Chagasic Colonopathy

Chagasic colonopathy has two progressive stages (Köberle 1968: 95). The first stage features no dilatation of the colon but includes disturbances of the motility of the large intestines, as Isica first suffered. Usual complaints are abdominal distention caused by gas (meteorism), irregularity of peristalsis, and difficulties in defecation. Similar symptomology is also found in the elderly and is attributed to the physiological diminution of ganglion cells in the colon with the increase of age. In similar fashion, Chagas’ disease diminishes ganglion cells in the colon. If T. cruzi reduce the ganglion cells below a critical limit of 55 percent, dilatation and hypertrophy of the colon begin. The mechanisms of destruction of the nervous intramural plexus are still not clear, but there is strong experimental data indicating that it is related to cell‑mediated immunity.[26]

As happened with Isica, this destruction normally leads to the second stage, megacolon, which Andeans usually attribute to entangled colon (vólvulo). Its major symptoms are an enlarged colon and the inability to defecate. Peasants sometimes have not defecated for from two to six months before they die (see Figure 9).

In megacolon, amastigote forms of T. cruzi encyst within the muscles of the colon. These amastigotes form psuedocysts which burst within the muscle and cause damage to the nerve ganglia within the myenteric plexus. Another possibility is that ganglia present T. cruzi antigen markers on their surfaces that become targets for attack by the immune systemsort of self attacking selfand are then destroyed. Without proper innervation of the smooth muscles of the gastrointestinal tract, peristalsis diminishes and, in an attempt to compensate, the muscle layers enlarge (hypertrophy). It is not the hypertrophy of the muscles that causes the most dramatic enlargement of the colon, it is the loss of rigidity provided by the muscle layers. The circular and longitudinal muscles give the gastrointestinal tract its shape, a boundary. Once the muscles hypertrophy and begin to lose their functional capability, the intestine begins to lose its form. Food taken in through the mouth can remain in the gut (gastrointestinal tract) for great periods of time, due to lack of peristalsis. As the gut fills up, the intestine expands to hold the contents, having lost its rigidity. Atonic constipation develops and parts of the bowel can become necrous and die. As the disease develops, the entire gastrointestinal tract can be affectedhence, the term megacolon.

^{Figure 19.}

^{Dr. Johnny Méndez is a surgeon at the Instituto de Gastroenterologia Boliviana Japones in Sucre, Department of Chuquisaca. Méndez specializes in operating on patients with megacolon, a common chronic symptom of Chagas’ disease. (Photograph by Joseph W. Bastien)}

In the Department of Chuquisaca, Bolivia, approximately 40 percent of patients’ gastrointestinal problems are attributed to Chagas’ disease. Both forms of chagasic colonopathy are found in the Department of Chuquisaca. In contrast, none of the patients in Viacha on the Altiplano, outside of La Paz, suffering from vólvulo had Chagas’ disease.[27]This complicates the problem, in that entangled colon (vólvulo) caused by altitudinal and genetic factors is found in Andean communities along with chagasic colonopathy. Only recently have biomedical personnel begun to distinguish between entangled colon (vólvulo) and chagasic colonopathy. Some Bolivian doctors dispute the high reported percentages of Chagas’ disease and attribute its pathology to altitudinal factors, genetics, and tangled colon (vólvulo) caused by improper diets.

Dr. Johnny Méndez Acuña is a surgeon at the Instituto de Gastroenterología Boliviano Japones in Sucre, Department of Chuquisaca. Méndez attributes toxins produced by T. cruzi as the cause of pathogenesis, a slightly dated theory for which there is less proof than for that of the antigenic mimicry hypothesis theory (Van Voorhis et al. 1991), discussed in Appendix II. Méndez specializes in operating on patients with megacolon, and he presents a surgeon’s view of the situation:

T. cruzi prefers to settle in the large intestines. The problem resulting is dolicomegacolon [large and wide colon]. It starts as retractile mesenteritis, an inflammation and drawing back of the mesentery. The mesentery contains fibers and vessels that support the intestines as well as pass the various nutrients to it. Toxins also affect the muscular walls of the intestines so that they become large and extended. When the intestines become large and wide, they are less able to contract and pass the digested food along, eventually causing aperistalsis. Gases accumulate. There is a problem of impacted bowels and inability to defecate.

Toxins eventually destroy the supporting wall of the mesentery that provides blood to the intestines. When the large intestine becomes too enlarged, it breaks loose from the mesentery and spins around, forming a volvulus, a twisting of the intestine upon itself that causes obstruction. Many Bolivians suffer from volvulus. This is deadly because the stomach becomes extremely enlarged, the person is unable to pass gas and fecal matter, and blood cannot reach the stomach. All patients with volvulus at our hospital have tested positive for Chagas’ disease. These patients have decreased nerve plexus of the colon.

We perform about fifteen operations a year for volvulus. Called the operation of Hartmann, it is a sigmoidectomy where we remove the engorged section of the intestines, disconnecting the intestines from the anus. The patient goes to the bathroom using a tube outside of the body. In six months, we perform an operation of reconversion, to connect the intestines with the rectum. (Méndez Acufia 6/24/91).

As Méndez indicated, for chagasic megacolon surgical repair is needed to remove part of the bowel.[28]Unfortunately, many Bolivians die from severe constipation because they go undiagnosed or are unable to pay for an operation. Others would rather die than undergo an operation and deal with the inconvenience associated with ileostomy, such as Isica illustrated. Ileostomy presents an extremely complicated technological situation for subsistence peasants.

A useful new technique for the treatment of chagasic megacolon is restorative proctocolectomy, practiced in Brazil (MacSweeny, Shankar, and Theodorous 1995:479). A twenty‑two‑year‑old woman was suffering from chronic constipation with overall malaise. Despite regular treatment with laxatives, she became worse. Finally her abdomen was opened and surgically examined. Surgeons found the entire colon grossly dilated, with small perforations of the transverse colon and ischemic caecum. They excised part of the colon (colectomy) and created a surgical passage through the abdominal wall into the ileum so that fecal matter drained into a bag worn on the abdomen (ileostomy). She wished to avoid permanent ileostomy, so they removed the anus and created a J‑pouch with a covering‑loop ileostomy followed by closure of the ileostomy. Restorative proctocolectomy produced good results in her case in that she subsequently has had four bowel actions per day and full control of continence.