Colica Mucosa

COLICA MUCOSA, mucous intestinal colic, a distinctive disease of the intestine consisting in the discharge of significant amounts of mucus and accompanied by attacks of pain. This disease is known under the most various names, of which the principal ones are: colitis mucosa, enteritis membranacea chronica (Ewald), entero-typhlo-colite mucomembraneuse (Dieulafoy), colo-succorrhee (Soupault) and many others. The already large number of names for one disease indicates that among authors there is no unanimous understanding of this clinical form, which however deserves description as a special nosological unit. The basis of disagreements among authors lies in the question of what origin the mucus is, the discharge of which is the most important and essential symptom of C. m. While some consider that the basis of the disease lies in inflammation of the intestinal mucous membrane (hence the name colitis membranacea, enteritis membranacea), others (the majority and including the most authoritative) believe that the basis of the disease is a peculiar disorder of mucus secretion on the basis of disease of the autonomic nervous system and that the entire disease represents a secretory neurosis of the intestines. Extremely few patho-anatomical studies give reason to think that in pure forms of the disease there is only an increase in the number of goblet cells of the intestinal mucous membrane and at most a very superficial leukocytic infiltration. As rectomanoscopy has shown (Foges), immediately before attacks one can see hyperemia and swelling of the mucous membrane, which disappear immediately upon termination of the attack, while the mucous membrane becomes especially pale and dry; this endoscopic picture also speaks against the inflammatory nature of the disease. In a number of cases however along with phenomena characteristic of C. m., unquestionable inflammatory changes of the intestinal wall are also observed, why one must speak of the presence of both mucous colic and colitis; obviously in these cases chronic colitis is accompanied by colica mucosa. The clinical picture of C. m. consists of three main symptoms: constipation, discharge of mucus and attacks of pain. The disease most often affects women aged 25-40 years (but cases of C. m. have also been described in men). Most often it concerns persons with constitutional or acquired neuropathic predisposition to dystonia of the autonomic system: these are neurasthenics, hysterics, hypochondriacs; however in individual cases C. m. is also observed in persons completely balanced and not neuropathically stigmatized. Sometimes habitual constipation precedes the disease. Patients often report having had attacks similar to attacks of appendicitis, sometimes about an operation performed by them for this purpose, which however did not free them from the attacks of pain. Sometimes long before the colic attacks they feel indefinite pains in the abdomen and even notice that the stool passed in the form of dense balls is covered on the surface with films of mucus. The attack of the disease consists of sharp pains in the left iliac fossa, urges to defecate, often accompanied by very painful tenesmus; at this time either liquid mucus alone is discharged, or separate pieces of stool with a large amount of mucus, or finally dense coagulated films. Sometimes this discharge of mucus occurs without pain (myxorrhoea simplex), but most often very frequent urges to defecate with painful tenesmus come to the forefront. Besides pains in the anus and left iliac fossa, patients sometimes complain of pains spreading throughout the abdomen. The pains are most often inconstant and appear in the form of spasms. At the height of the attack they become unbearable, then subside, only to appear again after some time with their former strength. The pains resemble pains in an acute attack of appendicitis or renal colic. The attack lasts for varying time - from 1/2 hour to a day and more. On palpation of the abdomen various characteristic data are obtained both at the height of pains during the attack and in the intervals between attacks. During the attack, despite the severe pains, palpation of the abdomen is still possible, since the abdominal wall does not give a protective reflex in the form of contraction of the muscle on palpation (defense musculaire). Usually a sharply contracted distal part of the intestine is palpated - the area of flexura sigmoideae and colon descendens. Sometimes the entire transverse intestine appears as a tightly drawn string (chorde colique); conversely, in the right iliac region one can palpate a normal or atonic, giving a splashing sound cecum. The very presence simultaneously of spastic and atonic phenomena from the side of the large intestines is characteristic of C. m. Palpation of the abdomen in the clear intervals often gives a picture of gastro- and enteroptosis, flabby musculature of the abdominal press, often spastically contracted sigmoid intestine. X-ray examination, which is not always possible to carry out due to frequent pain attacks, gives clear pictures of spasm of the large intestines, more often in their descending portion; b. ch. (by and large) the picture of distal constipation is expressed (see Constipation). Sometimes on the screen it is clearly visible that the lumen of the large intestines becomes almost thread-like, and this spasm usually extends to the lower part of the large intestines, remaining unchanged for a whole series of hours. In individual cases on the radiograph it is possible to see between the intestinal wall and the contrast mass a peculiar mottled shadow, which may depend on the thick layer of mucus covering the fecal cylinder. The general condition of patients during the attack varies: in some cases it is limited to malaise, and patients endure the attack on their feet; others present a picture of a severe disease with sharp pallor of the covers, coated tongue, small, almost thread-like pulse, resembling at first glance patients in a state of severe collapse. In the intervals between attacks the condition of patients is quite satisfactory, appetite is good, and they quickly gain weight after the attack. The frequency of attacks varies greatly: in some patients attacks appear weekly and even more often, in others - after several months and even years. Sometimes periods with frequent attacks alternate with long intervals of excellent condition of patients. The character of the stools must be considered an important symptom of the disease, without examination of which it is difficult to make the correct diagnosis. As a rule patients either long before the attack or constantly suffer from constipation with typical stools in the form of separate balls, or scybala. For these persons with habitual