review Invasive amoebiasis: A review of Entamoeba infections highlighted with case reports

Christopher Skappak PhD1, Sarah Akierman BSc BA2, Sara Belga MD3, Kerri Novak MD FRCPC1,4, Kris Chadee PhD1, Stefan J Urbanski MD FRCPC5, Deirdre Church MD PhD FRCPC1, Paul L Beck PhD MD FRCPC1,4

C Skappak, S Akierman, S Belga, et al. Invasive amoebiasis: L’amibiase invasive : une analyse des infections à A review of Entamoeba infections highlighted with case reports. Entamoeba mise en évidence par des rapports de cas Can J Gastroenterol Hepatol 2014;28(7):355-359. Les infections à Entamoeba histolytica des voies digestives sont couran- Entamoeba histolytica infections of the gastrointestinal tract are common tes dans les pays en développement, mais rares en Amérique du Nord. in the developing world but rare in North America. The authors present Les auteurs présentent deux cas : l’un d’une personne qui ne s’était pas two cases: one involving an individual who had not travelled to an rendue dans une région endémique et l’autre, d’une personne née en endemic area and another involving an individual who was born in Bulgarie. Toutes deux avaient eu des crampes abdominales importantes Bulgaria. Both presented with severe abdominal pain and diarrhea. et de la diarrhée. L’évaluation endoscopique a révélé des ulcérations Endoscopic assessment revealed scattered colonic ulcerations and one diffuses dans le colon, et l’imagerie a démontré la présence d’un abcès patient was found to have a liver abscess on imaging. Stool ova and hépatique chez l’une d’entre elles. Les examens parasitologiques dans parasite studies were negative in both cases and both were diagnosed on les selles étaient négatifs dans les deux cas, et tous deux ont été diag- review of colonic biopsies. On review of all Entamoeba cases in the nostiqués à l’analyse des biopsies du côlon. À l’examen de tous les cas Calgary Health Zone (Alberta), ova and parasite analysis found an d’Entamoeba dans la zone de santé de Calgary, en Alberta, les examens average of 63.7 Entamoeba cases per year and a pathology database parasitologiques ont permis de déterminer une moyenne de 63,7 cas review revealed a total of seven cases of invasive E histolytica (2001 d’Entamoeba par année et une analyse de la base de données to 2011). Both patients responded well to antibiotic therapy. E histolyt- pathologiques a révélé un total de sept cas d’E histolytica invasive ica should be considered in new-onset colitis, especially in individuals entre 2001 et 2011. Les deux patients ont bien réagi à l’antibiothérapie. from endemic areas. L’E histolytica devrait être envisagé en cas de colite de novo, particulière- ment chez des personnes provenant de régions endémiques. Key Words: Amoebic colitis; Entamoeba histolytica; Extraintestinal abscesses ntamoeba histolytica infections of the gastrointestinal (GI) tract are morphologically differentiated from Entamoeba dispar (a common non- Ecommon in the developing world; however, in first-world coun- invasive parasite) and Entamoeba moshkovskii (considered primarily to tries, they are typically found in first-generation immigrant popula- be a free-living amoeba); however, E dispar and E moshkovskii are gen- tions and returning international travellers. E histolytica is a parasitic erally believed to be nonpathogenic. Commercial ELISAs and protozoa that primarily infects the human bowel (1). It exists in two molecular biological testing, such as polymerase chain reaction forms, a short-lived mobile trophozoite (10 μm to 20 μm in length) (PCR), are available to differentiate E histolytica from E dispar but they that can invade multiple organ systems, and a long-surviving cyst are not routinely used in the CZ-AHS due to the rarity of these infec- form that can colonize a patient (1). Diagnosis of a non-travel- tions in the region. Entamoeba serology testing can diagnose infection related E histolytica infection in Canada is rare, with the most recent with E histolytica (both E dispar and E moshkovskii do not elicit an reported studies investigating cases in Inuit communities in Northern antibody response), although it also is not routinely ordered because it Labrador (2) and sexually transmitted cases in the homosexual popula- takes up to 12 weeks before results are available from the reference tion of Toronto, Ontario (3). Herein, we describe two cases of E histo- laboratory. Serology test results for most of the patients were, there- lytica colitis that presented to the Foothills Medical Centre, a large fore, not available. No commercial molecular methods are currently urban tertiary care centre located in Calgary, Alberta. available for distinguishing E moshkovskii, although PCR has been used to detect this parasite directly in stool samples during surveillance Methods studies (4). Because serology testing is sent to a reference laboratory, The Calgary Zone, Alberta Health Services (CZ-AHS) serves a popu- these data were not searchable. lation of 1.2 million residents of Calgary and surrounding commun- The CZ-AHS pathology database was searched from 2001 to 2011 to ities. All laboratory and pathology services for CZ-AHS are centralized identify all cases of invasive E histolytica. Data are presented as mean ± SEM. and have searchable databases. The pathology database was searched Statistical analysis was performed using Graph Pad Prism (GraphPad, for all reports containing the words “Entamoeba histolytica”, USA) using a parametric unpaired t test for age and nonparametric “Entamoeba” and “E. histolytica”, from 2001 to 2011. The microbiology Mann-Whitney for sex. Ethics approval was obtained from the database was searched for all positive stool studies consistent with CZ-AHS for a limited data recovery as above. Permission to present Entamoeba. The microbiology database was searched from 2006 to the cases was obtained from both individuals. 2011 for all positive stool ova and parasite (O&P) microscopic exam- inations that reported the presence of Entamoeba; data were only avail- Results able from this period of time. Age (2007 to 2011) and sex (2006 to Data were available for stool O&P analysis in the CZ-AHS from January 2011), however, were the only variables that could be assessed due to 2006 to December 31, 2011. From 2006 to 2011, a mean (± SEM) of privacy and ethics regulations. Unfortunately, E histolytica cannot be 63.7±2.3 cases of Entamoeba were diagnosed according to stool O&P

