation of the mucous membrane must be considered as distinct from primary atony.

6. Effect of Dehydration.—In considering the pathology underlying the symptoms in any given case it is important to distinguish between retention of the bowel contents in the different portions of the colon. The fact that by the time the bowel contents have reached the descending colon, dehydration has occurred, renders retention in this portion less serious than when it occurs in the caecum and ascending colon. Delay in the first part of colon is invariably associated with serious symptoms, as the contents of the bowel being still in a semi-fluid state, absorption is inevitable.

7. Source of Toxins.—Several distinct sources of poison must be recognised : Products of bacterial action, fermentation of carbohydrates, putrefaction of protein elements and products of incomplete metabolism.

LOCAL SYMPTOMS

Flatulence, a common local symptom is due usually to exaggerated peristalsis, and not to an excessive amount of gas in the bowel. In a minority of cases there is an excess of gas, which may arise either by putrefaction or fermentation.

Pain is usually present and varies in character from a dull ache to acute pain. A prickling sensation is often described as being present at sites corresponding to old standing ulceration, and often at the flexures and over the caecum. Pain in the back is troublesome, particularly in the lumbar region.

Colic is not usual in chronic disorder, but occurs from time to time from an exacerbation of an old inflammation.

Nausea, vomiting and gastric flatulence commonly occur and may be the only symptoms complained of.

Diarrhœa is a frequent symptom. It usually alternates with periods of constipation, and may last for a few hours or for several days. Patients who suffer from toxic symptoms frequently state that their worst symptoms follow on rapidly after a bout of diarrhœa.

Constipation of varying degree is the rule.

Nervous diarrhœa is practically always associated with some evidence of local damage to the bowel.

Intestinal sand is present in most cases of long-standing inflammation of the colon, though it often makes its appearance only after the colon has been irrigated for several days.

TOXIC AND GENERAL SYMPTOMS

The toxic symptoms vary greatly in intensity and character. In the mildest forms a slight degree of malaise, anorexia and headaches are present. The tongue is furred and there is some constipation. This group of symptoms is so universally recognised as being dependent on a disturbed bowel action, that the majority of patients recognise it at once and themselves apply a remedy in the form of a simple aperient, which often suffices to clear up the trouble. When, however, these symptoms occur frequently and do not respond to simple measures, there develop further symptoms of a more serious nature. The patients become irritable, sleep badly and lose weight ; the skin becomes pigmented, in prolonged cases as deeply as to make it difficult to exclude the pigmentation of Addison’s disease. The patient passes into a state of chronic ill-health and is frequently branded a neurasthenic. It is now recognised that patients presenting aggravated toxic symptoms may owe their ill-health to defective motility of the caecum and ascending colon, a condition which is described as caecal stasis or caecal constipation.

Patients suffering from caecal stasis present certain well-defined symptoms. Their general health is usually below par and at frequent intervals thy have bouts, almost paroxysmal in character, of a special group of symptoms, differing in individuals. Circulatory disturbances are common. The patients feel comparatively well on rising in the morning when, more or less suddenly, sometimes, but not always, following an evacuation of the bowels, they experience a sensation of “goneness,” palpitation becomes troublesome and they feel exhausted. The pulse rate varies from about 90 to 120, but the rhythm is normal and they rarely present any sign of organic heart disease. After lasting for a few minutes, or maybe for an hour or two, the attack passes off and the patient gradually recovers.

Severe headaches occur which may be unilateral or affect the whole of the head, with inability to read for long without inducing severe eye-strain and blurring of vision, followed by abnormal sensations, such as a burning feeling affecting the skin of the face and head.

The skin is variously affected. The muddy, unhealth skin of these patients is well recognised. There occur, however, in some cases more acute manifestations. The commonest is an urticarial eruption, sometimes affecting the whole body but more usually confined to face and the inner surfaces of the limbs. The irritation in these cases may be intense, and when the patients scratch the lesions, in attempts to get relief, the broken surface becomes infected and the condition is sometimes difficult to distinguish from scabies. Patients suffering from skin lesions often have no general symptoms and the bowel condition may be quiescent.

Chronic joint inflammation is so often associated with disordered colon that treatment of the bowel is most important. The nervous associations of arthritis (pain in the limbs, sensations of numbness, tingling and burning on the backs of the wrists and in the hands and fingers) are often dependent on the same toxic process.

PRESSURE SYMPTOMS

Patients in whom the caecum is large usually suffer from pain in the back, which is probably due to the dragging effect of the loaded caecum. Other pressure symptoms, however, occur and affect particularly the pelvic organs. Pressure on a cystic ovary may produce pelvic symptoms of such severity as to lead to laparotomy, when no adequate cause may be discovered for the pain.

During menstruation patients suffering from a loaded caecum frequently complain of intense pain which can be relieved only by appropriate treatment of the bowel condition.

Effect of Pregnancy.—Many patients definitely date the onset of their symptoms from pregnancy, especially when the onset of labour has been delayed and the birth a difficult one. Pressure by a pregnant uterus, leading to an increasing degree of constipation, especially in women who have previously suffered from dysentery or colitis, is a very important factor in producing serious inflammation of the colon, the results of which are both severe and prolonged. Similar results may be produced by pressure of a fibroid.

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