At the Focal Point

Severe right-sided colitis with asymptomatic multiple large liver

abscesses: unusual presentation of amebiasis

A 55-year-old alcoholic man had massive bright red

blood per rectum associated with postural symptoms. He
had had low-grade intermittent fevers over the preceding
2 weeks without associated abdominal pain, hematemesis,
diarrhea, change in appetite, or weight loss. Examination
revealed a pulse rate of 134 beats/min and systolic blood
pressure of 80 mm Hg. The liver was palpable 3 cm below
the right costal margin and was firm and tender. Rectal examination revealed fresh blood and no mass. The hemoglobin value was 8 g/dL (normal 12-18 g/dL); the total
leukocyte count was 12,600 cells/mL (4-11  103 cells/mL)
(neutrophils 82%[40%-75%], lymphocytes 16%[20%45%], monocytes 1%[2%-10%] and eosinophils 1%[1%6%]); the platelet count and coagulation studies were
normal. Blood urea and creatinine were 90 mg/dL (20-40
mg/dL) and 1.8 mg/dL (0.6-1.2 mg/dL), respectively. Liver
biochemical tests had normal results. After stabilization
and transfusion, colonoscopy was performed, which

revealed large ulcers with adherent clots in the cecum (A

and B). Multiple biopsy specimens were taken from the
edges of the ulcers, and intravenous treatment with metronidazole (500 mg every 6 hours) and ceftriaxone (1 g every
12 hours) was begun. Hematochezia ceased and renal
function normalized. To evaluate the patients tender hepatomegaly, US of the abdomen was performed; it revealed multiple hypoechoic lesions in both lobes of liver.
On CT these were seen as multiple hypodense lesions
(C). US-guided needle aspiration of these lesions revealed
anchovy-colored pus; multiple pigtail drains were placed in
the abscesses. Biopsy specimens taken at colonoscopy
showed multiple trophozoites of Entameba histolytica
on a background of necrotic inflammatory exudate (D; periodic acidSchiff stain, orig. mag. 40). Antibiotics were
given for 10 days and the pigtail drains were removed.
The patient had a complete recovery and is asymptomatic
8 months later.

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Volume 68, No. 2 : 2008 GASTROINTESTINAL ENDOSCOPY 375

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At the Focal Point

DISCLOSURES
The authors report that there are no disclosures relevant to this publication.
Surinder S. Rana, DM, Deepak K. Bhasin, DM, Varun
Mehta, DM, Kartar Singh, DM, Department of Gastroenter-

ology; Riatmbhra Nada, MD, Department of Histopathology, Post Graduate Institute of Medical Education and
Research (PGIMER), Chandigarh, India

doi:10.1016/j.gie.2008.01.031

Commentary
It is likely that the initial site of disease in this patient was the colon, after which access to the liver was gained through the
portal vein. In some diseases, such as diverticulitis, streaming in the portal vein may result in left colon disease localizing to the
left lobe of the liver and right colon disease to the right lobe of the liverdbut apparently not in amebiasis. Another interesting
part of this patients presentation includes the fact that the liver manifestations were clinically subtle with no right upper
quadrant abdominal pain, although there was hepatic tenderness; another reason to always perform careful physical examination! Symptoms of colon involvement (eg, diarrhea or dysentery) are seen infrequently (15% to 30%) in patients with amebic liver abscess, although colon ulcers are present in more than half the patients. The reason for the asymptomatic nature of
the colitis may be that colon involvement is usually minor, with small ulcers that involve the right side of the colon. In contrast,
symptomatic colon infection is associated with more diffuse ulceration and often involves the left side of the colon. The simultaneous presentation of large liver abscesses and large colon ulcers with massive bleeding is just another unusual feature
of this unusual case.
Lawrence J. Brandt, MD
Associate Editor for Focal Points

In vivo diagnosis of whipworm (Trichuris trichiura)

with high-definition magnifying colonoscope (with video)

A 68-year-old man underwent colonoscopy for a positive

fecal occult blood test. A whipworm (Trichuris trichiura),
which was seen to be moving gently in the cecum (A),
was discovered during the examination. The whipworm
was judged to be female because its caudal end was obtuse
(A, black arrow). By use of a magnifying colonoscope
(EC-590ZW/M, Fujinon, Saitama, Japan), we could identify some small eggs in the vicinity of vulva (B, yellow arrow), uterus (B, blue arrow), and intestine (B, red
arrow). At the esophageal part, there were round cells

called stichocytes that were regularly beaded into an arrangement (C) called a stichosome. Because the whipworm fixes itself to the bowel wall by inserting the
anterior part of its body into the cecal mucosa, biopsy
forceps was used to retrieve it (Video 1, available online
at www.giejournal.org). Fluid collected from the colon
during the examination revealed the characteristic lantern-shaped brown egg with bipolar plugs (D). Mebendazole (100 mg twice daily) was administered orally for 3
days to achieve complete eradication.

376 GASTROINTESTINAL ENDOSCOPY Volume 68, No. 2 : 2008

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