invasive : une analyse des infections à Entamoeba

gastrointestinal tract are common in the developing world but rare in North America. The authors present two cases: one involving an individual who had not travelled to an endemic area and another involving an individual who was born in Bulgaria. Both presented with severe abdominal pain and diarrhea. Endoscopic assessment revealed scattered colonic ulcerations and one patient was found to have a liver abscess on imaging. Stool ova and parasite studies were negative in both cases and both were diagnosed on review of colonic biopsies. On review of all Entamoeba cases in the Calgary Health Zone (Alberta), ova and parasite analysis found an average of 63.7 Entamoeba cases per year and a pathology database review revealed a total of seven cases of invasive E histolytica (2001 to 2011). Both patients responded well to antibiotic therapy. E histolytica should be considered in new-onset colitis, especially in individuals from endemic areas.

E ntamoeba histolytica infections of the gastrointestinal (GI) tract are common in the developing world; however, in first-world countries, they are typically found in first-generation immigrant populations and returning international travellers.E histolytica is a parasitic protozoa that primarily infects the human bowel (1).It exists in two forms, a short-lived mobile trophozoite (10 μm to 20 μm in length) that can invade multiple organ systems, and a long-surviving cyst form that can colonize a patient (1).Diagnosis of a non-travelrelated E histolytica infection in Canada is rare, with the most recent reported studies investigating cases in Inuit communities in Northern Labrador (2) and sexually transmitted cases in the homosexual population of Toronto, Ontario (3).Herein, we describe two cases of E histolytica colitis that presented to the Foothills Medical Centre, a large urban tertiary care centre located in Calgary, Alberta.

Methods
The Calgary Zone, Alberta Health Services (CZ-AHS) serves a population of 1.2 million residents of Calgary and surrounding communities.All laboratory and pathology services for CZ-AHS are centralized and have searchable databases.The pathology database was searched for all reports containing the words "Entamoeba histolytica", "Entamoeba" and "E.histolytica", from 2001 to 2011.The microbiology database was searched for all positive stool studies consistent with Entamoeba.The microbiology database was searched from 2006 to 2011 for all positive stool ova and parasite (O&P) microscopic examinations that reported the presence of Entamoeba; data were only available from this period of time.Age (2007 to 2011) and sex (2006 to 2011), however, were the only variables that could be assessed due to privacy and ethics regulations.Unfortunately, E histolytica cannot be morphologically differentiated from Entamoeba dispar (a common noninvasive parasite) and Entamoeba moshkovskii (considered primarily to be a free-living amoeba); however, E dispar and E moshkovskii are generally believed to be nonpathogenic.Commercial ELISAs and molecular biological testing, such as polymerase chain reaction (PCR), are available to differentiate E histolytica from E dispar but they are not routinely used in the CZ-AHS due to the rarity of these infections in the region.Entamoeba serology testing can diagnose infection with E histolytica (both E dispar and E moshkovskii do not elicit an antibody response), although it also is not routinely ordered because it takes up to 12 weeks before results are available from the reference laboratory.Serology test results for most of the patients were, therefore, not available.No commercial molecular methods are currently available for distinguishing E moshkovskii, although PCR has been used to detect this parasite directly in stool samples during surveillance studies (4).Because serology testing is sent to a reference laboratory, these data were not searchable.
The CZ-AHS pathology database was searched from 2001 to 2011 to identify all cases of invasive E histolytica.Data are presented as mean ± SEM.Statistical analysis was performed using Graph Pad Prism (GraphPad, USA) using a parametric unpaired t test for age and nonparametric Mann-Whitney for sex.Ethics approval was obtained from the CZ-AHS for a limited data recovery as above.Permission to present the cases was obtained from both individuals.Entamoeba histolytica infections of the gastrointestinal tract are common in the developing world but rare in North America.The authors present two cases: one involving an individual who had not travelled to an endemic area and another involving an individual who was born in Bulgaria.Both presented with severe abdominal pain and diarrhea.Endoscopic assessment revealed scattered colonic ulcerations and one patient was found to have a liver abscess on imaging.Stool ova and parasite studies were negative in both cases and both were diagnosed on review of colonic biopsies.On review of all Entamoeba cases in the Calgary Health Zone (Alberta), ova and parasite analysis found an average of 63.7 Entamoeba cases per year and a pathology database review revealed a total of seven cases of invasive E histolytica (2001 to 2011).Both patients responded well to antibiotic therapy.E histolytica should be considered in new-onset colitis, especially in individuals from endemic areas.Key Words: Amoebic colitis; Entamoeba histolytica; Extraintestinal abscesses l'amibiase invasive : une analyse des infections à Entamoeba mise en évidence par des rapports de cas Les infections à Entamoeba histolytica des voies digestives sont courantes dans les pays en développement, mais rares en Amérique du Nord.Les auteurs présentent deux cas : l'un d'une personne qui ne s'était pas rendue dans une région endémique et l'autre, d'une personne née en Bulgarie.Toutes deux avaient eu des crampes abdominales importantes et de la diarrhée.L'évaluation endoscopique a révélé des ulcérations diffuses dans le colon, et l'imagerie a démontré la présence d'un abcès hépatique chez l'une d'entre elles.Les examens parasitologiques dans les selles étaient négatifs dans les deux cas, et tous deux ont été diagnostiqués à l'analyse des biopsies du côlon.À l'examen de tous les cas d'Entamoeba dans la zone de santé de Calgary, en Alberta, les examens parasitologiques ont permis de déterminer une moyenne de 63,7 cas d'Entamoeba par année et une analyse de la base de données pathologiques a révélé un total de sept cas d'E histolytica invasive entre 2001 et 2011.Les deux patients ont bien réagi à l'antibiothérapie.L'E histolytica devrait être envisagé en cas de colite de novo, particulièrement chez des personnes provenant de régions endémiques.

