Gastrointestinal anthrax is extremely rare in the United States and western Europe but is more frequently encountered in developing countries around the globe. Research describing the clinical manifestations of this entity is scarce, poorly detailed, and inaccurate about appropriate management (5
We performed a MEDLINE search to evaluate data published on gastrointestinal anthrax. Research that could be accessed and reviewed consisted of 11 reports from 1970 to 2000, most of which described single cases. Most patients were from developing countries, namely Iran, Bangladesh, Zimbabwe, Thailand, Uganda, India, and Turkey (6
) (). Only two cases were reported from the United States, by CDC in 2000 (16
). The infection was uniformly associated with eating contaminated meat, although theoretically, any ingested item could act as a vehicle for the transmission of anthrax spores. One study by Ndyabahinduka et al. was of an epidemic of gastrointestinal anthrax in Uganda in 1984, which affected 143 of 155 persons who ate meat from an infected zebu (Asian ox). In most cases, symptoms were those of gastroenteritis, with abdominal tenderness, vomiting, and diarrhea. Three children had blood-tinged stools from which anthrax bacilli were isolated. Thirteen patients had pharyngeal edema of variable severity. A fatal outcome from fulminant gastroenteritis was reported in nine patients, all children. All other patients responded quickly to tetracycline or penicillin (10
). Another study by Phonboon et al. described an outbreak of gastrointestinal anthrax after an outbreak in cattle in Thailand; 74 persons become ill, and 3 died (9
Reports of gastrointestinal anthrax published from 1970 to 2000
In published cases of gastrointestinal anthrax, death was more common in patients who had severe symptoms, including hematemesis, vomiting, abdominal pain, and distention (phase III), and who were only treated with antibiotics (6
). Surgical exploration and bowel resection was performed in two patients first seen in phase III (8
). The disease involved the ascending colon alone in one case and the cecum and ascending colon in the other. After surgery and antibiotic therapy, both patients recovered and were discharged. These two cases illustrate the benefit of surgery in the advanced form of gastrointestinal anthrax. These findings support our current approach for managing patients whose condition remains unstable after 6 to 12 hours of treatment, namely, administering antibiotics and adequate resuscitation and then resecting the diseased bowel segment. The rationale behind surgical resection is to overcome not only the large bacterial load but also the larger load of toxin in diseased tissues. In all our cases, the disease was confined to a single bowel segment, mostly small bowel or cecum. The clinical condition of patients improved rapidly and steadily after resection. Initial results were disappointing, since several patients died postoperatively of anastomotic leaks, dehiscence, and fistulization. Incomplete resection, severe hypoproteinemia, and rapid reaccumulation of protein-rich ascitic fluid were the main causes of surgical failure.
Based on our experience, the approach used in the management of cases of gastrointestinal anthrax should consist of: 1) initiation of intensive intravenous antibiotic therapy as soon as the diagnosis is made, 2) wide resection into seemingly healthy tissues with primary anastomosis in patients who did not improve with medical therapy, 3) continuous drainage of the ascites, as fluid will continue to accumulate for several days after surgery, 4) and aggressive replacement of protein and electrolyte losses (2
). However, to make any generalization about the preferred mode of treatment of gastrointestinal anthrax in the absence of solid and reproducible clinical and epidemiologic data would be difficult. Furthermore, with the current improved access to medical care and advances in diagnostic techniques and supportive measures compared to the 1960s, surgical intervention might now be limited to few cases of advanced disease unresponsive to medical therapy.
Following the 1960s outbreak, some areas were recognized as being contaminated by anthrax spores. Grazing of livestock in these “damned fields” (as they were called by ancient French farmers) has since been avoided by shepherds, thereby virtually eliminating the disease from the Bekaa Valley (2