1Department of Medicine; 2Department of Biological Sciences, University of Calgary, Calgary; 3Department of Medicine, University of Alberta, Edmonton; 4Department of Medicine, Division of Gastroenterology; 5Department of Pathology, University of Calgary, Calgary, Alberta Correspondence: Dr Paul Beck, Room 1865, Foothills Hospital – Health Sciences Centre, 1403 – 29 Street Northwest, Calgary, Alberta T2N 2T9. Telephone 403-220-6538, fax 403-270-0995, e-mail [email protected] Received for publication December 9, 2013. Accepted June 9, 2014

Can J Gastroenterol Hepatol Vol 28 No 7 July/August 2014 ©2014 Pulsus Group Inc. All rights reserved 355 Skappak et al

Figure 2) Transverse (A) and coronal (B) computed tomography images of the abdomen demonstrating liver abscesses (black arrows) and colonic wall thickening (yellow arrows) on initial presentation of patient 1. Computed tomography images of the abdomen demonstrating worsening colitis (arrows), pericolic stranding and fluid on day 6 of hospital admission of patient 1 (C and D)

Figure 1) Cases of Entamoeba from stool ova and parasite analysis in the phosphatase (232 U/L [normal 30 U/L to 145 U/L]) and gamma Calgary Health Region (Alberta) according to year (A) and age (B) glutamyl-transferase (176 U/L [normal 11 U/L to 63 U/L]). Computed tomography (CT) imaging of the abdomen and pelvis revealed severe colitis involving the cecum and ascending colon, and examination (Figure 1A). Again, this would include E histolytica, E dispar liver abscesses (Figures 2A and 2B). The liver abscesses were drained and E moshkovskii. During the time period assessed, Entamoeba was and the fluid was analyzed. Although microscopic examination of the more commonly diagnosed in men (39.0±2.4 cases/year) versus fluid revealed an increased number of neutrophils, no organisms were women (24.7±3.4 cases/year) (P<0.01). The average age of diagnosis visualized on Gram stain and the fluid cultures were negative. At this was 31.7 years, with men being slightly older (33.2 years) than females point, the differential diagnosis included infection, ischemia and new- (30.1 years) (P=0.25 [not significant]) (Figure 1B). onset inflammatory bowel disease (IBD). Blood and stool cultures, The CZ-AHS pathology database search from 2001 to 2011 stool testing for O&P and Clostridium difficile were all negative. revealed a total of seven cases, with three females and a mean age of Serology for Entamoeba and Yersinia were also sent to the reference 55±7.4 years (this includes the two cases reported below). In six cases, laboratory. The patient was initially treated with broad-spectrum anti- colitis with invasive E histolytica was only noted in the cecum and biotics and conservative management. ascending colon and, in one case (patient 1 below), there was evi- Despite broad-spectrum antibiotics and conservative management, dence of E histolytica throughout the colon involving the rectum to the the patient deteriorated, developing more severe abdominal pain, with cecum. Again, no further details of these cases could be obtained guarding and nausea. A repeat CT scan revealed worsening of colitis except for the two cases decribed below. with increased bowel wall thickening, pericolic stranding and free fluid (Figures 2C and 2D). A colonoscopy was performed and classic Patient 1 amoebic ulcers were visualized (Figures 3A and 3B) and biopsies A 56-year-old heterosexual man presented to the emergency depart- were collected. Histological examination revealed classic features of ment with a 10-day history of abdominal pain, nausea and vomiting, E histolytica (Figures 4A and 4B). The patient was treated with 14 days and diarrhea. The patient denied taking any medication and had no of metronidazole (750 mg per oral three times per day) followed by history of recent travel. His medical history was also unremarkable and seven days of paromomycin (500 mg per oral three times per day). His he denied having any previous homosexual partners. On physical symptoms resolved rapidly; however, a colonoscopy performed three examination, the patient had a temperature of 38.4°C, a heart rate of months later showed normal colonic mucosa with a mid-transverse 110 beats/min and a blood pressure of 95/55 mmHg. Head and neck, colonic stricture. After six weeks, his serology result was available and respiratory and cardiovascular, and musculoskeletal examinations were was positive for E histolytica and negative for Yersinia. This stricture did all normal. The patient had a distended abdomen and identified not cause symptoms and it has gradually improved over three years of marked right lower quadrant tenderness with guarding. Laboratory follow-up. results revealed a hemoglobin level of 127 g/L (normal 127 g/L to 165 g/L), an increased white blood cell count of 18.2×109/L (nor- Patient 2 mal 4.0×109/L to 11.0×109/L), lactate level of 8.2 mmol/L (nor- A 24-year-old heterosexual man presented to the outpatient gastro- mal 0.5 mmol/L to 2.2 mmol/L) and increased levels of alkaline enterology clinic with a three-month history of intermittent diarrhea

356 Can J Gastroenterol Hepatol Vol 28 No 7 July/August 2014 Invasive amoebiasis: A review of Entamoeba infections

Figure 3) Colonoscopic imaging of patient 1 (A and B) and patient 2 (C and D) demonstrating classic amoebic ulceration in both patients (arrows) and rectal bleeding. He lived in Bulgaria until eight years of age before immigrating to Canada. The patient had returned to Bulgaria for five months approximately one year previously. He was never sick nor did he experience any GI issues during his stay. Approximately four months after his visit to Bulgaria, he developed bloody diarrhea (at most six bowel motions per day) and lost 5.85 kg (13 lbs), which was associated with abdominal pain, bloating and tenesmus. At that time, Figure 4) A and B Colon biopsies of patient 1. Alcian blue periodic acid his hemoglobin level was normal but his platelet count was slightly Shiff (PAS) stain (A: original magnification ×40, B: higher magnification elevated (408×109/L [normal 150×109/L to 400×109/L]), as was his of A), arrows indicate Entamoeba histolytica trophozoites (many do not white blood cell count (11.9×109/L [normal 4.0×109/L to 11.0×109/L]) have arrows). C and D Patient 2 (hematoxylin and eosin stain C: original and erythrocyte sedimentation rate (13 mm [normal 0 mm to 10 