What is amoebic dysentery?

There are several different species of amoebae, but the most dangerous, such as Entamoeba histolytica, live predominantly in tropical areas. These species are able to burrow through the intestinal wall and spread through the bloodstream to infect other organs, such as the liver, lungs and brain. Amoebic dysentery (amoebiasis) is an infection of the intestine (gut) caused by an amoeba called Entamoeba histolytica that, among other things, can cause severe diarrhoea with blood. But it may cause milder chronic symptoms of: frequent loose stools abdominal pain cramps fatigue intermittent constipation diarrhoea with abdominal swelling flatulence. Amoebae are parasites that are found in contaminated food or drink. They enter the body through the mouth when the contaminated food or drink is swallowed. The amoebae are then able to move through the digestive system and take up residence in the intestine and cause an infection.

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How do you get amoebic dysentery?

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Entamoeba histolytica can exist in two forms in contaminated food and drink: as free amoebae (known as 'trophozoites') as infective cysts, which are a group of amoebae surrounded by a protective wall, that have been passed (excreted) in the carrier's faeces (human or animal). If you swallow contaminated food that contains the free amoebae (trophozoites), hardly anything is likely to happen because they usually die in the stomach on account of its acidity. On the other hand, cysts are particularly resistant to the acidic contents of the stomach, and food contaminated with cysts represents a genuine risk of infection. When the cysts reach the intestine of another person, the individual amoebae are released from the cysts and are able to cause infection. Amoebic dysentery is passed on by careless or negligent hygiene, where contaminated food and drink is consumed without adequate heat treatment. Salads washed with contaminated water are a common method of spread.

What does amoebic dysentery feel like?

Amoebic dysentery may not demonstrate any symptoms for long periods of time (months, even years). But infected individuals still excrete cysts and, consequently, infect their surroundings. When the amoebae attack, they damage the walls of the large intestine causing ulceration and subsequent bleeding. The milder symptoms of this are: y stomach cramps (colic) y painful passage of stools (tenesmus) y bloody, slimy diarrhoea that's often foul smelling. But the course of the disease can become complicated and alter radically if the amoebae break through the intestinal wall and its lining (peritoneum), causing peritonitis (inflammation of the peritoneum). The amoebae may be transported via the blood to the liver and other organs and usually do NOT give rise to a high temperature (this can be useful ie bloody diarrhoea with a fever suggests a bacterial infection) and a seriously debilitated condition. In the long term, the amoebae can, among other things, form enormous cysts in the liver and other organs, which sometimes may only be discovered on investigation by a doctor for other conditions, such as unexplained weight loss or illness.

What can you do to help yourself? (health teaching)

In practice, the only way to avoid infection with amoebic cysts is to ensure that everything you eat or drink has been washed or sterilised properly and cooked thoroughly. Drinking water can be made safe in two ways: y by boiling it for 10 to 15 minutes (a little longer at high altitudes), and then cooling it rapidly and keeping it covered y by adding water-purifying tablets and then leaving the mixture to stand for at least 15 minutes before use y by using a filtration device, such as Aquapure Traveller (combined ceramic and iodine filters). Chemical methods of sterilisation do not, however, guarantee complete destruction of all possible harmful organisms. Foods to avoid include salads, unpeeled fruit and ice cream. Ice cubes may also have been made with contaminated water. So, avoid having drinks that contain ice cubes, unless you're certain that the water used to make them has been sterilised.

Diagnosis
Anyone who develops bloody diarrhoea should see a doctor as soon as possible and ensure that they tell the doctor they have been travelling in the tropics, as amoebic dysentery doesn't normally occur in the UK. In the presence of the classic symptoms of amoebic dysentery, the diagnosis can often be made by means of a stool analysis. Bloody diarrhoea is seen in many other illnesses, but in tropical areas the diagnosis will typically be either amoebic dysentery or shigellosis (bacillary dysentery which is caused by bacteria and more likely associated with a fever).

