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treatment guidelines
Amoebiasis
Entamoeba histolytica
y Protozoan, intestinal parasite
y Other subtypes of Entamoeba
Largely non pathogenic
e.g. E. dispar
Cyst vs trophozoite
y Cyst - infective
y Trophozoite - invasive
Incidence
Huge global problem
y 50 million infections/ year (developing nations)
40 000 - 100 000 deaths/ year
Indigenous population NT
Homosexual men, NSW
Immigrants form India/ SE Asia/ Central + Sth
America
y Returned travellers (8 - 12 week delay)
Immigrants
Institutionalized
Communal co-habitation
Promiscuous male homosexual sex
Immunosuppresion
y HIV
y Transplant
Clinical features
Asymptomatic
y Most common form of infestation
y carriers
These people almost never develop symptoms but can
spread disease
y
y
y
Clinical features
Symptomatic
y Amoebic colitis
Subacute presentation (weeks)
y
y
y
y
Clinical features
Symptomatic
y Ameobic liver abscess
Most common extraintestinal manifestation
(10% of infected patients develop liver
abscesses)
Hepatomegaly
y Jaundice (5%)
Due to large or multiple abscesses and/ or
bacterial superinfection/ or abscess at the porta
y Uncommon
Right lower lobe pneumonia
Jaundice
Severe sepsis - usually indicates secondary bacterial
infection
Investigation
FBE
y Aneamia, leukocytosis, eosinophilia
LFTs
y Jaundice, hypoalbuminaemia
y Elevated AST (acute) and ALP (chronic)
Stool sample
y Low sensitivity (only 30% of patients have
concomitant intestinal amoebiasis)
Investigation
Serologic testing - Enzyme
immunoassay for antibodies to E
hystolitica
y Absence of antibodies after one week of
symptoms almost exclusive of Amoebic
liver abscess
y Cannot distinguish between carriage and
acute infection - largely insignificant
problem in Australia
Diagnosis
USS
y Initial diagnostic modality as imaging of
biliary tree also possible
y Sensitivity 75-80% (for liver abscess)
y Non-homogenous round or oval
hypoechoic lesions with well-defined
margins and lack prominent peripheral
echoes
Diagnosis
CT
y Greater sensitivity 88-95%
y Abscess - low density with smooth margins
and a contrast-enhancing peripheral rim.
Diagnosis
MRI
Technetium white cell scanning
Hepatic angiography
Treatment
Medical
1. Eradication of invasive trophozoites
Treatment
Surgical
1. Aspiration of cyst
To confirm diagnosis (vs pyogenic)
If no response to antibiotic therapy after 5-7d
High risk of rupture (diameter > 5cm, abscess
wall < 10mm)
Left lobe abscess (high rate or rupture at
smaller size into peritoneum or pericardium)
Treatment
Surgical
2. Open drainage
Treatment
Follow up
y Stool antigen testing after eradication and
repeat treatment as necessary
y No repeat imaging
Changes take months to years to resolve
Difficult presentations
Left lobe abscess presenting as
jaundice, sepsis and encephalopathy
Right lobe abscess with cough and foul
sputum
RUQ pain, sepsis, peritonism
Multiple abscesses
Complications
Intestinal
y Fulminant colitis
y Toxic megacolon
0.5% - usu in patients inappropriately
administered steroids (inflammatory bowel
disease)
40% mortality - perforation, peritonitis, massive
bleeding
y Perianal disease
Complications
Extraintestinal
y Liver abscess rupture
Pleuro-pulmonary disease
y Bronchopulmonary fistula
Subphrenic abscess
Intraperitoneal rupture
Pericardial rupture
Complications
Rare
y Cerebral infection
y Genitourinary infection
y Cutaneous infection
Prognosis
Most cases resolve within 7 days of
treatment
Mortality is uncommon but can occur
with abscess rupture
Assessment
y Differential diagnosis
Pyogenic liver abscess
Hydatic liver abscess
Ameobic liver abscess
y Uncommon differentials
Cholecystitis with phlegmon, Hepatic
carcinoma, Hepatitis with liver cyst any septic
syndrome with unrelated solitary liver lesion
Pyogenic
Hydatid
Duration of
symptoms
Days - weeks
Hours - days
Months - years
Features on
history
Recent travel
GI or biliary
Contact with
pathology. IVDU, sheep
immunocompro
mised
Degree of sepsis
Mild
Severe
Mild
Investigation differences
Amoebic
Pyogenic
Hydatid
Bloods
Positive
serology
Jaundice +
other LFT
derangement,
Positive blood
cultures
Eosinophilia,
positive
serology
Imaging
Large, usu
Multiple lesions Unilocular
right sided cyst
large cyst with
daughter cysts
Resuscitation
Basic bloods and imaging
If stable hydatid and amoebic serology
If unstable and low probability of hydatid
then percutaneous drainage
Chemotherapy or surgery as
appropriate
References
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