Data
invasive amoebiasis: A review of Entamoeba infections highlighted with case reports examination (Figure 1A).Again, this would include E histolytica, E dispar and E moshkovskii.During the time period assessed, Entamoeba was more commonly diagnosed in men (39.0±2.4 cases/year) versus women (24.7±3.4 cases/year) (P<0.01).The average age of diagnosis was 31.7 years, with men being slightly older (33.2 years) than females (30.1 years) (P=0.25 [not significant]) (Figure 1B).The CZ-AHS pathology database search from 2001 to 2011 revealed a total of seven cases, with three females and a mean age of 55±7.4 years (this includes the two cases reported below).In six cases, colitis with invasive E histolytica was only noted in the cecum and ascending colon and, in one case (patient 1 below), there was evidence of E histolytica throughout the colon involving the rectum to the cecum.Again, no further details of these cases could be obtained except for the two cases decribed below.

Patient 1
A 56-year-old heterosexual man presented to the emergency department with a 10-day history of abdominal pain, nausea and vomiting, and diarrhea.The patient denied taking any medication and had no history of recent travel.His medical history was also unremarkable and he denied having any previous homosexual partners.On physical examination, the patient had a temperature of 38.4°C, a heart rate of 110 beats/min and a blood pressure of 95/55 mmHg.Head and neck, respiratory and cardiovascular, and musculoskeletal examinations were all normal.The patient had a distended abdomen and identified marked right lower quadrant tenderness with guarding.Laboratory results revealed a hemoglobin level of 127 g/L (normal 127 g/L to 165 g/L), an increased white blood cell count of 18.2×10 9 /L (normal 4.0×10 9 /L to 11.0×10 9 /L), lactate level of 8.2 mmol/L (normal 0.5 mmol/L to 2.2 mmol/L) and increased levels of alkaline Computed tomography (CT) imaging of the abdomen and pelvis revealed severe colitis involving the cecum and ascending colon, and liver abscesses (Figures 2A and 2B).The liver abscesses were drained and the fluid was analyzed.Although microscopic examination of the fluid revealed an increased number of neutrophils, no organisms were visualized on Gram stain and the fluid cultures were negative.At this point, the differential diagnosis included infection, ischemia and newonset inflammatory bowel disease (IBD).Blood and stool cultures, stool testing for O&P and Clostridium difficile were all negative.Serology for Entamoeba and Yersinia were also sent to the reference laboratory.The patient was initially treated with broad-spectrum antibiotics and conservative management.
Despite broad-spectrum antibiotics and conservative management, the patient deteriorated, developing more severe abdominal pain, with guarding and nausea.A repeat CT scan revealed worsening of colitis with increased bowel wall thickening, pericolic stranding and free fluid (Figures 2C and 2D).A colonoscopy was performed and classic amoebic ulcers were visualized (Figures 3A and 3B) and biopsies were collected.Histological examination revealed classic features of E histolytica (Figures 4A and 4B).The patient was treated with 14 days of metronidazole (750 mg per oral three times per day) followed by seven days of paromomycin (500 mg per oral three times per day).His symptoms resolved rapidly; however, a colonoscopy performed three months later showed normal colonic mucosa with a mid-transverse colonic stricture.After six weeks, his serology result was available and was positive for E histolytica and negative for Yersinia.This stricture did not cause symptoms and it has gradually improved over three years of follow-up.

