Parasitic Infestations

Liver & Biliary tract

Dr Kapil K Agrawal
TATA MAIN HOSPITAL, JSR
 Parasitic Infestations

Parasitic diseases: Caused by Protozoa or Helminths

Endoparasitic protozoa:
A diverse group of >10,000 eukaryotic
unicellular organisms

Endoparasitic helminths of humans:

Two phyla – (1) Platyheminths (Flatworms)

(2) Nematoda (Round-worms)
• Global problem – more in third world
countries

• Commonly undiagnosed and neglected

health problem

• Un-noticed cause of malnourishment &

deficiency disorders
 Why Don’t We Know They Are
There?

• A smart parasite lives without being detected –

as the symptoms are mild and nonspecific

• They are intelligent in their ability to survive and

reproduce

• No organ is immune from their infestation

 Symptoms of Parasites

• Forgetfulness • Pain in back, thighs

• Slow reflexes shoulders
• Gas and bloating • Lethargy
• Loss of appetite • Burning in the stomach
• Increase in appetite but • Indigestion
still feel hungry after • Dry lips during the day
eating • Semisolid stools, mucus
• Yellowish face • Jaundice
• Grinding of teeth • Non sp. Abd pain
 What Parasites Do?

• Eat : Nutrients

• Secrete : Toxins

• Reproduce : Cycling
• Parasitic infestations include mainly :
Hydatid disease
Amoebiasis
Ascariasis
Fascioliasis
Schistosomiasis
Trichuris
Necator
Ancylostoma
Toxocara
Hydatid disease of the liver
Carnivores (dog,
dingo) definitive
host, lives in the
small intestine
Sheds ova into
faeces

Sheep, cattle
(kangaroos, pigs)
intermediate host
• Liver (most common)
• Lungs
• Brain
• Bone
• Secondary spread
 Pathology

• Migration via portal circulation

• Essentially creates a cyst

(mucopolysaccharide)

• lined by inflammatory reaction of the host

tissue
Ectocyst
(laminated
membrane)
Endocyst Scoleces
(Germinal (400,000 scoleces
Membrane) per 1 ml of ‘hydatid sand’)
 Natural course

• Growth rate 1-2 cm / year

• Eventually reach the capsular surface of liver –

rupture
- intraperitoneally
- intrathoracic
- biliary system
- pericardium (Lt lobe)
 Presenting symptoms

• Asymptomatic
• Abdominal pain (RUQ mass) – Liver being pushed down
• Jaundice
• Acute abdomen/ Rupture
• Cholangitis
• Secondary infection
• chest pain / cough / haemoptysis / bilioptysis
2013 patients - uncomplicated 82%
- biliary complications 12%
- thoracic complications 2.2%
- other rarer complications
Zaouche et al Tunisienne de Chirurgie 1997
 Diagnosis
• History of exposure
• Clinical examination
- Abdominal lump/Ac abdomen
- Jaundice
- Chest symptoms
• Imaging
• Blood tests
CT scan findings
 Laboratory diagnosis of hydatid disease

• ELISA - very sensitive

- cross reactive with other parasites

• IEP
• Immuno HaemAglutination
- Has replaced the others over last 3 years
- Approx 98% accurate
 Treatment

• Symptomatic vs Aysmptomatic

1. Medical Rx only

2. Surgery - open
- laparoscopic

3. PAIR
 Benzimidazoles

• Albendazole, Mebendazole
• Albendazole - most commonly used
- 1-month oral doses(10-15mg/Kg/day)
- ± Praziquantal
• Anti-helminthic – direct effect on the parasite and
perhaps on the cyst wall

• Side effect – Hepatic enzyme disturbances, Alopecia,

Glomerulonephritis, Neutropaenia
• Current role of Albendazole ± Praziquantal
1. Perioperatively
2. Widely disseminated disease
3. Poor surgical risk
4. Alveolar echinococcosis
5. Small deep seated hydatids