mm]). magnification ×100, D: higher magnification C, arrows indicate PAS- His electrolyte and thyroid stimulating hormone levels, liver function positive E histolytica trophozoites (many do not have arrows) studies, celiac serology, HIV serology and stool studies (O&P, C difficile toxin, culture and sensitivities) were all normal. A colonoscopy was performed (Figures 3C and 3D) and biopsies were collected. There other risk factors (9). Because most studies from endemic areas report were many endoscopic features consistent with Crohn disease includ- that <1% of individuals with E histolytica colitis develop a liver abscess ing skip segments, deep ulcers and some linear ulcers. The ileum was and only 10% with E histolytica in their stool develop invasive disease, normal. Biopsies again revealed classic features of E histolytica one could estimate that in the Toronto area (based on one E histolytica (Figures 4C and 4D). A CT scan was performed after the diagnosis and abscess per year) there are >100 cases of E histolytica colitis per year revealed colonic inflammation but no liver abscesses (not shown). and approximately 1000 without invasive disease (carriers). The patient had a complete and rapid response to a 10-day course of Our two sources of review of the CZ-AHS databases consisted of metronidazole (750 mg per oral three times per day) followed by seven identifying positive stool studies and intestinal pathology. On average, days of paromomycin (500 mg per oral three times per day). Serology 63.7 cases of Entamoeba were identified by stool studies per year was not performed. (Figure 1). As noted above, these are based on light microscopy assess- ment of morphology and cannot differentiate E histolytica from the Discussion nonpathogenic E dispar and E moshkovskii. This is likely an underesti- Locally acquired E histolytica infections are a very rare occurrence in mate of the incidence/prevalence of Entamoeba in the CZ-AHS due to urban Canada aside from travellers, recent immigrants and the male the low sensitivity and specificity (discussed further below). In the homosexual population (5). A recent study investigating the preva- Ontario study above, only 24% of cases of proven E histolytica were lence of intestinal parasites in the United States demonstrated that found to have positive stool studies (9). Seven (including our two for individuals infected with a single GI parasite, <5% were caused cases) were identified on review of pathology over a 10-year period. by E histolytica or a similar asymptomatic species (E dispar) (6). In the There are several risk factors for acquiring E histolytica infection United States, the annual incidence of amoebic liver abscess (occur- other than recent travel to an endemic area, including men who have ring in <1% of E histolytica colitis cases) was 1.38 per million popula- sex with men (MSM). In a study from Los Angeles (USA), 6% of tion and mostly occurred in Hispanic men in the western and southern MSM were seropositive for E histolytica; however, significantly higher states (7). Similar studies have not been undertaken across Canada; rates have been reported in MSM populations in other parts of the however, E histolytica infections have been reported in both humans world including Rome, Italy (21%), Mexico City, Mexico (25% of and canines in Canadian northern Aboriginal communities (2,8). A HIV-positive MSM) and South Africa (43% in HIV positive and 15% recent study from Ontario (9) reported 29 cases of amoebic liver in HIV negative, and 69% in those 50 to 59 years of age) (10,11). Both abscesses that presented to seven hospitals in Toronto over a 30-year individuals in our study denied ever engaging in sex with men. period. Of these cases, 86% had recent travel to endemic areas and E histolytica is a parasite that is transmissible by the oral-fecal route. some patients were born in endemic areas (9). They did not report any Infections can range from asymptomatic to severe or fatal invasions of cases that developed in Canada without recent travel, foreign birth or multiple organ systems. Asymptomatic infections are responsible for

Can J Gastroenterol Hepatol Vol 28 No 7 July/August 2014 357 Skappak et al the continuous transmission of the parasite because numerous cysts are may have antibodies from previous exposure (15). Again, stool studies produced and passed in feces. If exocystation occurs, E histolytica (microscopy and culture) can miss cases, with studies reporting 10% to trophozoites are produced and invade the intestinal wall leading to 50% sensitivity. Because E histolytica trophozoites degenerate rapidly in amoebic dysentery and resulting in amoebic ulcers (1). Trophozoites unfixed fresh samples, fixation and multiple collections increase the yield are capable of penetrating the intestinal wall and can lead to more (18,19). Again, microscopy cannot differentiate E histolytica from other severe complications including liver abscesses (the most common) Entamoeba species. The best tests at present are the PCR- and ELISA- and, in rare cases, can spread to the brain and/or lungs, which is often based assays that detect E histolytica DNA or antigens in stool, and fatal (12). A typical treatment regimen for E histolytica infection is have sensitivities and specificities of 90% to 95% and 95% to 100%, metronidazole for 10 to 14 days (500 mg to 750 mg three times per respectively (15,18,20,21). With the increase in world travel and emi- day) followed by a seven-day treatment of paromomycin (25 mg/kg to gration, we may have to consider increasing our use of more rapid and 35 mg/kg daily in three divided doses) to eliminate colonization (13). accurate DNA/antigen-based stool studies. Amoebic liver abscesses usually present with fever and pain in the Because E histolytica-associated colitis can be localized to the right upper quadrant (13,14). Diagnosis of E histolytica is based on the cecum and right colon, a sigmoidoscopy can miss cases (18). patient’s history, imaging modalities, serological findings, stool studies, Endoscopically, E histolytica colitis is associated with mucosal thicken- fecal antigen testing (via ELISA) as well as real-time PCR (9,14). ing, multiple discrete ulcers separated by regions of normal-appearing Stool microscopic assessment (which is the most common test used in mucosa, diffuse inflammation and erythema and, rarely, necrosis and Canada) has a low