Patient 2
A 24-year-old heterosexual man presented to the outpatient gastroenterology clinic with a three-month history of intermittent diarrhea

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)
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, his hemoglobin level was normal but his platelet count was slightly elevated (408×10 9 /L [normal 150×10 9 /L to 400×10 9 /L]), as was his white blood cell count (11.9×10 9 /L [normal 4.0×10 9 /L to 11.0×10 9 /L]) and erythrocyte sedimentation rate (13 mm [normal 0 mm to 10 mm]).His electrolyte and thyroid stimulating hormone levels, liver function 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 were many endoscopic features consistent with Crohn disease including skip segments, deep ulcers and some linear ulcers.The ileum was normal.Biopsies again revealed classic features of E histolytica (Figures 4C and 4D).A CT scan was performed after the diagnosis and revealed colonic inflammation but no liver abscesses (not shown).The patient had a complete and rapid response to a 10-day course of metronidazole (750 mg per oral three times per day) followed by seven days of paromomycin (500 mg per oral three times per day).Serology was not performed.

dIsCussIon
Locally acquired E histolytica infections are a very rare occurrence in urban Canada aside from travellers, recent immigrants and the male homosexual population (5).A recent study investigating the prevalence of intestinal parasites in the United States demonstrated that for individuals infected with a single GI parasite, <5% were caused by E histolytica or a similar asymptomatic species (E dispar) (6).In the United States, the annual incidence of amoebic liver abscess (occurring in <1% of E histolytica colitis cases) was 1.38 per million population and mostly occurred in Hispanic men in the western and southern states (7).Similar studies have not been undertaken across Canada; however, E histolytica infections have been reported in both humans and canines in Canadian northern Aboriginal communities (2,8).A recent study from Ontario (9) reported 29 cases of amoebic liver abscesses that presented to seven hospitals in Toronto over a 30-year period.Of these cases, 86% had recent travel to endemic areas and some patients were born in endemic areas (9).They did not report any cases that developed in Canada without recent travel, foreign birth or other risk factors (9).Because most studies from endemic areas report that <1% of individuals with E histolytica colitis develop a liver abscess and only 10% with E histolytica in their stool develop invasive disease, one could estimate that in the Toronto area (based on one E histolytica abscess per year) there are >100 cases of E histolytica colitis per year and approximately 1000 without invasive disease (carriers).
Our two sources of review of the CZ-AHS databases consisted of identifying positive stool studies and intestinal pathology.On average, 63.7 cases of Entamoeba were identified by stool studies per year (Figure 1).As noted above, these are based on light microscopy assessment of morphology and cannot differentiate E histolytica from the nonpathogenic E dispar and E moshkovskii.This is likely an underestimate of the incidence/prevalence of Entamoeba in the CZ-AHS due to the low sensitivity and specificity (discussed further below).In the Ontario study above, only 24% of cases of proven E histolytica were found to have positive stool studies (9).Seven (including our two cases) were identified on review of pathology over a 10-year period.
There are several risk factors for acquiring E histolytica infection other than recent travel to an endemic area, including men who have sex with men (MSM).In a study from Los Angeles (USA), 6% of MSM were seropositive for E histolytica; however, significantly higher rates have been reported in MSM populations in other parts of the world including Rome, Italy (21%), Mexico City, Mexico (25% of HIV-positive MSM) and South Africa (43% in HIV positive and 15% in HIV negative, and 69% in those 50 to 59 years of age) (10,11).Both individuals in our study denied ever engaging in sex with men.
E histolytica is a parasite that is transmissible by the oral-fecal route.Infections can range from asymptomatic to severe or fatal invasions of multiple organ systems.Asymptomatic infections are responsible for the continuous transmission of the parasite because numerous cysts are produced and passed in feces.If exocystation occurs, E histolytica trophozoites are produced and invade the intestinal wall leading to amoebic dysentery and resulting in amoebic ulcers (1).Trophozoites are capable of penetrating the intestinal wall and can lead to more severe complications including liver abscesses (the most common) and, in rare cases, can spread to the brain and/or lungs, which is often fatal (12).A typical treatment regimen for E histolytica infection is metronidazole for 10 to 14 days (500 mg to 750 mg three times per day) followed by a seven-day treatment of paromomycin (25 mg/kg to 35 mg/kg daily in three divided doses) to eliminate colonization (13).