EBM review
• Three available RCTs showed that ABZ had a better effect on hydatid cysts than
• placebo [17, 21] or MBZ[20]. One prospective controlled trial compared ABZ and
• praziquantel versus ABZ alone [24] and concluded that the combined treatment was
• more effective than ABZ alone. However, complete disappearance of all cysts was
• not reached according to these data. Therefore chemotherapy is not the ideal
• treatment for hydatid cyst of the liver when used alone (level II evidence, grade B
• recommendation). Dzeri et al WJS 2004
 Surgery

• Principles – Remove all the hydatid scolicoles

– complete removal of laminated membrane
• Prevent - Abscess / sinus formation
- Biliary leak

• Avoid intra-operative anaphylaxis

• Avoid peritoneal spillage and dissemination

• Definitve surgical options

• Conservative

• Radical

1) Excision of cyst and Pericyst

2) Partial hepatectomy
• Pack behind liver and pack-off the cyst

• Scolicidal agents
- 15-20% saline (Most effective)
- 75% ethanol
- 0.1-0.5% cetrimide
- 1% povidone

• Avoid Formalin & 0.5% Silver Nitrate

 Communication with the biliary tree

• Clinical or biochemical suspicion

• Visual inspection
• Cholangiogram - identifies communication
- cysts in ducts
• Biliary communications closed off with sutures if small,
peripheral ducts
• Larger duct communication is (US/CT) predictable on
pre-op imaging ( close to ducts) LFTs

• consider: CBD Stenting, T-tube

 Percutaneous Aspiration, Injection
& Reaspiration (PAIR)

• Scolicidal agents - Ethanol, Hypertonic saline, Providone

used in conjunction with Albendazole

• < 5% incidence of anaphylaxis

• Safe and effective

• Uncomplicated small cysts

 Percutaneous aspiration, injection
and reaspiration (PAIR)
• Meta-analysis 769 patients with PAIR + Albendazole vs 952 era
matched patients treated surgically

• PAIR & Alb ↑ clinical efficacy

↓ morbidity, mortality, recurrence
↓ LOS Smego Clin infect Dis 2003

According to our systematic review, PAIR with or without benzimidazole coverage may be
comparable or superior to surgery or medical treatment with benzimidazoles alone for
uncomplicated hepatic hydatid cysts, but the data are not sufficient to draw definite
conclusions. Therefore, we cannot recommend the use of PAIR with or without benzimidazole
coverage outside randomised clinical trials for treating patients with uncomplicated hepatic
hydatid cyst
Cochrane Collaboration 2006
 Parasitic infestations

Hydatid disease
Amoebiasis
Ascariasis
Fascioliasis
Schistosomiasis
Trichuris
Necator
Ancylostoma
Toxocara
 Amebiasis
Entamoeba histolytica
• Pseudopod, non-flagellated protozoa

• Only member that causes: Amebic colitis & liver abscess

• Life Cycle consists of:

(1) Infectious cyst
(2) Invasive trophzoite

Trophozoites adhere to colonic mucin and epithelial

cells  kill host epithelial & immune cells  tissue
destruction
 Amebiasis

Entamoeba histolytica Entamoeba histolytica

trophozoite mature cyst
Amebiasis

Infection of Entamoeba histolytica occurs by ingestion of

mature cysts in fecally contaminated food, water, or
hands (2). Feco-oral route
trophozoites released in the small intestine (3)  migrate to
the large intestine (4). Trophozoites multiply by binary
fission and produce cysts (5) passed in the feces.

Cysts are responsible for the transmission.

In many cases, trophozoites remain confined to the intestinal

lumen (noninvasive infection) of individuals who are
asymptomatic carriers, passing cysts in their stool.

In some patients trophozoites invade the intestinal mucosa

(intestinal disease), or, through the bloodstream,
extraintestinal sites such as the liver, brain, and
lungs (extraintestinal disease), with resultant pathologic
manifestations.
Trophozoites of Entamoeba histolytica (Trichrome stain)

Two diagnostic characteristics: ingested erythrocytes

nuclei have a small, centrally located karyosome & uniform
peripheral chromatin.
 Entamoeba histolytica
Epidemiology

• Greatest morbidity/mortality in the developing countries of Central &

South America, Africa, and India

• Disease more severe in:

