Title: Intestinal obstruction during shigellosis: Incidence, clinical features, risk factors, and outcome
Abstract: To determine the incidence and outcome of intestinal obstruction during shigellosis, the authors assessed 1211 consecutive patients with shigellosis admitted during a lli-month period to a diarrhea treatment center in Dhaka, Bangladesh.Obstruction was identified in 30 (2.5%) patients.Ten (33.3%) of these patients died, compared with 97 (8.2%) of the 1181 patients without obstructions (P < 0.001; RR = 4.1).In a case-control study, patients with obstructions were compared with 30 control patients with shigellosis but without obstructions.Case and control patients were similar in age (median, 18 months vs. 24 months; NS).Before admission to the hospital, case patients had less often been breast-fed than control patients (33% vs. 85%; P = 0.008) and had more often received antimicrobial agents (53% vs. 13%; P = 0.001).Case patients more often had abdominal tenderness (73% vs. 13%; P < O.OOl), altered consciousness (50% vs. 17%; P = O.OOS), and SKgeZZa dysenteriae type 1 infection (73% vs. 27%, P = 0.001) and had a higher median blood leukocyte count (40 x 103/pL vs. 14 x 103/kL; P = 0.007) and serum potassium concentration (5.0 mmol/L vs. 4.3 mmol/L; P = 0.016), and lower median serum sodium (123 mmol/L vs. 131mmoUL; P = 0.003) andtotalprotein (52 g/L vs. 60 g/L; P = 0.025) concentrations than did control patients.Eight (27%) patients with obstructions developed the hemolytic-uremic syndrome, compared with none of the control patients (P = 0.003).It was concluded that obstruction is an ominous complication of shigellosis and that therapies in addition to provision of antimicrobial agents need to be evaluated. Shigellosis is a major cause of diarrhea-associated mortality in Bangladesh and other less-developed countries (l-3).At the Diarrhea Treatment Centre of the International Centre for Diarrhoeal Disease Research, Bangladesh, the fatality rate for 9780 patients admitted with culture-confirmed shigellosis during the 15-year period 1974-1988 was 9.1% (4).Unlike the secretory diarrheas caused by infection with either Vibrio cholerae or toxin-producing Escherichia coli, in which the pathogenesis and treatment of the major lethal complication, dehydration, is well understood, our knowledge of complications leading to death in shigellosis is limited.The often dramatic systemic complications-the hemolytic-uremic syndrome (5), the leukemoid reaction (6), sepsis (7), and hypoglycemia (8)-that occur in association with Shigella infection have received the most attention.Less attention has been given to the nature and importance of complications at the primary site of infection in the gut (9).Infection with Shigella is usually confined to the epithelial layer of the colon (9-11) and produces the ulcerations and inflammatory exudate that are characteristic of bacillary dysentery.However, more profound colonic disease may occur, and cases of toxic megacolon have been reported (12,13).In the course of treating patients with shigellosis it became apparent that severe colonic disease resulting in obstruction, abdominal distention, and alteration in consciousness and resembling toxic megacolon was a major factor affecting the care and prognosis of pa-