Amoebic liver abscesses usually present with fever and pain in the right upper quadrant (13,14).Diagnosis of E histolytica is based on the patient's history, imaging modalities, serological findings, stool studies, fecal antigen testing (via ELISA) as well as real-time PCR (9,14).Stool microscopic assessment (which is the most common test used in Canada) has a low sensitivity (10% to 50%) and cannot differentiate E histolytica from the noninvasive, nonpathogenic E dispar and E moshkovskii (both of our cases had negative stool O&P studies) (9,14,15).Typically, a patient's history reveals recent travel from an endemic area or other risk factors; however, this was not the case in either of our two cases.Serological testing can differentiate E histolytica from E dispar and E moshkovskii (the latter two do not induce antibody responses) (9); the sensitivity and specificity ranges from 85% to 95% (9)(10)(11)15).It is important to differentiate E histolytica from E dispar because, even in asymptomatic individuals, E histolytica should be treated to prevent spread and invasive disease.Unfortunately, most diagnostic laboratories in most centres in Canada refer serological testing to an external site, which can take several weeks before results are available.Stool antigen and DNA tests are generally not available 'in house' at most Canadian centres and are discussed further below.
Our first case was unique because it occurred in an individual who was born in Alberta, had not recently travelled to endemic areas and had no other identifiable risk factors.Furthermore, the differential for both cases included IBD.Corticosteroids are contraindicated in E histolytica because, not surprisingly, it has been associated with more adverse outcomes (16).The second case could also have been locally acquired; however, because of his history of travel to Bulgaria for five months in the past year, it is highly possible that he acquired E histolytica infection abroad because Eastern Europe has significantly higher prevalence rates than North America (17).As noted above, many individuals who are infected with E histolytica are asymptomatic and only approximately 10% develop invasive disease.Thus, although this entity is rare in Canada, one should consider this diagnosis in patients with new symptoms of colitis, especially in those with recent travel to endemic areas.
It can be difficult to differentiate E histolytica-associated colitis from IBD and invasive bacterial dysentery.In general, those who present with E histolytica-associated colitis have a duration of symptoms >7 days, most will be fecal occult blood positive whereas only approximately 40% of those with invasive bacterial dysentery will be fecal occult positive and generally experience a shorter disease duration (18).Fever (>38°C) is common in invasive bacterial dysentery but is less common in individuals with uncomplicated IBD or E histolytica-associated colitis (<40%) (1) (although those with E histolytica liver abscesses are commonly febrile) (18).E histolytica-associated 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 whereas frank blood in stools and fever are rare (18).In short, the history, stool studies and colonic biopsy assessment play critical roles in differentiating E histolytica-associated colitis from IBD and invasive bacterial dysentery.Unfortunately, E histolytica antigen and antibody tests are not readily available in most North American centres; most laboratories outsource these tests, with results taking seven to 21 days.These ELISA-based antibody tests have a sensitivity and specificity of 85% to 95% but are less useful in patients from endemic areas because they may have antibodies from previous exposure (15).Again, stool studies (microscopy and culture) can miss cases, with studies reporting 10% to 50% sensitivity.Because E histolytica trophozoites degenerate rapidly in unfixed fresh samples, fixation and multiple collections increase the yield (18,19).Again, microscopy cannot differentiate E histolytica from other Entamoeba species.The best tests at present are the PCR-and ELISAbased assays that detect E histolytica DNA or antigens in stool, and have sensitivities and specificities of 90% to 95% and 95% to 100%, respectively (15,18,20,21).With the increase in world travel and emigration, we may have to consider increasing our use of more rapid and accurate DNA/antigen-based stool studies.
Because E histolytica-associated colitis can be localized to the cecum and right colon, a sigmoidoscopy can miss cases (18).Endoscopically, E histolytica colitis is associated with mucosal thickening, multiple discrete ulcers separated by regions of normal-appearing mucosa, diffuse inflammation and erythema and, rarely, necrosis and perforation (18).Recently, Upadhyay et al ( 22) described E histolytica ulcers as having a 'poached egg' appearance.They describe a patient who had multiple large irregular ulcers with a white slough and yellowish necrotic material on the top of the white slough, giving a 'poached egg' appearance.Both of our cases had irregular ulcers with white slough but neither patient had ulcers with the 'poached egg' appearance (they were missing the yellowish necrotic material).The most feared complication of E histolytica-associated colitis is acute necrotizing colitis and the development of toxic megacolon.This is rare but has been reported in approximately 0.5% of cases and is associated with high mortality (18).E histolytica colitis can also rarely be associated with penetrating disease, causing enterocutaneous, rectovaginal and enterovesicular fistulas (18).E histolytica can also cause inflammation of the appendix and present as appendicitis; in addition, it can cause pronounced granulomatous inflammation resulting in a pseudotumour that can lead to bowel obstruction (18).Fewer than 1% of individuals with E histolytica infections develop extraintestinal features that can include pericarditis, lung abscesses, peritonitis and skin lesions; however, the most common is hepatic abscesses (18).Hepatic abscesses are more common in men (male:female ratio 3.3:1 [23], 7.2:1 [24]), with a peak age of incidence between 30 and 50 years (25), and appears to be associated with increased alcohol consumption (18).Interestingly, a laboratory-based study (26) found that testosterone increased the susceptibility of mice to E histolytica liver abscesses by decreasing interferon-gamma secretion by natural killer T cells (26).

