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.
Esophageal Problems
Another gastrointestinal complication found in the Department of Chuquisaca, Bolivia, in chagasic patients is achalasia of the esophagus, or the nonrelaxation of the lower esophageal sphincter (see Marcondes de Rezende and Ostermayer 1994:151-58). Motility of the esophagus is altered in chagasic patients throughout Latin America, and there is no agreement on the prevalence of either megaesophagus or megacolon.[29] The function of the esophagus is to contract and expand so as to push food through the throat to the stomach. A variety of explanations are found for intrinsic denervated esophagus that produces loss of peristalsis, so that the esophagus does not dilate and food cannot pass through it (Marcondes de Rezende and Luquetti 1994). The upper part of the esophagus enlarges, and patients have difficulty swallowing (dysphagia), at times being unable to swallow liquids.[30] Chagasic patients in Santa Cruz often gloss over the fact that they are suffering from dysphagia by a stereotypical answer to the physician’s inquiry. Many respond: “But, Doctor, who doesn’t have difficulty when eating cold rice?”
Very significantly, patients with megaesophagus have lost more than 95 percent of the ganglion cells of the myenteric plexuses (Köberle 1968:91).[31] Temporary stagnation or retention of food stretches the esophagus, causing distention of the muscle fi
bers, which leads to hypertrophy of the muscle, causing more powerful contractions and making still more difficult the passage of food.
In Sucre, chagasic megaesophagus is commonly found. Resulting serious side effects among patients who are unable to swallow for several days include starvation and malnourishment.[32] Sufferers regurgitate food and water into the bronchial tubes and lungs, either choking or becoming further infected with respiratory diseases. Again, this is particularly deadly in high-altitude regions, which have markedly lower oxygen levels and a higher prevalence of respiratory pathogens.
Many Bolivians adapt to chagasic esophageal problems by consuming liquids whenever they are able to do so. Herbalists recommend teas from coca leaves to relax the throat and relieve the soreness. Peasants frequently chew coca leaves to achieve the same effects. Coca leaves have fourteen alkaloids, some of which are activated only through hydrolysisthat is, released by saliva or water (Bastien 1987a:57; Martin 1970:422; Duke, Aulik, and Plowman 1975). Bolivian doctors generally recommend bland semi-solid foods, especially cooked Andean cereals of quinua and cañiwa, warmed to body temperature so that the esophagus will drain by force of gravity; but this is often ineffective. The solution has been to surgically cut the esophageal muscle. Doctors in Sucre performed about twenty such operations in eleven years; but this figure doesn’t indicate the actual number of achalasia patients who are unable to afford an operation, fear such procedures, or remain unaware of the option. Doctors at the Gastro-Intestinal Hospital in Sucre use the Heller technique modified by Pinotti. Originally, Heller cut the restricted area, but this did not produce effective results. Pinotti modified the procedure by only removing a narrow strip of muscle lengthwise along the constricted region. The resulting outcome of these operations has been satisfactory (Méndez Acufia, interview 6/24/91).
Bolivians rarely attribute difficulty swallowing to infection of T. cruzi. They explain choking and regurgitating as emotional states caused by disproportion of the certain humors or to the fact that they have not balanced their meals with wet and dry substances. This results in inadequate proportions of phlegm to aid in swallowing. They also relate certain emotions to these humors; so that, for example, someone with excessive bile is said to be angry and consequently has insufficient phlegm to swallow. As another explanation, they see the accumulation of fluids as a malfunctioning of the tubes relating to distillation processes of the body that work in centripetal and centrifugal motions.
An Afterthought
Juana’s history demonstrates both the hubris and humility that can be associated with Chagas’ disease and other diseases that at first appear so clinically self-evident to scientists. When serious scholars begin to examine disease pathogens, they often discover that the world of microbiology can be immersed in environmental, social, and cultural systems. For years Andeans have suffered from cólico miserere and vólvulo, which they have understood according to their ethnophysiology. When modern science explains this away in terms of bugs and parasites, there often persists continued adherence to what they have believed. A crucial insight can be gained when cólico miserere is seen not only as an entity with a cause but as a sign or symbol of some disequilibrium, imbalance, social infraction, or spiritual chaos. This sign is written upon the human body in painful and contorted ways. To remove part of a bodily tube or insert another orifice while detaching another can be seen to sacrilegiously deform a body that is imaged after the land, with fluids entering, concentrating, and dispersing. The hubris of the scientists who imagine that their uncovering of clinical facts will save people from disease is often turned to humility. And Juana, recognizing that she, her sister, and her mother had been bitten by infected vinchucas, still reverted to folk beliefs surrounding cólico miserere. She recognizes, as do most other Andean peasants, that biomedical science is only as valuable as its capacity to eradicate disease and heal the sick; within her family, it is not a social and economic reality.
