This section is from the book "Diseases Of The Intestines", by Max Einhorn. Also available from Amazon: Diseases Of The Intestines A Text-Book For Practitioners And Students Of Medicine.
Enteritis chronica; Chronic catarrh of the bowels.
An affection characterized by a chronic inflammation of the intestinal mucosa, giving rise to various disturbances in the function of the bowels.
Chronic intestinal catarrh may arise either from a severe acute enteritis which shows no tendency to a cure, or (most often) from repeated attacks of acute enteritis following each other at short intervals before the bowels have had a chance to recover fully. This often occurs in patients who do not pay sufficient attention to their apparently slight trouble and disregard the dietetic rules prescribed by the physician. The direct factors causing chronic enteritis are the same as those of the acute condition. Like acute enteritis, chronic intestinal catarrh may be divided into a primary and a secondary form, the primary being idiopathic, while the secondary appears in connection with affections predisposing to this condition. Thus diseases of the lungs, especially tuberculosis, affections of the heart, liver, and kidneys, and diabetes are often accompanied by chronic intestinal catarrh. Intestinal parasites, round worms, tapeworms, etc., are quite often the cause of a secondary chronic enteritis, due to the irritation of the intestinal mucosa which they evoke.
The anatomical changes in chronic intestinal catarrh are similar to those of the acute condition and are characterized by hyperaemia, swelling, and in-creased secretion of the mucous membrane. However, instead of the bright red or intensely dark red color seen in acute catarrh, the mucosa in the chronic form presents a grayish brown-red tint. The blood-vessels are greatly distended, and often curved into a serpentine shape. In cases of long duration the intestinal mucosa frequently appears of a slate color intermingled with black pigment (changed red blood pigment which has escaped from the blood-vessels). These black dots are often found accumulated at the tips of the villi and also in the immediate neighborhood of the lymph follicles and of the glands of Lieberkuehn. The surface of the mucosa is as a rule covered with a viscid and transparent mucus. The epithelial cells are cloudy, in a condition of fatty degeneration, and partly desquamated. The interstitial tissue is infiltrated with cellular elements. The glands themselves are of irregular shape, sometimes elongated and tortuous, occasionally much smaller than normally.
In cases in which there is an interstitial tissue proliferation, a constriction around the neck of a gland arises,. As a consequence there is retention of the glandular secretion, and ultimately a cyst may develop. Hyperplastic processes around the inflamed area very often lead to the formation of polypi. The latter as a rule consist of muscular and fibrous tissues and contain no glands. Exceptionally polypoid excrescences may appear on the intestinal mucosa (especially in the colon), which consist of a real proliferation of the intestinal mucosa containing glands. An excellent instance of this rare occurrence has been described by Woodward.1
In some of the most advanced cases, atrophy of the mucosa may be present. As in the stomach, this process may arise from two entirely different conditions. In the one the process originates in the glandular tissue; the latter becoming inflamed, the seat of fatty degeneration, and ultimately atrophied. In the second group the process leading to atrophy originates from an interstitial tissue proliferation; the connective tissue becoming hypertro-phied, compresses the glands, and, gaining the upper hand, ultimately leads to their entire disappearance. These atrophic processes, as a rule, do not extend over the entire intestine, but more often involve certain parts. Thus, the caecum and its immediate neighborhood have often been found in this state, even in persons who apparently during life had no intestinal affection (Noth-nagel). Large portions of the small and large intestines or the entire intestinal tract are but rarely found atrophied, more often in children than in grown-up persons. Ewald 2 mentions that he has observed this rare condition in six autopsies in adults.
They all had suffered during life from pernicious anaemia and gastro-intestinal disturbances.
Both the hyperplastic and atrophic processes, as a rule, are not limited to the intestinal mucosa alone, but also involve the neighboring structures (the submucosa and the muscularis). Thus in the hyperplastic form the thickness of the wall of the small intestine may be increased to six times its normal size, while the large bowel may become three times as thick as normally. In atrophy of the intestine there is also a degeneration of the muscles. The ganglionic cells of the Meissner and Auerbach plexus have been found in a state of fatty degeneration, smaller and lessened in number in the atrophic form (Jurgens 1 and Sasaki 2). Whether these changes in the nervous tissue are the cause or the result of this general intestinal atrophy is as yet not known.