suMMARy
With increased travel and emigration, we must keep E histolyticaassociated colitis in our differential diagnosis list.Because one of our patients had no risk factors for E histolytica, we should entertain this diagnosis when we encounter new cases of colitis and wait for biopsies and stool studies before starting corticosteroids for presumed IBD.It is abundantly clear that IBS is indeed common worldwide, with reasonably similar prevalence rates being reported from nations in Europe, the Americas, Asia, and Africa.While the global map of IBS is far from complete and many aspects of its epidemiology need to be investigated further in many parts of the world, some interesting trends are beginning to emerge.Most interesting -and most surprising to a Western audience -is the finding that there are striking differences in the prevalence of IBS among males and females in other parts of the world.In India and China, for example, IBS is not a predominantly female disorder, but is as common among males or, in some surveys, even more common in males.IBS in Asia may also feature somewhat different symptoms at presentation.Although current research is merely scratching the surface of this fascinating area, it is abundantly clear that research into similarities and differences between IBS in different parts of the world has the potential to advance the understanding of IBS for all.
One issue that deserves special attention is the role of pathogens in the initiation of IBS -postinfectious IBS (PI-IBS).PI-IBS has been well described among victims of large outbreaks of food poisoning or enteric infection in Europe, North America, and China, prompting an examination of relationships between the enteric reasonably similar prevalence rates being reported from nations in Europe, the Americas, Asia, and Africa.While the global map of IBS is far from complete and many aspects of its epidemiology need to be investigated further in many parts of the world, some interesting trends are beginning to emerge.Most

What is viral hepatitis?
Hepatitis means inflammation of the liver.Viral hepatitis is inflammation of the liver caused by infection with a virus.
A virus is an infectious agent that needs to enter a living cell before it can multiply.Inflammation of the liver may be caused by many other agents, for example, alcohol, poisons, as well as some medications.

What causes viral hepatitis?
There are several viruses that may infect human liver cells, Nausea, loss of appetite and occasionally some loose bowel movements may follow these earlier symptoms.While many people will have no symptoms at all, those who are symptomatic may take many weeks to recover.
For those with severe hepatitis, the urine will start to turn dark, the whites of the eyes with start to yellow (this is jaundice).Fatigue tends to lessen once jaundice appears.
Jaundice generally lasts one or two weeks.However, in some, particularly those infected with Hepatitis A, jaundice may be more prolonged and associated with severe itching of the skin.This is particularly common in young women taking birth control pills.Birth control pills should be stopped as soon as an individual knows or suspects that they have viral hepatitis.Colon cancer can affect people of all ages but is most common after the age of 50.In 2009, it is expected that 22,000 Canadians will be diagnosed with colon cancer and that about 8,900 of those will die.Colon cancer is the third most prevalent cancer in Canada, the second most common cause of cancer deaths and, the second most expensive cancer to treat.