On the side of doctors and biomedical science, there is no clear agreement either-certain doctors are hesitant to accept that the high incidence of gastrointestinal problems in some communities is related to chagasic colonopathy; other doctors contend that T. cruzi is the exclusive cause of volvulus in other communities. Scientists are slow to believe that Chagas’ disease exists in higher altitudes, such as the Altiplano, where it is too cold for vinchucas, so they attribute gastrointestinal symptoms to other factors. Yet, evidence shows that Chagas’ disease is found in higher regions, and its present spread includes many new regions. The rule should be that when some of the above symptoms appear in Bolivia, a largely endemic zone of the disease, patients should be tested for Chagas’ disease.
CHAPTER SIX
Bertha: Mal de Corazon
Bertha (a pseudonym) is a resident of La Paz, Bolivia, who suffers chronic heart ailments from Chagas’ disease. Bertha’s medical history provides insights into the natural history of Chagas’ disease. As a child in the 1930s, Bertha was bitten by vinchuca bugs and infected with Trypanosoma cruzi in Tupiza, a small rural village in Bolivia. Later, as a mother with four daughters, she moved to La Paz after being abandoned by her husband. She made a meager living sewing for wealthy people. Late in 1974 she suffered heart disease and was diagnosed with Chagas’ disease. Presently, at age sixty-one, Bertha still sews dresses but also receives additional income from her married daughters.
Bertha is a small slender lady with sparkling dark brown eyes. She speaks Spanish, dresses in western-style clothes, and is of the mestizo class, in contrast to the cholo class, those who maintain Aymara and Quechua identity. Bertha narrated the following account to Dr. Pedro Jáuregui, her personal physician, on July 22, 1991, illustrating the effects of chronic Chagas’ disease.
I was raised in a community of Tupiza, a valley of Potosí. We always traveled to the country. In the village the vinchucas entered the houses. I didn’t know anything about them when I was a child. Vinchucas were an inch long with wings, some were brown, brown-black, and they usually bit us. They laid their eggs, and we played with their eggs. At night without electricity we could feel them, we would pull off their heads. This was the way to kill them.
At other times I awoke with eyes swollen, then I put a little tea water and some leaves over the swelling. It was not a large swelling.
We didn’t have fear of them. As a child, I played with them, putting their eggs in a basket as if they were chicken eggs. I didn’t know that this bug was dangerous. We had sheep, chickens, and corrals where vinchucas would dig their nests. Another insect was chinchina. There were both types of insects because we lived in the valley. My father was an administrator in a mine so he traveled frequently. I think that vinchucas (barbeiros) inhabited most of the houses.
I left Tupisa when I was twenty years old and moved to La Paz. And until the age of forty-four I was a healthy person, going up and down the hills. I had no idea that I was sick with Chagas’ disease until 1974 when I felt fatigue, although before [that time] I had some allergies when I ate lentils. I began to get a swollen throat and spit blood. I didn’t know what it was. I didn’t feel anything for forty years. I didn’t have any idea that this was caused by vinchucas. I would get tired, fatigued, and experienced dizziness and many fainting [spells] around 1974. I was without a husband and when I knit alone, I experienced fainting. My daughter who slept at my feet felt that I was trying to kick her. This fainting continued for a year, and the next year I had more severe fainting, and the next year I was found laying in my room with another stroke after I had arose to get a drink of water.
After my children found me, they insisted that I see a doctor. Dr. Jáuregui hospitalized me. He felt my pulse which was very low. He suspected Chagas’ disease and had me undergo a test [xenodiagnosis] where they determined it was Chagas’ disease with the same bites of [uninfected] vinchucas. I could feel the bites, and after they itched and burned a bit.
Only then did I learn about Chagas’ disease that was caused by vinchucas. I thought my sic
kness was from overwork and problems with work (Bertha interview 7/22/91).
After Bertha was hospitalized, Dr. Jáuregui examined her and found a low pulse. An electrocardiogram indicated that she was suffering from arrhythmia (irregular heartbeats) and bradycardia (slow heartbeats). X-rays indicated a normal-sized heart, not one enlarged as in cardiomegaly. Jáuregui suspected that trypanosomes had affected the nervous system of the heart and that Bertha had developed a heart block, a potentially fatal complication. He believed that a heart block is more deadly than cardiomegaly, a more frequent cardiac form caused by lesions.
Heart block occurs when there is blockage in the conduction system of the heart. The sinoatrial (SA) node is a small control center near the top of the heart that emits signals to the atrioventricular (AV) node, which regulates heartbeats. It is similar to the electrical control harness in an automobile that regulates electricity to the horn, lights, and radio. If one of these wires is cut, for example, then the horn will not work. In Chagas’ disease, heart block occurs when there are lesions in the conduction system causing the heart’s beats to be slow.
Because Bertha grew up in an endemic chagasic area, Jáuregui suspected that T. cruzi were weakening her heart, and he used xenodiagnosis to determine if T. cruzi could be found in her blood. For Bertha’s exam, forty uninfected vinchucas were divided into two small jars. The jars were placed underneath Bertha’s arms so that the bugs could draw her blood. This continued for one-half hour, until all the bugs had ingested from 7 to 8 milliliters of blood. Bertha later complained about the bites and itching, and, when her daughter was later suspected of having Chagas’ disease, Bertha discouraged her from this exam. Results for Bertha tested positive, so Jáuregui began treating her with benznidazole, diuretics, and tranquilizers.
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