Treatment
Amoebic dysentery is treated with metronidazole (eg Flagyl tablets) or Tinadazole (Fasigyn). Probelms can arise when some of the parasites will not respond to treatment, and also if the drugs required to treat the disease are not readily available (ie Paromoycin or diloxanide furoate). Complications, such as perforation of the intestinal wall or the presence of abscesses within the body's organs, require specialist hospital treatment. In an emergency for instance, if you have bloody diarrhoea and are on holiday in the tropics and cannot get medical help: you can treat yourself with metronidazole, eg two 400mg tablets, three times a day for five days. This is the dose for adults who are neither pregnant nor breastfeeding. It's important to avoid drinking alcohol during treatment. Even if you have to treat yourself, it's important to see a doctor to ensure that the treatment has been truly effective. UK General Practitioners are not supposed to provide NHS prescriptions for travellers. As metronidazole requires a prescription, you could ask your own doctor or travel clinic to write a private prescription in advance, if you know that you'll be travelling to remote tropical areas where access to a doctor or hospital can be difficult. Such prescriptions need to be issued privately, ie the cost of the drug has to be paid in full to the pharmacist. Anatomy and Physiology: Amebiasis is an intestinal illness thats typically transmitted when someone eats or drinks something thats contaminated with a microscopic parasite called Entamoeba histolytica (E. histolytica). The parasite is an amoeba, a single-celled organism. Thats how the illness got its name amebiasis. In many cases, the parasite lives in a persons large intestine without causing any symptoms. But sometimes, it invades the lining of the large intestine, causing bloody diarrhea, stomach pains, cramping, nausea, loss of appetite, or fever. In rare cases, it can spread into other organs such as the liver, lungs, and brain.

I. Structure. The GI System consists of the oral structures, esophagus, stomach,

small intestine, large intestine and associated structures. A. Oral Structuresinclude the lips, teeth, gingivae and oral mucosa, tongue, hard palate, soft palate, pharynx and salivary glands. B. The esophagus is a muscular tube extending from the pharynx to the stomach. 1. Esophageal openings include: a. The upper esophageal sphincter at the cricopharyngeal muscle. b. The lower esophageal sphincter (LES), or cardiac sphincter, which normally remains closed and opens only to pass food into the stomach. C. The Stomach is a muscular pouch situated in the upper abdomen under the liver and diaphragm. Te stomach consists of three anatomic areas: the fundus, body (i.e., corpus), and antrum (i.e., pylorus) D. Sphincters. The LES allows food to enter the stomach and prevents reflux into the esophagus. The pyloric sphincter regulates flow of stomach contents (chyme) into the duodenum. E. The small intestine, a coiled tube, extends from the pyloric sphincter to the ileocecal valve at the large intestine. Sections of the small intestine include the duodenum, jejunum and ileum F. The large intestine is a shorter, wider tube beginning at the ileocecal valve and ending at the anus. The large intestine consists of three sections: 1. The cecum is a blind pouch that extends from the ileocecal valve to the vermiform appendix. 2. The colon, which is the main portion of the large intestine, is divided into four anatomic sections: ascending, transverse, descending and sigmoid. 3. The rectum extends from the sigmoid colon to the anus. G. The ileocecal valve prevents the return of feces from the cecum into the small intestine and lies at the upper border of the cecum. H. The appendix, which collects lymphoid tissues, arises from the cecum. I. The GI tract is composed of five layers. 1. An inner mucosal layer lubricates and protects the inner surface of the alimentary canal. 2. A submucosal layer is responsible for secreting digestive enzymes. 3. A layer of circular smooth muscle fibers is responsible for movement of the GI tract. 4. A layer of longitudinal smooth muscle fibers also facilitates movement of the GI tract. 5. The peritoneum, an outer serosal layer, covers the entire abdomen and is composed of the parietal and visceral layers. II. Function. The GI system performs two major body functions: digestion and elimination. A. Digestion of food and fluid, with absorption of nutrients into the bloodstream, occurs in the upper GI tract, stomach and small intestines. 1. Digestion begins in the mouth with chewing and the action of ptyalin, an enzyme contained in saliva that breaks down starch. 2. Swallowed food passes through the esophagus to the stomach, where digestion continues by several processes. a. Secretion of gastric juice, containing hydrochloric acid and the enzymes pepsin and lipase ( and renin in infants) b. Mixing and churning through peristaltic action