UNDERSTAN DING VIRAL HEPATITIS
Regular colonoscopies every three years can detect almost 100% of colon cancers.Those with a family history of colon cancer, polyps and inflammatory bowel disease (IBD) and people over 50 should all be screenedeven in the absence of any symptoms.Early colon cancer is more than 90 per cent curable with endoscopic removal or surgery and yet fewer than 20 per cent of Canadians who are eligible for screening are making use of this preventative option.

What causes colon cancer?
The cause of colon cancer is unknown, however, certain risk factors have been discovered.Colon cancer is more common in developed countries.This may be caused by dietary and other lifestyle factors in industrialized countries.It has been estimated that about 35% of all cancers in the United States might be attributable to dietary factors and that many colon cancers may be preventable through dietary modifications.A diet high in fat appears to increase the risk of colon cancer, whereas high fiber, including vegetables and fruits, may lower the risk.Some vitamins called antioxidants, like vitamin E, or others like vitamin D or the use of ASA (aspirin), may also lower the chance of getting colon cancer.Smoking and obesity appear to increase the risk of colon cancer, whereas physical activity and the use of aspirin/nonsteroidal antiinflammatory drugs may decrease the risk.
Genetic predisposition (heredity) greatly increases the risk of colon cancer.A close relative with colon cancer or polyps is a strong risk factor.It appears that an inherited, genetic risk factor is present in at least half of all cases of colon cancer.The more relatives affected, and the younger they are when diagnosed with the disease, the higher the risk to the individual of developing colon cancer.
Most colon cancers arise from polyps.These are small growths within the colon that usually do not cause any symptoms.They appear as small bulges from the bowel wall (much like a mushroom protrudes from the ground).Over time the polyps will grow and, under appropriate conditions, turn into colon cancer.If detected early, polyps can be easily removed through colonoscopy, thereby eliminating the polyps and their risk.Since colon cancer typically arises from colonic polyps, and since polyps do not lead to symptoms, early testing may help to detect and remove polyps and prevent progressive disease.It is important for patients at risk to be checked early to prevent cancer from developing.

Why is colonoscopy done?
The most common reasons to perform colonoscopy are to evaluate bleeding, changes in bowel habit or abdominal pain.Other reasons include to diagnose iron deficiency anemia, to confirm abnormal barium enema findings or, to evaluate the extent and severity of the response to treatment in patients with inflammatory bowel disease.
Colonoscopy is also used for colon cancer screening and to remove polyps.Currently, it is the most accurate test for identifying polyps.

How do I prepare for colonoscopy?
Your doctor will provide specific instructions on how to prepare for the procedure.The instructions will describe how to clean the bowel to provide the doctor with the best look at the colon as well as potential medications to avoid before or after the procedure to reduce the likelihood of complications.
You will probably be asked to avoid solid food for 24 to 48 hours before the examination.A clear fluid diet is generally recommended for at least 24 hours (such as clear jello, broth, juices without pulp).
You will also be required to take a laxative to purge the bowel of any stool.There are several different preparations and the type and timing may be chosen based your medical history.It is important that you follow the instructions carefully and take all the preparations to allow for a safe and thorough examination.

UNDERSTANDING COLONOSCOPY www.CDHF.ca
What is ERCP?

Endoscopic
Retrograde Cholangiopan creatography (ERCP) is an endoscopic test that is done to examine the bile ducts, gallbladder and pancreatic duct by passing X-ray material (dye) through a tube in the small intestine.This test also allows the doctor to see the upper small intestine and the opening of ducts into the small intestine.

Why is ERCP done?
The ERCP is done for a number of reasons that can include

How is ERCP done?
The ERCP may be done as an inpatient or as an outpatient (day care) procedure.
An intravenous is usually started to allow drugs to be given.After sedation, a flexible tube with a camera on the end (endoscope) is passed down the swallowing tube and through the stomach into the upper small intestine.The opening of the ducts is identified and X-ray material is pushed into the ducts through a catheter (small plastic tube) within the scope.After the X-ray material is injected into the ducts, X-rays are taken to identify areas of abnormality.
If stones are present, these can usually be removed at the same time by cutting open the lower portion of the bile duct (sphincterotom y) and pulling them out with different instruments.
If there is an abnormal narrowing, tubes (stents) can be left in place to relieve the blockage.This procedure is technically difficult and is occasionally not successful.
Sometimes one or more repeat procedures are necessary to achieve the desired outcome.
After the procedure, most patients are still sleepy and are observed to be sure that their blood pressure, pulse and temperature remain stable and that they do not develop pain.Most patients do not remember their test.Some discomfort may be present when sedation wears off.Severe pain is uncommon.
Patients are usually discharged once they are fully awake unless there are other reasons for which the patient needs to be in hospital.