1 Woodward: L. c.
2 C. A. Ewald. "Diseases of the Intestines. " Twentieth Century Practice of Medicine, vol. ix., p. 127.
Several varieties of ulcerative processes exist complicating chronic intestinal catarrh. Some ulcerations arise in consequence of superficial erosions of the mucosa, which do not heal. The defect, once produced, gradually grows deeper. Several superficial ulcers adjacent to each other may grow larger and unite. Thus a considerable irregular ulceration develops. The ulcerative process increasing in depth may lead to a secondary phlegmonous inflammation of the submucosa, and ultimately to perforation of the intestinal walls. Another danger lies in the ulcerative process involving a blood-vessel which may cause hemorrhage. If the perforation through the intestinal walls occurs rapidly, fatal peritonitis results; but if the perforative process develops slowly, then agglutination takes place and a .localized peritonitis with or without the formation of a fecal abscess follows. These eventualities are, however, rare. Generally the ulcerations either remain unchanged (not progressing) for a long period of time or they cicatrize.
In the latter event strictures of the intestinal lumen may occasionally develop.
Follicular enteritis is also occasionally the cause of the formation of an ulcer. The lymph nodules swell up to pea size, soften, and burst. A small ulcer thus arises. As a rule, healing takes place, the mucosa of the immediate neighborhood extending over and gradually overlapping the defect. Sometimes, however, the ulcerative area is covered with a layer of mucus secreted by the goblet cells of the neighboring glands. From time to time the accumulated mucus is removed from the defect and appears in the dejecta in form of particles resembling sago. Extensive ulcerations are seldom met with in chronic enteritis. Most often they occur in the enteritis accompanying pulmonary tuberculosis.
1 Jurgens: Berl. klin. Wochensch.. 1892, p. 357.
2 Sasaki: Virch. Arch., Bd. 96, p. 287.
Chronic intestinal catarrh may occasionally exist without giving rise to any subjective complaints. As a rule, however, there is a feeling of discomfort and sometimes of slight pains in the abdomen. These abnormal sensations may be especially marked some time after the ingestion of food or shortly before the evacuations. In some cases, again, these annoying sensations appear early in the morning, about an hour or two before rising. Borborygmi often occur; occasionally there is a feeling of tension or of bloating in the abdomen, which may be relieved by the passing of flatus. The latter symptom may be so constant and annoying that the patient is afraid to appear in society or may be hindered in his vocation. An accumulation of gases in the intestine, especially in the colon, may sometimes exert pressure upon the diaphragm and give rise to asthmatic complaints, palpitations of the heart and angina pectoris, congestion of the head and vertigo. Belching or passing of wind alleviates these symptoms or entirely removes them.
Colicky pains sometimes appear and are of short duration. Severe pains, however, are almost always absent.
If the catarrh has lasted for some time, then symptoms relating to the general state of health often appear. Thus the patient may feel weak, show a disinclination to work, be irritable and somewhat melancholic. Some patients greatly lose in flesh, and present an appearance of suffering, have cold extremities and a slow pulse. Headaches, nausea, and anorexia are also often met with.
Whether these symptoms are due to auto-intoxication as some, especially of the French writers, assume (Bouchard 1) is very difficult to state. It is, however, certain that this theory does not apply to all cases of this kind.
Gastric symptoms (nausea, anorexia, etc.) are as a rule met with only in cases in which the small intestine is affected. If the catarrh is limited to the large bowel these symptoms are usually absent.
In some cases the abdomen is bloated, especially shortly after meals, and somewhat tender to pressure. There may be tenderness all along the colon; occasionally the ascending colon can be felt as a sausage-like body containing hard masses, which change their shape upon digital pressure, or this part of the colon is filled with gas and liquids and a splashing sound can then be easily evoked. Similar phenomena may be observed also in the descending part of the colon (S Roma-num) in the left iliac fossa. Tenderness along the colon upon pressure is often found; usually the pains are felt just beneath the area where the pressure is exerted; sometimes, however, the pain appears in a more remote spot. Thus, for instance, upon pressing upon the ascending colon in the right iliac fossa, pain is felt across the abdomen in a line lying horizontally at two fingers' width above the navel (transverse colon). Intestinal peristalsis may be observed in persons with thin abdominal walls, especially after a palpatory examination.
All these signs, however, are occasionally absent.
1 Bouchard: "Leconssur les Auto-intoxications." Paris. 1887.
In the symptomatology of the chronic intestinal catarrh the character and frequency of the stools are of greatest importance. While in acute intestinal catarrh diarrhoea is almost a constant characteristic symptom, there is much variation in the frequency of the dejecta in the chronic form. With regard to this point Nothnagel divides cases of chronic intestinal catarrh into the four following groups:
1. Cases characterized by pronounced constipation. An evacuation appears only once in two, three, or four days; sometimes only with the aid of cathartics. The fecal matter is usually hard. As a cause of the constipation, Nothnagel assumes a decreased activity of the automatic nervous apparatus of the intestines, this being the result of the catarrhal process.