sensitivity (10% to 50%) and cannot differentiate perforation (18). Recently, Upadhyay et al (22) described E histolytica E histolytica from the noninvasive, nonpathogenic E dispar and E mosh- ulcers as having a ‘poached egg’ appearance. They describe a patient kovskii (both of our cases had negative stool O&P studies) (9,14,15). who had multiple large irregular ulcers with a white slough and yellow- Typically, a patient’s history reveals recent travel from an endemic area ish necrotic material on the top of the white slough, giving a ‘poached or other risk factors; however, this was not the case in either of our two egg’ appearance. Both of our cases had irregular ulcers with white cases. Serological testing can differentiate E histolytica from E dispar and slough but neither patient had ulcers with the ‘poached egg’ appear- E moshkovskii (the latter two do not induce antibody responses) (9); ance (they were missing the yellowish necrotic material). The most the sensitivity and specificity ranges from 85% to 95% (9-11,15). It is feared complication of E histolytica-associated colitis is acute necrotiz- important to differentiate E histolytica from E dispar because, even in ing colitis and the development of toxic megacolon. This is rare but asymptomatic individuals, E histolytica should be treated to prevent has been reported in approximately 0.5% of cases and is associated spread and invasive disease. Unfortunately, most diagnostic laborator- with high mortality (18). E histolytica colitis can also rarely be associ- ies in most centres in Canada refer serological testing to an external ated with penetrating disease, causing enterocutaneous, rectovaginal site, which can take several weeks before results are available. Stool and enterovesicular fistulas (18). E histolytica can also cause inflamma- antigen and DNA tests are generally not available ‘in house’ at most tion of the appendix and present as appendicitis; in addition, it can Canadian centres and are discussed further below. cause pronounced granulomatous inflammation resulting in a Our first case was unique because it occurred in an individual who pseudotumour that can lead to bowel obstruction (18). Fewer than was born in Alberta, had not recently travelled to endemic areas and 1% of individuals with E histolytica infections develop extraintestinal had no other identifiable risk factors. Furthermore, the differential for features that can include pericarditis, lung abscesses, peritonitis and both cases included IBD. Corticosteroids are contraindicated in E histo- skin lesions; however, the most common is hepatic abscesses (18). lytica because, not surprisingly, it has been associated with more Hepatic abscesses are more common in men (male:female ratio 3.3:1 adverse outcomes (16). The second case could also have been locally [23], 7.2:1 [24]), with a peak age of incidence between 30 and 50 years acquired; however, because of his history of travel to Bulgaria for five (25), and appears to be associated with increased alcohol consumption months in the past year, it is highly possible that he acquired E histo- (18). Interestingly, a laboratory-based study (26) found that testosterone lytica infection abroad because Eastern Europe has significantly higher increased the susceptibility of mice to E histolytica liver abscesses by prevalence rates than North America (17). As noted above, many decreasing interferon-gamma secretion by natural killer T cells (26). individuals who are infected with E histolytica are asymptomatic and only approximately 10% develop invasive disease. Thus, although this Summary entity is rare in Canada, one should consider this diagnosis in patients With increased travel and emigration, we must keep E histolytica- with new symptoms of colitis, especially in those with recent travel to associated colitis in our differential diagnosis list. Because one of endemic areas. our patients had no risk factors for E histolytica, we should entertain It can be difficult to differentiate E histolytica-associated colitis this diagnosis when we encounter new cases of colitis and wait for from IBD and invasive bacterial dysentery. In general, those who biopsies and stool studies before starting corticosteroids for pre- present with E histolytica-associated colitis have a duration of symp- sumed IBD. toms >7 days, most will be fecal occult blood positive whereas only approximately 40% of those with invasive bacterial dysentery will be Acknowledgements: Dr Beck is an Alberta Innovates Health fecal occult positive and generally experience a shorter disease dur- Solutions Clinical Scholar and has research grants from Canadian Institute ation (18). Fever (>38°C) is common in invasive bacterial dysen- of Health Research and Crohn’s and Colitis Foundation of Canada. tery but is less common in individuals with uncomplicated IBD or E histolytica-associated colitis (<40%) (1) (although those with E histo- disclosures: The authors have no financial disclosures or conflicts lytica liver abscesses are commonly febrile) (18). E histolytica-associated of interest to declare. colitis more commonly presents with weight loss compared with those with invasive bacterial dysentery (18). More than 90% of patients with E histolytica-associated colitis present with diarrhea and tenesmus References whereas frank blood in stools and fever are rare (18). In short, the his- 1. Adams EB, MacLeod IN. Invasive amebiasis. I. Amebic dysentery tory, stool studies and colonic biopsy assessment play critical roles in and its complications. Medicine (Baltimore) 1977;56:315-23. differentiating E histolytica-associated colitis from IBD and invasive bacterial 2. Sole TD, Croll NA. Intestinal parasites in man in Labrador, dysentery. Unfortunately, E histolytica antigen and antibody tests are not Canada. Am J Trop Med Hyg 1980;29:364-8. 3. Keystone JS, Keystone DL, Proctor EM. Intestinal parasitic readily available in most North American centres; most laboratories infections in homosexual men: Prevalence, symptoms and factors in outsource these tests, with results taking seven to 21 days. These transmission. Can Med Assoc J 1980;123:512-4. ELISA-based antibody tests have a sensitivity and specificity of 85% to 4. Ali IK, Hossain MB, Roy S, et al. Entamoeba moshkovskii infections 95% but are less useful in patients from endemic areas because they in children, Bangladesh. Emerg Infect Dis 2003;9:580-4.