constipation the appearance of diarrhea after the attack as a result of irritation of the intestinal wall by stagnant fecal masses is characteristic. If C. m. appears in people suffering from colitis, then the stools are usually also outside the attack covered with a thin layer of transparent mucus, giving doctors reason to speak of colic. During the attack the mucus is discharged either in the form of formless liquid masses, or in the form of films, or in the form of dense strands, or finally in the form of hollow tubular or festoon-like formations. If these films are placed in water, they have a very characteristic appearance, sometimes resembling the finest lace. Microscopically besides the usual for stools detritus, bacteria, food remains, a significant amount of cylindrical epithelium, soaps is found; leukocytes and erythrocytes are usually not found, but eosinophilic cells can be found; here typical Charcot-Leyden crystals are also often found. Chemical examination of the films shows that they consist almost entirely of mucin; fibrin and protein are contained in very small amounts, but often much inorganic salt is found in the form of intestinal sand, consisting of calcium phosphate. This circumstance also served as the basis for some authors to consider colica mucosa and lithiasis intestinalis as related diseases. With frequently recurring attacks sometimes to the pure form of C. m. inflammatory phenomena from the side of the intestinal mucosa are added, and then it is a matter of a mixed disease: secretory neurosis and simultaneously colitis (see Colitis); in these cases also in the clear intervals from attacks pains in the abdomen, diarrhea and mucus in the stools may appear. From the accompanying diseases of C. m. most often various diseases of the female genital sphere (often on a gonorrheal basis), nephroptosis, phenomena of recurrent chronic appendicitis or chronic typhlocolitis are encountered. From the side of the nervous system there are usually more or less expressed symptoms of dystonia of the autonomic system with hypertension of its parasympathetic part, general phenomena of psycho- and neurasthenia. Recognition of C. m. presents no difficulties during the attack if one takes into account all the above described symptoms; in the clear intervals the diagnosis can be easily made if patients show the doctor films discharged during the attack and often taken by them for tapeworms. Often the disease is confused with renal, lead colic, appendicitis, local peritonitis, extrauterine pregnancy, twisting of an ovarian cyst etc. However careful examination, mainly palpation of the abdomen, examination of the stools, sometimes X-ray examination, as well as the typical anamnesis make it possible to differentiate C. m. from all these diseases.

It is more difficult to determine whether in this case we are dealing with a pure form of S. or a mixed form with colitis, as well as whether there are other inflammatory processes in the abdominal cavity causing mucous colic. The pathogenesis of S. t. is not sufficiently clear, and to explain it, a whole series of theories has been proposed: some authors believe that the cause of the disease is habitual constipation; others consider the cause to be spasms of the intestines due to a viscero-visceral reflex from the peritoneum, for example, in appendicitis, cholecystitis, adnexitis, etc. (Sou-pault et Jouaust); still others believe that the cause is psychogenic factors (Du-bois); finally, Combe considers that the cause lies, as in enteritis, in infection of the intestines. Undoubtedly, all the mentioned factors can be observed in different patients with S. t.; but still, the listed theories do not bring us closer to understanding the mechanism of the process, which results in a sudden appearance of intestinal spasms with the secretion of large amounts of non-inflammatory mucus. On more than one occasion, attacks of S., accompanied by the presence of eosinophils and Charcot-Leyden crystals in the feces, have given grounds to draw an analogy between this disease and bronchial asthma, and perhaps we will come closer to understanding this disease if we consider it as an allergic disease of the intestine.--The prognosis is generally favorable unless we are dealing with mixed forms with colitis, which take a stubborn, chronic course with frequent relapses. Prophylactically, great importance is attached to general strengthening treatment, strengthening of the nervous system, and the fight against habitual constipation, careful treatment of gynecological diseases, orthopedic treatment of splanchnoptosis, and especially nephroptosis. Some authors (Boas) recommend as a preventive measure the restriction of meat food, which predisposes to constipation, and the exclusion from the diet of all substances that irritate the nervous system (coffee, alcohol, spicy, pungent substances). Great importance is also attached to the prohibition of enemas with tannin and astringent substances, in connection with the abuse of which attacks of colica mucosa are often observed.--Treatment. During an attack of S., bed rest is absolutely necessary; warmth is applied to the abdomen (linseed seed poultices, hot water bottles, thermophores, alcohol-water compresses); in severe pains, atropine (1/2-1 mg) is injected under the skin, atropine together with morphine, or atropine and papaverine. Great benefit is derived from hot enemas of physiological saline solution, chamomile, and sometimes hot oil or paraffin enemas. There is also an indication for the administration of subcutaneous injections of a 1:1,000 solution of adrenaline 0.5-1 cm³ or enemas of 1 glass of chamomile and 10 drops of adrenaline (1:1,000 solution). Between attacks, the main treatment is for the nervous system, habitual constipation (climatic, dietary, physiotherapeutic, balneological, and medicinal). It is recommended not to prescribe saline laxatives or strongly mineralized springs (Essentuki, Izhevsk water, water of Staraya Russa, Batalki, etc.). On the contrary, there are indications for the prescription of hot lime spring waters. Great importance is attached to improving general nutrition. Very light food (mucilaginous soups, kissels, weak tea with cream, crackers with butter) immediately after the attack is soon replaced by an egg-milk-vegetable diet (pureed vegetables and pureed fruits) with a gradual transition to coarser food with a small amount of fish or meat. Balneological procedures (sitting aromatic baths), diathermy. Of medications, systematic treatment with atropine, preparations of lime (Calcium lacticum no 0.5 two to three times a day) is beneficial; an attempt can be made to treat with peptone, keeping in mind its antispasmodic and anti-allergic properties. Lit.-see lit. to article Colitis.