The very young, Elderly, Pregnant women

• Worldwide: 40-50 million symptomatic infections/year

100,000 deaths annually
 Entamoeba histolytica
C linical Manifestations
Amebic colitis
Sign or Symptom % of Patients Affected
Symptoms > 1 wk Most patients
Diarrhea 94-100
Dysentery 94-100
Abdominal pain 12-80
Weight loss 44
Fever >38oC 10
Heme (+) stool 100
Immigrant from or traveler
to endemic area >50
Prevalence (male/female) 50/50
 Entamoeba histolytica
C linical Manifestations

Amebic colitis

Patients with chronic, non-dysenteric intestinal

amebiasis may complain for months to years of
abdominal pain, flatulence, intermittent diarrhea,
mucus in the stools, and weight loss

Chronic non-dysenteric intestinal amebiasis has

been mistakenly diagnosed as ulcerative colitis
Amebic Colitis:
Severe dysentery with multiple flask shaped ulcers in the large bowel,
and a bloody diarrhoea
Histopathology of a typical flask-shaped ulcer of
intestinal amebiasis
 Entamoeba histolytica
Clinical Manifestations

Amebic Liver Abscess

• Develops in about 10% of patients with invasive E.
histolytica infections

• Few patients have concurrent dysentery – most report

dysentery within the preceding year

• Occurs in any age group

• Patients with a more chronic illness (2-12 weeks of

symptoms) commonly present with hepatomegaly and
weight loss
 Entamoeba histolytica
Clinical Manifestations

Amebic Liver Abscess

Sign or Symptom % of Patients Affected
Symptoms > 4 wks 21-51
Fever 85-90
Abdominal tenderness 84-90
Hepatomegaly 30-50
Jaundice 6-10
Diarrhea 20-33
Weight loss 33-50
Cough 1 0-30
Immigrant from or traveler
to endemic area >50
Prevalence (male/female) 50/50 in children; 90/10 in adults
Gross pathology of liver containing amebic abscess
Gross pathology of amebic abscess of liver. Tube of
"chocolate" pus from abscess.
 Entamoeba histolytica
Laboratory Findings and Diagnosis

• Diagnostic Tests:

– EIA is best for specific diagnosis of amebiasis

(Sensitivity & specificity of assay on stool >95%)

– Colonoscopy remains important to evaluate for other causes

– Serology for antibodies: IHA

– Positive in: 88% amebic dysentery, 70-80% liver abscess, 50% of

general population
 Entamoeba histolytica
Laboratory Findings and Diagnosis

• Diagnostic Tests:
– Ultrasonography
– CT Scan
– MRI
None differentiate amebic from pyogenic abscess
Diagnosis is frequently a diagnosis of exclusion

IHA: Acutely, E. Histolytica antibody can be detected in serum in

70-80% of cases
EIA: Can detect E. histolytica antigen in serum in ~96% of patients with abscess
Amebic liver abscess
Amebic liver abscesses
 Entamoeba hystolityca
Prevention

Asymptometic amebiais:
Luminal agent (Paromomycin, Diloxanide furoate)

Amebic Colitis: Metronidazole & a luminal agent

Amebic Liver Absces: Metronidazole & a luminal agent

 Entamoeba Histolityca
Prevention
Prevention of E. hisolytca transmission requires
disruption of the fecal-oral spraed of amebic cysts

Individuals should be advised regarding:

• Risk of traveling to endemic areas
• Safeguards to prevent ingesting colonic organisms

Because humans and primates are the only known

reservoirs of E. histolytica, a successful vaccine
Could potentially eliminate this disease
 Parasitic infestations

Hydatid disease
Amoebiasis
Ascariasis
Fascioliasis
Schistosomiasis
Trichuris
Necator
Ancylostoma
Toxocara
 Intestinal Nematodes
Round Worms

• The most common parasitic infections in humans; affect

one quarter of the world population

• Remain a major cause of physical growth delay,

cognitive delay, and malnutrition throughout the world

• In certain endemic populations, children are

disproportionately affected

• Being increasingly encountered in the developed world.