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5. Marcus VA, Ward BJ, Jutras P. Intestinal amebiasis: A diagnosis not 17. Nowak P, Jochymek M, Pietrzyk A. [Occurrence of human to be missed. Pathol Res Pract 2001;197:271-4; discussion 275-8. intestinal parasites in selected populations of Cracow region in the 6. Amin OM. Evaluation of a new system for the fixation, years 2000-2006 on the basis of parasitological stool examinations concentration, and staining of intestinal parasites in fecal performed in the Laboratory of Parasitology of the District Sanitary- specimens, with critical observations on the trichrome stain. Epidemiological Center]. Wiad Parazytol 2007;53:285-93. J Microbiol Methods 2000;39:127-32. 18. Choudhuri G, Rangan M. Amebic infection in humans. 7. Congly SE, Shaheen AA, Meddings L, Kaplan GG, Myers RP. Indian J Gastroenterol 2012;31:153-62. Amoebic liver abscess in USA: A population-based study of 19. Proctor EM. Laboratory diagnosis of amebiasis. Clin Lab Med incidence, temporal trends and mortality. Liver Int 2011;31:1191-8. 1991;11:829-59. 8. Unruh DH, King JE, Eaton RD, Allen JR. Parasites of dogs from 20. Mirelman D, Nuchamowitz Y, Stolarsky T. Comparison of use of Indian settlements in northwestern Canada: A survey with public enzyme-linked immunosorbent assay-based kits and PCR health implications. Can J Comp Med 1973;37:25-32. amplification of rRNA genes for simultaneous detection of 9. Wuerz T, Kane JB, Boggild AK, et al. A review of amoebic liver Entamoeba histolytica and E. dispar. J Clin Microbiol abscess for clinicians in a nonendemic setting. Can J Gastroenterol 1997;35:2405-7. 2012;26:729-33. 21. Haque R, Ali IK, Akther S, Petri WA Jr. Comparison of PCR, 10. Hung CC, Chang SY, Ji DD. Entamoeba histolytica infection in men isoenzyme analysis, and antigen detection for diagnosis of who have sex with men. Lancet Infect Dis 2012;12:729-36. Entamoeba histolytica infection. J Clin Microbiol 1998;36:449-52. 11. Samie A, Barrett LJ, Bessong PO, et al. Seroprevalence of 22. Upadhyay R, Gupta N, Gogia P, Chandra S. Poached egg Entamoeba histolytica in the context of HIV and AIDS: The case of appearance in intestinal amebiasis. Gastrointest Endosc Vhembe district, in South Africa’s Limpopo province. 2012;76:189-90. Ann Trop Med Parasitol 2010;104:55-63. 23. Acuna-Soto R, Maguire JH, Wirth DF. Gender distribution in 12. Stanley SL Jr. Amoebiasis. Lancet 2003;361:1025-34. asymptomatic and invasive amebiasis. Am J Gastroenterol 13. Li E, Stanley SL Jr. Protozoa. Amebiasis. Gastroenterol Clin North 2000;95:1277-83. Am 1996;25:471-92. 24. Shandera WX, Bollam P, Hashmey RH, Athey PA, Greenberg SB, 14. Marn H, Ignatius R, Tannich E, Harms G, Schurmann M, White AC Jr. Hepatic amebiasis among patients in a public Dieckmann S. Amoebic liver abscess with negative serologic teaching hospital. South Med J 1998;91:829-37. markers for Entamoeba histolytica: Mind the gap! Infection 25. Blessmann J, Van Linh P, Nu PA, et al. Epidemiology of amebiasis 2012;40:87-91. in a region of high incidence of amebic liver abscess in central 15. Fotedar R, Stark D, Beebe N, Marriott D, Ellis J, Harkness J. Vietnam. Am J Trop Med Hyg 2002;66:578-83. Laboratory diagnostic techniques for Entamoeba species. 26. Lotter H, Helk E, Bernin H, et al. Testosterone increases Clin Microbiol Rev 2007;20:511-32. susceptibility to amebic liver abscess in mice and mediates 16. Kobayashi CI, Yamamoto G, Hayashi A, et al. Fatal amebic colitis inhibition of IFNgamma secretion in natural killer T cells. after high-dose dexamethasone therapy for newly diagnosed PLoS One 2013;8:e55694. multiple myeloma. Ann Hematol 2011;90:225-6.