3. From the pylorus, the mixed stomach contents (i.e. chyme) pass into the duodenum through the pyloric valve. 4. In the small intestine, food digestion is completed, and most nutrient absorption occurs. Digestion results from the action of numerous pancreatic and intestinal enzymes (e.g., trypsin, lipase, amylase, lactase, maltase, sucrase( and bile. B. Elimination of waste products through defacation occurs in the large intestines and rectum. In the large intestine, the cecum and ascending colon absorb water and electrolytes from the now completely digested material. The rectum stores feces for elimination.
Pathophysiology Laboratory Diagnosis: 1. Stool exam (cyst, white and yellow pus with plenty of amoeba) 2. Blood exam (Leukocytosis) 3. Proctoscopy/Sigmoidoscoppy Diagnosis of amoebiasis can be very difficult. One problem is that other parasites and cells can look very similar to E. histolytica when seen under a microscope. Therefore, sometimes people are told that they are infected with E. histolytica even though they are not.Entamoeba histolytica and another ameba,Entamoeba dispar, which is about 10 times more common, look the same when seen under a microscope. Unlike infection with E. histolytica, which sometimes makes people sick, infection with E. dispardoes not make people sick and therefore does not need to be treated. If you have been told that you are infected with E. histolytica but you are feeling fine, you might be infected with E. dispar instead. Unfortunately, most laboratories do not yet have the tests that can tell whether a person is infected with E. histolytica or with E. dispar. Until these tests become more widely available, it usually is best to assume that the parasite is E. histolytica. A blood test is also available but is only recommended when your health care provider thinks that your infection may have spread beyond the intestine (gut) to some other organ of your body, such as the liver. However, this blood test may not be helpful in diagnosing your current illness because the test may still be positive if you had amoebiasis in the past, even if you are no longer infected now. Complications: 1.

Rectovaginal fistulas 2. Amebic liver abscess  Intrathoracic or intraperitoneal rupture with or without secondary bacterial infection  Direct extension to pleura or pericardium 3. Brain abscess Treatment: 1. Metronidazole (Flagyl) 800mg TID X 5 days 2. Tetracyline 250 mg every 6 hours 3. Ampicillin, quinolones sulfadiazine

   

Amebic colitis Fulminant or necrotizing colitis Toxic megacolon Ameboma

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Streptomycin SO4, Chloramphenicol Lost fluid and electrolytes should be replaced

Several antibiotics are available to treat amoebiasis. Treatment must be prescribed by a physician. You will be treated with only one antibiotic if your E. histolytica infection has not made you sick. You probably will be treated with two antibiotics (first one and then the other) if your infection has made you sick. Nursing Management: 1. Observe isolation and enteric precaution 2. Provide health education and instruct patient to  Boil water for drinking or use purified water  Avoid washing food from open drum or pail  Cover leftover food  Wash hands after defacation and before eating  Avoid ground vegetables (lettuce, carrots, and the like) Introduction: Amoebiasis protozoal infection of human beings initially involves the colon, but may spread to soft tissues, most commonly to the liver or lungs, by contiguity or hematogenous or lymphatic dissemination. Amoebiasis is the third leading parasitic cause of death worldwide, surpassed only by malaria and schistosomiasis. On a global basis, amoebiasis affects approximately 50 million persons each year, resulting in nearly 100,000 deaths.