In the USA, groups at increased risk include:
international travelers, recent immigrants, refugees, and
international adoptees
 Ascaris lumbricoides

• The most common helminthic infection in humans

• 1.2 billion infected worldwide
• 51 million children are currently estimated to be
infected
• Commonly affects children living in economically
week communities
• Young children seem to be affected more severely
than adults (larger worm burden, parasite-induced
malnutrition)
Ascaris lumbricoides
Ascaris lumbricoides

Transmission - Feco-oral Route

Embryonated eggs

Poverty, Overcrowding

Unhygienic living conditions

Human excreta as fertilizer

Unsafe water supply

Pickling of vegetables
 Ascaris lumbricoides
Clinical Manifestations

• Ascariasis usually have a benign course

but it can lead to –

• Chronic infection  malnutrition due partly to

malabsorption (proteins, fat & vitamin A)

• Heavy infestation  intestinal obstruction

• Some times it goes to biliary tract and causes obstructive
symptoms with jaundice
Adult worm Biliary Ascariasis

Bile Duct

Jejunum Via the Ampulla

Propensity to
Excessive worm load explore openings

Intestinal infections
(viruses,bacteria,parasites)
Abnormal mobility .

Fasting
 Common Bile DuctBiliary Colic,Cholangitis,
Pigment stones

Bile Duct Intrahepatic DuctsCholangitis,Pigment stones

Strictures, Hepatoliathiasis

Gall Bladder Acute Cholecystitis,

Empyema,Stones

Liver Hepatic Abscess,

Hepatoliathiasis

Pancreas Acute Pancreatitis

 Ascaris lumbricoides
Diagnosis

• Characteristic ova in stools

• Eosinophilia
• LFT
• pulmonary infiltrates on chest radiograph
• USG abdomen
• Cholangiogrm- ERCP/MRCP
 Treat Cholangitis
Aim Paralysis of worms in intestines
by Drugs Expulsion

o
Conservativ
Modalities e-Majority

o
Endoscopic-
Failures
 Ascaris lumbricoides treatment

• Mebendazole (100 mg twice daily X 3 days) or

• Albendazole (400 mg as a single dose)

(The above are not generally given to children < 1 yr)

• Pyrantel pamoate (11 mg/kg up to 1 gm/day, X 3

days)
 Ascaris lumbricoides
Prevention
• Safe disposal of excreta
• Wash hand, Wash eatables
• Diagnosis, effective treatment

• In endemic areas (infection rate is >50%), antihelmenthic

agents administration to school-age children has been
recommended as part of a targeted deworming program

• Sustained economic growth is most effective means of

long-term parasite control
Hydatid disease
Amoebiasis
Ascariasis
Fascioliasis
Schistosomiasis
Trichuris
Necator
Ancylostoma
Toxocara
• F hepatica (most common)
• F. gigantica (Africa)
• Infective stage

• Excystation

• Migration

• Diagnostic stage
• Fasciola species
inhabit the
hepatobiliary system
causing considerable
human morbidity
dependent on the
• number of worms and
stage of infection
• The course of infection passes through three phases:
• The acute phase : Immature flukes penetrates liver
capsule and reaches to bile channels- Toxic & Allergic
(3-4 months)
• The chronic phase : Flukes in bile ducts, relatively
free of symptoms (10-13 yrs)
• The obstructive phase :epithelial and parenchymatic
changes, recurrent cholangitis, cholecystitis, jaundice,
calcification, fibrosis

Ectopic fascioliasis
 Complications

1. Liver abscess and haematoma (subcapsular) (acute

stage)
2. Biliary cirrhosis :due to the peri-ductal fibrosis
3. Obstructive jaundice : Obstruction of the common bile
duct by Fasciola adults +
4. Biliary sludge and stones
5. Hemobilia
 Diagnosis

• Clinical
• Parasitological
• Immunodiagnosis –
– ELISA
– Indirect haemagglutination test (IHA)
– Counter immuno electrophoresis (CIEP)
– Indirect fluorescent antibody test (IFA)
• Imaging- USG/CT/MRI/ERCP/PTC
• Liver biopsy
 Treatment
• Chemotherapeutic agents in common use in
human fascioliasis:
 Effective with no or little side effects:
Triclabendazole, bithionol, Mirazid
 Effective with side effects: severe
(dehydroementine), or moderate
(Metronidazole)
 Controversial therapeutic results (Praziquantel)
THANK
YOU!