Can J Gastroenterol Hepatol Vol 28 No 7 July/August 2014 359 www.CDHF.ca UNDERSTANDING VIRAL HEPATITIS VIRAL HEPATITIS

IRRITABLE BOWEL SYNDROME – IBS What is viral hepatitis? UNDERSTANDING COLONOSCOPY Hepatitis means inflammation of the liver. Viral hepatitis is Other viruses can infect man y different organs in the inflammation of the liver caused by infection with a virus. and sometimes the liver. body Examples include the Epst A virus is an infectious agent virus that causes infectious mononucleosis and ein-Barr How do I prepare for colonoscopy? Irritable bowel syndrome 2009 — that needs to enter a fectious mononucleosis on how to living cell cytomegalovirus (CMV What is colonoscopy? Your doctor will provide specific instructions on how to before it can multiply. Inflammation of the liver may be ). CMV only appearsCOMPRENDRE to cause LA PANCRÉATITE , MD Colonoscopy is an examination of the large intestine structions will describe caused by many ot inflammation of the liver when the infected personsignificant is on prepare for the procedure. The instructions will describe global recognition,Eamonn M.M. Quigley Marchnew 2010. ideas her agents, for example, a iver when the infected per with the best ects of lcohol, poisons, drugs to prevent rejection of a transplanted organ. (colon or large bowel) that is performed by a trained how to clean the bowel to provide the doctor as well as somend manymedications asp . ection of a transplanted or Quelle est la cause de la e and many asp doctor. A slim flexible tube (colonoscope) is inserted into medications to avoid Source: World Gastroenterology News, S iss far from completecomplet a ny Aperçu look at the colon as well as potential medications to avoid ted further in ma du pancréas, pancréatite ? UNDERSTANDINGe to reduce the likelihood of ENDOSCOPIC d as global map of IBSIB i ond à une inflammation the anus and rectum and is advanced through the before or after the procedure to reduce the likelihood of need to be investiga Une pancréatite corresp pancréatite aiguë sont principalement been recognize its epidemiology What causesrends are begin viralning hepatit Symptoms n, à côté du La plupart des cas de la drome (IBS) has long some interesting t fondeur dans l'abdome UNDERSTANDING canal COLON CANCER beginning of the colon (cecum) and sometimes higher complications. CHOLANGIOPANCREATOGRAPHY (ERCP) er for the gastro- t surprising to a is? une glande située en pro lculs biliaires obstruant le Irritable bowel syn parts of the world, There are several viruses that may infect human liver cells, Those in the early phases of the acute infection may it des enzymes digestives nécessaires provoqués par des ca into the small intestine (ileum). For the patient who has d challenging disord teresting – and mos of the acutefoie. infection Le pancréas may produ cès d'alcool. D’autres causes possibles d food for 24 to h America. Recent t there are striking experience muscle aches our réguler pancréatique ou par l’ex You will probably be asked to avoid solid food for 24 to an important an ty to emerge. Most in such as Hepatitis A ents, et libère l'insuline p au élevé de had a bowel operation with creation of an ostomy RETROGRADE rn Europe and Nort – is the finding tha , B, C, D,d femalesE and G. Hepatitis A , fatigue, and àsometimes la digestion joi des alim s médicaments, d’un nive A clear fluid diet is enterologist in weste ve raised the possibili Western audience E are causedamong ongby viruses males .an Infection with these virus andes Hepatitis occurs (especially with acute He nt pains il libère ses sont la prise de certain Overview 48 hours before the examination. A clear fluid diet is d other regions ha GO xample, patitis B) that can be tro pancréas est enflammé, illonsns ou dans (colostomy, ileostomy) the scope can be placed directly least 24 hours (such as For this reason, W prevalence of IBS am la glycémie. Lorsque le virale telle que les oreoreillo What is ERCP? studies from Asia an differences in the as a result ofnd the China, contamination for e of food or drinking water. Sore throat and swellin ublesome. s à l'intérieur graisses, d’une infection Colon cancer is a disease where cancerous cells (tumours) might be attributab into this opening directly into the gut. The colonoscope generally recommended for at least 24 hours (such as evalent elsewhere. thee world. In India a g of the lymph propresglands aenzymes (qui sont généralement stocké ire. La le to dietary factors an lp). ive Health Day (WDHD) isorder,der, but is as common re common. certains cas, cette mamalaladiedie peut être héréditahéréditaire. d that many colon clear jello, broth, juicesEndoscopic without Retrogr pulp).ade Cholangiopancreatography that IBS may be pr in other parts of th The virus is spread orall n Nausea, loss of appetite and occasionally some loose des dommages au pancréas et aux tissus are present in the wa cancers may be preventable through dietaryis used modificatio to see the lining of the gastrointestinal tract. The ocus for World Digest nantly female ddisor y and can give rise to mild ite and occasionallyde l'organe)some l causant est principalement caucauséesée par la ll of the large intesti e preventable through (ERCP) is an endoscopic test that is done to examine the chose IBS as its f itious, as the topic n more common i , moderate bowel movements may fo pancréatite chronique of genetic and e ne (colon). A mix purge the media, IBS is not a predomi or rarely, a very severe illness. Total recovery is usual and tes ounvironmental par factors A diet high in fat procedure usuallyns. takes 20-30 minutes but occasionally (small plastic tube) t proved most prop r, in some surveys, eve llow these earliervoisins. symptoms ltes ou par can cause cells in the appears to increase You will also be requiredbile ducts, to gallbladdertake a laxative and to pancreatic purge the duct by passing 2009 – a choice tha lay press and omewhat different . While consommation chronichroniqueque d'alcool chezlining les of aduladu the bowel to turn cancerous. The first step in thi the risk of colon cancer different preparations among males or,o re-infection should not many people will have no symptoms at