More informat ion
For more information about protecting and enhancing your digestive health, please visit www.CDHF.ca

Figure 1 )
Figure 1) Cases of Entamoeba from stool ova and parasite analysis in the Calgary Health Region (Alberta) according to year (A) and age (B)

Figure 3 )Figure 4 )
Figure 3) Colonoscopic imaging of patient 1 (A and B) and patient 2 (C and d) demonstrating classic amoebic ulceration in both patients (arrows)

ACKnoWledGeMents:
Dr Beck is an Alberta Innovates Health Solutions Clinical Scholar and has research grants from Canadian Institute of Health Research and Crohn's and Colitis Foundation of Canada.dIsClosuRes: The authors have no financial disclosures or conflicts of interest to declare.
Irritable bowel syndrome (IBS) has long been recognized as an important and challenging disorder for the gastroenterologist in western Europe and North America.Recent studies from Asia and other regions have raised the possibility that IBS may be prevalent elsewhere.For this reason, WGO chose IBS as its focus for World Digestive Health Day (WDHD) 2009 -a choice that proved most propitious, as the topic generated a great deal of interest in the lay press and media, as well as among gastroenterologist s and health-care professionals in general.WDHD became WDH Year, such was the interest generated by IBS!A central part of the WGO's contribution to this exploration of IBS was the creation of a multinational task force on global aspects of IBS.The task force met immediately before Digestive Disease Week at the end of May and shared comments on a draft paper electronically thereafter, with the process culminating in the formal presentation of the proceedings of their deliberations at Gastro 2009 in London.This presentation took place in the context of a WGO satellite symposium on IBS, which set out to explore not only global aspects of IBS, but also new ideas in the pathophysiology of IBS.What did the audience learn?
World Gastroenterology News, March 2010.www.CDHF.caImportant:This information should not be used as a substitute for the medical care and advice of your physician.There may be variations in treatment that your physician may recommend based on individual facts and circumstances.More information is available at www.CDHF.caThis peer-reviewed scientific article appeared in E-World Gastroenterology News, the official newsletter of the World Gastroenterology Organisation.It has been used with the permission of the WGO.www.worldgastroenterolo gy.com.global map of IBS is far from complete and many asp its epidemiology need to be investigated further in parts of the world, some interesting trends are begin to emerge.Most interesting -and most surprising to a Western audience -is the finding that there are strikin differences in the prevalence of IBS among males an in other parts of the world.In India and China, for e IBS is not a predominantly female disorder, among males or, in some surveys, even more co males.IBS in Asia may also feature somewhat differ symptoms at presentation.Although current resea merely scratching the surface of this fascinating ar abundantly clear that research into similarities and di between IBS in different parts of the world has the potenti to advance the understanding of IBS for all.One issue that deserves special attention is the ro pathogens in the initiation of IBS -postinfect IBS).PI-IBS has been well described among victims outbreaks of food poisoning or enteric infection in Eur North America, and China, prompting an exami relationships between the enteric reasonably similar prevalence rates being reported from nations in Europ Americas, Asia, and Africa.While the global m far from complete and many aspects of its epidemiolog need to be investigated further in many parts of the world some interesting trends are beginning to emerge.Most Irritab le bowel syndr ome 2009globa l recog nition , new ideas , MD March 2010.This peer-reviewed scientific article appeared in E-World Gastroenterology News, the official newsletter of the World Gastroenterology Organisation.It has been e permission of the WGO.www.worldgastroenterolo gy.com.