2. Cases in which constipation and diarrhoea constantly alternate. For two or three days there may be a daily evacuation of very hard dejecta. On the following day there may be four to six very thin or mushy movements mixed with mucus, accompanied by violent pains, and then again constipation for a day or two, etc. Or there may be quite normal evacuations (once daily) for a few days in succession and then again four to seven diarrhoeal movements in one day, and after this constipation. The principal feature of these cases is the constipation, but the excitability of the nervous apparatus being quite good, the decomposed stagnant contents often cause increased peristalsis and diarrhoea. Sometimes these alternating periods of constipation and diarrhoea continue for a long time. Thus the patient may be constipated for four or five weeks, or even for a few months, and then again the diarrhoea may set in, lasting several weeks or months.
3. In a very limited number of cases there is a daily evacuation, which is usually not formed and mushy.
4. Cases in which there are for months several diarrhoeal evacuations daily. The dejecta as a rule show the biliary reaction, or they may contain yellow fragments of mucus, yellow tinged epithelia, and round cells. In these cases the catarrhal process affects not only the large bowel but also the small intestine. The absorption suffers and there are more abnormal products in the contents (acids), which give rise to increased peristalsis in the small as well as large bowel.
Besides these typical cases there are some in which the nervous element plays a part in combination with the catarrhal process. Thus there are patients who are molested with diarrhoeal movements only during the night or in the early morning hours (morning diarrhoea of Delafield 1), while they feel well during the remainder of the day.
The quality of the dejecta in those cases in which there is constipation is almost normal, with the only exception that there is an admixture of mucus. N'othnagel considers this point the most important in the recognition of a catarrhal condition of the intestine. The mucus may be absent in rare instances in which the scybala are small and the layer of mucus within the intestine is very tough and adherent, so that the fecal matter cannot carry it along in its passage.
The quantity of mucus varies greatly. While in most cases only small particles of mucus are found, there are some in which a considerable amount may be passed. Large amounts of mucus without fecal matter are often found in enteritis membranacea, less frequently in chronic enteritis.
1 F. Delafield: Medical Record, May 11th, 1895.
In cases in which the dejecta are more or less thin, mushy or watery, the fecal matter has a light color, brownish-yellow or grayish-yellow, and may at times be very poor in biliary matters. In these instances, undigested food particles are easily found. Thus small particles of meat or starchy food may be discovered.
The microscopical examination of the dejecta is often very useful, for even in cases in which macroscopically nothing abnormal can be discovered, the microscope may reveal considerable amounts of undigested meat fibres, starch granules, and fat globules. Such substances, if frequently present, indicate that the catarrhal affection is principally within the small intestine. The microscope here further shows the presence of epithelial cells, sometimes of a yellow color and mostly in a shrivelled condition and embedded in mucus.
According to Rosenheim, 1 chemical examinations of the dejecta have no practical value in this affection. The reaction with regard to litmus varies greatly and is dependent upon the frequency of the stools and the quality of the ingested food. As a rule, however, an alkaline reaction is found.
The degree of fermentative processes in the intestines may be gauged by the intensity of the feeling of tension in the abdomen, the frequency of flatus, and the condition of the dejecta. The latter may present a very fetid odor and a foamy surface. If the movements are diarrhoeal, a fermentation tube may be filled with the liquid contents and kept at blood temperature for a few hours; the amount of gas developed in the tube will indicate the degree of fermentation. The character of the urine is also of importance with regard to this point. In conditions in which there is considerable fermentation and absorption of decomposed products within the small intestine, it usually gives a more or less strong indican reaction and also a decided Rosenbach reaction (Burgundy red color after boiling and the addition of nitric acid).
1 Theodor Rosenheim: "Pathologie und Therapie der Krankheiten des Darms, " Wien und Leipzig, 189?
Chronic enteritis complicated with catarrhal ulcers manifests itself by more frequent attacks of diarrhoea, admixture of blood or pus in the dejecta, and pain. All these symptoms are especially apt to be present if the lower part of the intestinal tract is affected; if the ulcer is in the small intestine, diarrhoea is often absent, nor need there be any signs of blood or pus in the dejecta.
Atrophic processes may also accompany the enteritis. If these involve only a small part of the intestinal tract, no symptoms whatever.may result; if, however, larger parts of the small intestine are affected, the absorption of food is greatly impaired and then severe symptoms occur. Diarrhoea without passage of mucus and accompanied by a gradual but steady loss in weight is present, as are occasional symptoms of pernicious anaemia. This condition is found much oftener in infancy than in later life.