all, those who are whereas high fiber, including vegetablesup and to an f hour. , is injected into the withinduc the scope. After the eal of interest in the iaa may also feature s occur. Hepatitis A and E tend o symptoms at all, those ez les jeunes. Dans cerrtainstains cas, une bowel of any stool.X-ray There material are several (dye) through a tube in the small intestine. generated a great d d health-care currentrrent research is ptômes de la une fibrose kystique chezch les jeunes.transformation Dans ce occurs when a collection of abnormal cell ruits, may osen based your h males. IBS in AsAsi in epidemics. is to occur symptomatic may take many weeks to recover. e pancréatite. Les sym de risque s lower the risk. Some of abnormality. If stonests, are X-rays present, are taken these to can iX-ray usually material be gastroenterologists an esentation.ntation. Although cu weeks to recover.Il existe deux formes d ur de risque vitamins called a and the type andThis timing test mayalso beallows chosen the baseddoctor your to see the upper small me WDH Year, suc ascinating area, it ine, peuvent pancréatite est génétique. L'obésitécalled est un a factefacteurpolyp forms. s ntioxidants, like vitami ollow the as well as among symptoms at presepr paraissent de façon souda E, or others like vitamin D or the use of ASA (aspirin), mayn removed at the sam dentify areas eneral. WDHD beca the surface of this f fferences pancréatite aiguë ap pancréatite aiguë et sévère. amin D or the use o Why is colonoscopy done? medical history. intestineIt is important and the that open you follow the professionals in g merely scratching Hepatitis B, C, D andlarities G are and al dil spread via blood-to-blood For those with severe hepatitis, the urine will start to turn uvent, cette bien connu causant une also lower the ch preparations to allow e time by cutting open the nerated by IBS! ial e hepatitis, the urine w ner à la mort. Le plus so Colon canceraugmentera can af ance of getting colon c instructions carefully and take all the of the bile duct (sphi r that research into simi ldd has the potentipotent être très graves et me itéé » du monde occidental fect people of all ages but is most ancer.The most Smoking common and reasons to perform colonoscopy are ing of ducts into the sma was the interest ge abundantly clearclea contact. In the case of dark, the whites of the eyes with start to yellow (this is teinte « L'épidémie d'obésd'obésit obesity appear to i ncterotomy) and pulling ion ferentrent parts of the worlwor eyes with start to yellow ( e fois que la cause de l'at common afters décennies. the age of 50. In 2009, it is expected that ncrease the risk of bit or abdominal for a safe and thorough examination. different instruments. If there is an abnormal narrowlower portioning, on to this explorat r all. Hepatitis B, other tissue f glande s'améliore, un atients dans les prochaine colonto cancer,evaluate whereas bleeding, changes in bowel ha ll intestine. between IBS in difdiffeinfectious. Sexual fortrans all.mission of Hepatitis B isluids the mostare also jaundice). Fatigue tends to lessen once jaundice appears. onique (à le nombre total de p physical activity and the use of aspirin/nonsteroidal them out with the WGO’s contributi erstanding of IBS fo ds to lessen once jaund imée. La pancréatite chr 22,000 Canadians wi the use of aspirin/ Why is ERCP done?n supplements) are tubes (stents) can be left in place to relieve the blockage. tional task force on pancréatique est suppr ll be diagnosed with inflammatory drugs may decrease the risk.pain. Otheranti- reasons include to diagnose iron deficiency A central part of to advance the undcommon form of spread Jaundice generally lasts one or two weeks. However, in s continus du colon cancer and ugs may decrease the Some medicationsThe ERCP (blood is donethinners, for iron supplements) are This procedure is te ation of a multina ely before in the western world. Thi s one or two weeks.long Howe terme) est caractérisée par des dommage that about 8,900 of th e to reduce of IBS was the cre met immediat entiontion is the role of leurs ose will die. Colon c anemia, to confirm abnormal barium enema findings or, Hepatitis B can be found in semen. Sexual transms issionis because of some, particularly thos tre accompagnés de dou Comment puis-je savoirmost prevalent si je cancsouffre ancer is the third stopped up tojaundice a week (yellownessbefore the procedur ofa numberthe skine to ofand reducereasons eyes), thatabnor c mal liver successful. Sometimeschnically one or difficult more repeat and is proced oc ures are IBS. The task force serves special attenatt e infected with Hepatitispancréas A qui peuvent ê er in Canada, the Genetic predisposition (heredity) greatly increases the risk om the test . Be sure global aspects of of May and shared One issue that de postinfecttinfectious IBS (PI- , jaundice second most commo tion (heredity) gr to evaluate the extent and severity of the response to complications or improve the view from the test . Be sure Hepatitistiation Cof is IBS much – pos less common. Hepatitisrge D is quite rare in may be more prolonged duction permanente du cause of cancer deaths and, the second most expensive n of colon cancer. tests or abdominal X-ra an include necessary to achieve the desired outcome. casionally not e Week at the end e initiation of IBS – and associated withconstantes sever et d’une ré d’une pancréatite ? A close relative with co treatment in patients with inflammatory bowel disease. s well beforehand. Digestive Diseas ally thereafter, with pathogens in ththe ini mongong victims of la of the skin. This is particularly common in young womene itching bituellement lon cancer or polyp to ask your doctor about your medication raft paper electronic the Northen well America described and aam only occurs in patientsope, who are also pancréas. t chroniquecancer commence to treat. ha is a strong risk factor. It appears that an inherited, genet s or weight loss. The y tests, unexplainedyour judgment abdom presentation of icularly common in fonctionnementyoung du La pancréatite aiguë e tor. It appears that Colonoscopy is also used for colon cancer screening and After the