The literal translation of the Pidgin name is "stomach of a pig." I imagine it is called that because kids get sick after eating a protein meal, often after a mumu with pig meat. Children with chronic protein malnutrition are most susceptible. People who live in the highlands of PNG eat mostly fruits and vegetables, with occasional protein from peanuts, eggs, or chicken. So kids here are definitely at risk of protein malnutrition. Sweet potatoes also increase the risk of pigbel because they contain a trypsin inhibitor. This inhibitor blocks an enzyme and prevents the body from breaking down the toxin.
Symptoms of pigbel include abdominal pain, distention, bloody diarrhea, and emesis with black flecks. Eventually the small bowel necrosis leads to perforation and death of the patient. Antibiotics are first line therapy, but patients frequently need surgery to remove the dead bowel.
Children with pigbel get really sick. And diagnosis is a challenge because pigbel can masquerade as typhoid, gastroenteritis, or dysentery. If you aren't on the lookout, you can easily miss a case. I know, I have.
Last Friday I was on call with Francine, one of our visiting medical students. Francine came to tell me about one of our kids on A-ward. Israel was admitted the day before with diarrhea and there was concern he might have pigbel. He was on multiple antibiotics, but had been getting worse throughout the day. Around noon he became confused. His abdomen started to swell and a couple of hours later he began vomiting. The emesis contained black flecks. This was definitely looking like pigbel and our patient was getting worse. It was time to do surgery.
We called in Dr. Graham, the volunteer surgeon who is covering for Dr. Jim. A hour later we said a word of prayer and started cutting. At first the bowel looked completely normal. We wondered if we had made the right diagnosis and decision. As we followed the bowel toward the jejunum, we found what we were looking for. Thankfully this is one case we didn't miss. The inflammed and necrotic area was removed, the good bowel reapproximated, and the abdomen closed. Israel did well during the surgery and is now recovering on the ward.
Wow... what a way to end this crazy week.
During the 1960's and 1970's, pigbel was the leading cause of death in children over age 1 who lived in the highlands of PNG. A vaccine was introduced and the disease almost disappeared for several decades. In 2005, PNG stopped paying and the manufacturer stopped making the vaccine. And surprise, surprise... pigbel is back. Not quite with the vengeance of 50 years ago (yet), but it is back.