As a rule chronic enteritis is a very tedious affection. It may last many years, even until the end of life. The intensity of the symptoms varies a great deal, and there may be periods of apparent perfect euphoria. There always remains, however, a decided weakness of the intestine, which is easily upset by slight errors in diet, which in healthy persons would be harmless.
The diagnosis of chronic enteritis is made if there are abnormal sensations within the abdomen, accompanied by irregularity of the bowels and the presence of mucus in the stools. Habitual constipation can be easily differentiated from enteritis: (1) by the absence of mucus; (2) by the fact that it does not so easily nor so completely respond to mild cathartics. Malignant growths are often accompanied by enteritis, and thus the symptoms of the latter often give rise to mistakes. A longer period of observation, however, will aid in arriving at a correct diagnosis. In case of a neoplasm symptoms of cachexia will not fail to appear nor will the accompanying enteritis be so readily alleviated as if it were the only affection. In ulcer of the intestine pains predominate and are a marked feature. Constipation and diarrhoea dependent upon disease of the stomach will be recognized: (1) by the absence of mucus in the stools; and (2) by an examination of the gastric contents. They will readily yield to treatment directed toward the gastric disorder.
With regard to the localization of the process, the following is of importance: Chronic inflammation confined to the small intestine is usually accompanied by gastric symptoms, constipation, and the presence of small particles of mucus in the stools, having a yellow tinge and being well mixed with the dejecta. If the large bowel alone is involved (colitis), there is constipation with the presence of more or less mucus of a grayish color, either covering the entire fecal mass or appearing here and there on its surface. Occasionally, especially if the lower part of the bowel is affected, the mucus appears at the end of the defecation and is then voided without any admixture of fecal matter. If the inflammatory process involves both the small and the large intestines, constant diarrhoea is a predominant feature. The mucus found in the dejecta has a yellowish color; besides considerable quantities of undigested food are discovered in the fecal matter.
The prognosis of chronic enteritis depends upon the intensity of the symptoms, the duration of the disease, and also.greatly upon the age and the constitution of the patient. In infancy and in old age chronic catarrh of the intestines must be considered a grave affection. The same applies to persons with a weakened constitution (tuberculosis, cardiac or other important lesions). A chronic enteritis of intense type which has lasted a long period of time is hardly ever cured perfectly. There may be improvements in the condition of the patient, but relapses are sure to follow soon. Cases of a mild nature, however, often end in recovery, especially under an appropriate treatment. In old age a complete cure rarely takes place. If atrophy of the intestines has developed, then the condition is very unfavorable, the patient succumbing after a period of about twelve to eighteen months.
As in the treatment of chronic gastric catarrh, and perhaps in a still greater degree, hygienic and dietetic measures here play the chief part. It will be at first important to regulate the mode of living of the patient - not too much work, not too great business strain, plenty of outdoor life and exercise, regularity of meals. Exposure to cold should be carefully avoided. The patient should dress warmly, especially the abdomen and feet (flannel bandage around the abdomen), and should be particularly careful not to get his feet wet. In rainy weather shoes with thick soles or rubbers should be worn. With regard to diet the following rules are of value: the meals should be taken frequently and in small portions. Indigestible substances should be avoided. Sufficient nourishment should be given, and care taken that there is an increase rather than a decrease in weight. In cases of diarrhoea the following should be forbidden: acid or sweet wines, all mineral waters charged with carbonic-acid gas, lemonade, all kinds of fruits, salads, all kinds of cabbage including cauliflower, rye bread, and pastries.
Give eggs (soft-boiled or scrambled), light meats, especially sweetbread, calf's brain, spring chicken, steak, lamb chops, 03-sters, lean fish, white bread well baked or toasted, fresh butter, cream soups, bouillon, rice, sago, macaroni, mashed or baked potatoes, milk, cacao, tea. Kumyss, matzoon, ginger ale, good claret or Tokay may also be allowed. As a rule nothing should be taken in large portions, and the drinks should be warm or cool (temperature of the room), but not cold. Large amounts of liquids should be avoided. Patient with very severe symptoms (frequent diarrhoea, intense pains, great weakness) must be kept abed for a short time and put on a rigorous diet at first, as in cases of acute enteritis. Upon improvement of the condition the dietetic rules described above should be followed.
In cases attended with constipation the diet may be more liberal. Besides all the articles of food mentioned in the diarrhoeal group, light fruits, as oranges, grapes, ripe pears, and green vegetables, green peas, cauliflower may be added. The ingestion of large amounts of starchy foods, easily assimilated fats, butter, cream, and of fluids is very beneficial. The more indigestible articles of food, like bran breads (pumpernickel), sausages, lobster salad, mayonnaise dressings, cabbage, cucumbers, etc., should be avoided. Beer, ale, Rhine wine taken moderately are permissible.