Ileocolitis of Childhood.
Synonyms:—Enterocolitis; enteritis; inflammatory diarrhea; enteritis follicularis.
Definition:—Ileocolitis is a condition in children characterized by diarrhea, vomiting and abdominal distress. It is analogous to acute catarrhal enteritis in adults. It has a more definite pathology than acute gastroenteric intoxication, and is not so restricted in etiology as dysentery.
Etiology:—It usually occurs in infants, though the disease is common up to the fifth year. Errors in diet are the most frequent predisposing factors. Children artificially fed are most frequently attacked, especially when the milk supply is of poor quality or is contaminated, and where the modification of the milk does not properly adapt it to the child's digestive powers.
The disease occurs more frequently in hot weather. Sudden changes in temperature in the fall months seem to be connected with some outbreaks. Ileocolitis may be secondary to acute infectious diseases, particularly measles, diphtheria and broncho-pneumonia. Bacteriologically the disease seems to be due to a mixed infection. The streptococcus is most frequently present. Forms of the colon bacillus are also present, which are perhaps pathogenic only when the resistance of the child is markedly reduced by other factors. The bacillus pyocyanetis is found in some cases.
Symptomatology:—The symptoms of acute ileocolitis in childhood vary greatly in their severity, depending on the pathology. This may be a mild catarrhal inflammation, a severe catarrhal inflammation, ulceration of the lymph nodules—i. e., a follicular inflammation—or it may exhibit a membranous form.
In mild catarrhal cases there is a slight rise of temperature of from 1° to 2°, with a moderate diarrhea, five or six movements a day, containing some mucus and particles of undigested food.
The onset may be sudden, with vomiting. In severer catarrhal cases the vomiting continues, there is severe abdominal pain and the passage of frequent yellowish or greenish-yellow stools, with considerable mucus and undigested food. Later the mucus may be streaked with blood. Tenesmus may be quite severe; the tongue is coated and there is marked anorexia and the fever may be high. The loss of flesh is rapid and prostration becomes pronounced.
There is usually some tenderness over the colon, and there is abdominal distention. In the ulcerated form the stools may be few each day, but they are foul-smelling and contain much mucus, but only occasional streaks of blood. The mouth and tongue are dry and covered with sordes. There may be only a moderate febrile reaction, but the toxemia is severe.
In the membranous form the stools contain much mucus and blood and particles of a false membrane. Toxemia in these cases is particularly marked. Cerebral symptoms may develop and obscure the intestinal manifestations of the disease.
Diagnosis:—The ileocolitis of childhood is to be differentiated especially from typhoid fever, which may be done by the relative rarity of typhoid in infants and the commonness of ileocolitis; by the absence of rose spots, the Widal reaction and the enlarged spleen of typhoid, and by the fact that constipation is frequent in the typhoid of children.
The character of the stools, the abdominal distress and the slower course of the disease will usually enable a differentiation to be made from cholera infantum.
Prognosis:—The prognosis depends upon a variety of factors. The disease is apt to be more severe before the fourth year. Children denied fresh air and wholesome surroundings have a diminished resistance to the disease. High fever, evident toxemia, many stools, continued vomiting and marked nervous symptoms make the prognosis grave. Much can be done by appropriate treatment for all types of cases, and in general the prognosis is more favorable than in cholera infantum.
Treatment:—The treatment of this condition depends upon the degree of involvement. Usually, however, the indications for aconite and bryonia with which to allay the inflammation are quite plain. If there is an excessive outpour of mucus, this will be in part controlled by small doses of belladonna, which will also antagonize the local hyperemia. The uncomplicated cases will present indications similar to the entire symptoms found in a mild case of cholera infantum, and the remedies there suggested will be indicated. The catarrhal diarrhea usually needs immediate attention. With the other indicated remedies it may be a good plan to give from three to five grains of subnitrate of bismuth every two hours while the diarrhea persists. The washing out of the lower bowel after severe bowel movements must not be neglected, and I have found where there was tenderness over the colon, especially if tenesmus was present, that the condition could be more quickly relieved if two or three ounces of sweet oil was thoroughly stirred into the water before its introduction.
If there be an excessive mucus discharge, it is a good plan to give small doses of turpentine. This agent will be of value also if typhoid symptoms appear, especially if there be tympanites. In either case one or two drops in a palatable emulsion may be given every two hours for perhaps twenty-four hours. It will work in harmony with the belladonna above advised.
Tenesmus is a common symptom in this disorder. If severe, gelsemium should be given after the flushing of the bowels. If this is not sufficient, two or three ounces of warm starch water, to which a few drops of opium are added, should be injected with a small syringe. If an intestinal astringent is desired, geranium may be used after active inflammatory symptoms have abated.
External appplications are important in ileocolitis. Antiphlogistine, applied very warm and kept warm for twenty-four hours, will assist in the mitigation of the symptoms. If the colicky pains are very severe, when the abdomen is quite tender, mustard may be applied with advantage. If an immediate effect is desired, it should be applied warm in full strength for from six to ten minutes, but should not be permitted to blister. If counter irritation only is desired, powdered mustard should be mixed with three or four times its weight of flour and of this a poultice should be prepared and kept on continuously. If there is tympanites, turpentine stupes will be available.
During convalescence the patient should be kept in a mild atmosphere, should have out-of-door exercise without exhaustion, and should have a carefully selected diet. Tonic treatment will usually be demanded. It will be found that those tonic remedies which improve the condition of the nervous system while they act directly upon the gastrointestinal tract will be the most serviceable. Hydrastis, collinsonia, nux, the bisulphate of quinin, and some simple form of iron will meet the indications in most of the cases.