procedure, most patients are still sleepy and are comments on a d IBS). PI-IBS has bebeeninfected with Hepatitisric infection B. in Eur taking birth control pi néralement, You should arrange for an escortse symptoms home as your may judgmentbe due to nating in the formal don. od poisoning or ente f lls. Birth control pills should be par des douleurs dans lele haut de l'abdomen. Gé risk factor is present in at least half of all cases ic inflammation or leakage in theo relax bile andyou pancreaticduring inal duc paints the process culmi Gastro 2009 in Lon g an examination o Regular colonoscopieuu duies dos. every three years can de nt in at least half of to remove polyps. Currently, it is the most accurate test observed to be sure that their blood pressure, pulse and ite outbreaks of fo as soon as an individual knows or suspects that thestoppedy have †: la pancréatite e directement vers le milmilie cancer. The more relatives affected, and the youngerof colon they might be altered(for example, by medications stones, tumo given to relax you duringblockage or eir deliberations at , andd China, promptinprompting nows or suspects thatLa pancréatite the affecte un million de Canadiens la douleur se propag tect almost proceedings of th context of a WGO satell onablynably similar 100% of colon canced'alcool ou elatives affected, an for identifying polyps. temperature remain stable and that they do not develop bal North AmericaAmerica, an e, the viral hepatitis. ; et, la t aprèsprès la consommation rs. Those with a fami are when diagnosed the test. Youproblems). must not drive. ur, inflammation or postop n took place in the een the enteric reasreaso chronique touche plus de 300 000 Canadiens Cette douleur surviensurvient a ly history of colon with the disease, the This presentatio xplore not only glo relationships betw nationsations in Europ adiens. Les cancer, polyps agnéeandée inf delammatory bowel disease (IBD) a higher the risk to pain. Most patients do not remember their test. Some S, which set out to e ogy of ing reported from n cte plus de 600 000 Can à la suite d’un repas. EEllllee est souvent accompaccompagn the individual of developing colon cancer. erative the pathophysiol global map of IBS is pancréatite aiguë affe people over 50 shole patient nd loping colon canc discomfort may be pr symposium on IB prevalence rates be ospitalisés ents.ts. Elle s’aggrave quandquand uldle patient all be screened — t also new ideas in nd Africa. While the coûts de soins de courte durée aux patients h nausées et de vomissemvomissemen even in the absenc off its epidemiology www.CDHF.ca of any symptoms.’on seEarly penche colon cancer is more than 90 per e Most colon cancers ar How is ERCP done? www.CDHF.ca pain is uncommon. Patesentients when are usually sedation discharged wears once aspects of IBS, bu Americas, Asia, a , s parmi les à plat,lat, et s’apaise lorsqu’onlorsqu ise from polyps. Thes udience learn? te and many aspects o souffrant des maladies du pancréas sont classé s’allonge sur le dos, à p cent curable with endoscopic removal or surgery and yet e are small growths IBS. What did the a far from completecomple ny parts of the world a, s’élevant peuteut entrainer within the colon that usually do not cause any symptoms. The ERCP may be done a they are fully awake unless there are other reasons off. for Severe ide, ated further in many s les plus chères au Canad cass graves, la pancréatite p usually do not cause igated further in ma cinq maladies digestive vers l'avant. Dans les ca fewer than 20 per cent of Canadians who are eligible for They appear as sm common worldw need to be investiginvest to emerge. Most all bulges from the b (day care) procedure. An sintravenous an inpatient is orusually as an started ou to which the patient needs to be in hospital. rted from nds are beginning de dollars par an. clear that IBS is indeed à environ 120 millions screening are making use of this preventative option. a mushroom protrudes from the ground).owel O verwall time (much the like allow drugs to be given. It is abundantly tes being repo some interesting tre from the ground). O tpatient similar prevalence ra and Africa. While the polyps will grow and, under appropriate conditions,ver time turnthe a camera on the end (endosAftercope) sedation, is passed a flexible down the with reasonably , www.CDHF.ca nd, under appropria More information the Americas, Asia, erology News te conditions, turn ld Gastroent into colon cancer. If detected early, polyps can be easily swallowing tube and through the stomach into the upper nations in Europe, eared in E-Wor It has been What causes colon cancer er. If detected early, tube with For more information about protecting and enhancing ic article app anisation. viewed scientif rology Org gy.com. polyps can be easily This peer-re ld Gastroente gastroenteroloastroenterolo ? removed through colonoscopy, thereby eliminating the small intestine. The opening of the ducts is identified and tter of the Wor . www.worldwww.worldg The cause of colon c olonoscopy, thereby your digestive health, please visit e and advice the official newsle of the WGO ancer is unknown, ho eliminating the the medical car e permission wever, certain risk polyps and their risk. substitute for recommend factors have been d X-ray material is push t be used as a hysician may a used with th Since colon cancer typ ion should no t that your p www.CDHF.c iscovered. Colon cancer ically arises from www.CDHF.ca ns in treatmen available at is more common colonic polyps, and since polyps do not lead to symptoms, ed into the ducts through Important: This informat ay be variatio ormation is in developed countries. This may be caused by dietary and cian. There m ances. More inf of your physi and circumst early testing may help to detect and remove polyps and ividual facts other lifestyle fa a catheter based on ind ctors in industrialize d countries. It has been prevent progressive disease. It is important for patients at estimated that about 35% of all cancer s in the United Stat risk to be checked e es arly to prevent canc er from developing. www.CDHF.ca www.CDHF.ca M EDIATORSof INFLAMMATION

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