such as Hepatitis A, B, C, D, E and G. Hepatitis A and Hepatitis E are caused by viruses.Infection with these viruses occurs as a result of the contamination of food or drinking water.The virus is spread orally and can give rise to mild, moderate or rarely, a very severe illness.Total recovery is usual and re-infection should not occur.Hepatitis A and E tend to occur in epidemics.Hepatitis B, C, D and G are all spread via blood-to-blood contact.In the case of Hepatitis B, other tissue fluids are also infectious.Sexual transmission of Hepatitis B is the most common form of spread in the western world.This is because Hepatitis B can be found in semen.Sexual transmission of Hepatitis C is much less common.Hepatitis D is quite rare in North America and only occurs in patients who are also infected with Hepatitis B. Other viruses can infect many different organs in the body and sometimes the liver.Examples include the Epstein-Barr virus that causes infectious mononucleosis and cytomegalovirus (CMV).CMV only appears to cause significant inflammation of the liver when the infected person is on drugs to prevent rejection of a transplanted organ.Symptoms Those in the early phases of the acute infection may experience muscle aches, fatigue, and sometimes joint pains (especially with acute Hepatitis B) that can be troublesome.Sore throat and swelling of the lymph glands are common.
www.CDHF.caOtherviruses can infect man and sometimes the liver.Examples include the Epst fectious mononucleosis cytomegalovirus (CMV).CMV only appears to cause cytomegalovirus (CMV).CMV only appears to cause cytomegalovirus (CMV inflammation of the liver when the infected per drugs to prevent rejection of a transplanted or Those in the early phases of the acute infection may experience muscle aches, fatigue, and sometimes joi (especially with acute Hepatitis B) that can be tro Sore throat and swelling of the lymph glands a Nausea, loss of appetite and occasionally some l bowel movements may follow these earlier symptoms many people will have no symptoms at all, those symptomatic may take many weeks to recover.e hepatitis, the urine w dark, the whites of the eyes with start to yellow ( ds to lessen once jaund s one or two weeks.Howe e infected with Hepatitis A may be more prolonged and associated with sever icularly common in young lls.Birth control pills should be as soon as an individual knows or suspects that the VIRAL HEPATITIS Aperçu Une pancréatite correspond à une inflammation du pancréas, une glande située en profondeur dans l'abdomen, à côté du foie.Le pancréas produit des enzymes digestives nécessaires à la digestion des aliments, et libère l'insuline pour réguler la glycémie.Lorsque le pancréas est enflammé, il libère ses propres enzymes (qui sont généralement stockés à l'intérieur de l'organe) causant des dommages au pancréas et aux tissus voisins.Il existe deux formes de pancréatite.Les symptômes de la pancréatite aiguë apparaissent de façon soudaine, peuvent être très graves et mener à la mort.Le plus souvent, cette glande s'améliore, une fois que la cause de l'atteinte pancréatique est supprimée.La pancréatite chronique (à long terme) est caractérisée par des dommages continus du pancréas qui peuvent être accompagnés de douleurs constantes et d'une réduction permanente du fonctionnement du pancréas.La pancréatite affecte un million de Canadiens †: la pancréatite chronique touche plus de 300 000 Canadiens ; et, la pancréatite aiguë affecte plus de 600 000 Canadiens.Les coûts de soins de courte durée aux patients hospitalisés souffrant des maladies du pancréas sont classés parmi les cinq maladies digestives les plus chères au Canada, s'élevant à environ 120 millions de dollars par an.Quelle est la cause de la pancréatite ?La plupart des cas de la pancréatite aiguë sont principalement provoqués par des calculs biliaires obstruant le canal pancréatique ou par l'excès d'alcool.D'autres causes possibles sont la prise de certains médicaments, d'un niveau élevé de graisses, d'une infection virale telle que les oreillons ou dans certains cas, cette maladie peut être héréditaire.La pancréatite chronique est principalement causée par la consommation chronique d'alcool chez les adultes ou par une fibrose kystique chez les jeunes.Dans certains cas, une pancréatite est génétique.L'obésité est un facteur de risque bien connu causant une pancréatite aiguë et sévère.« L'épidémie d'obésité » du monde occidental augmentera le nombre total de patients dans les prochaines décennies.Comment puis-je savoir si je souffre d'une pancréatite ?La pancréatite aiguë et chronique commence habituellement par des douleurs dans le haut de l'abdomen.Généralement, la douleur se propage directement vers le milieu du dos.Cette douleur survient après la consommation d'alcool ou à la suite d'un repas.Elle est souvent accompagnée de nausées et de vomissements.Elle s'aggrave quand le patient s'allonge sur le dos, à plat, et s'apaise lorsqu'on se penche vers l'avant.Dans les cas graves, la pancréatite peut entrainer COMPRENDRE LA PANCRÉATITE www.CDHF.caQuelle est la cause de la pancréatite ?La plupart des cas de la pancréatite aiguë sont principalement provoqués par des calculs biliaires obstruant le canal pancréatique ou par l'excès d'alcool.D'autres causes possibles sont la prise de certains médicaments, d'un niveau élevé de graisses, d'une infection virale telle que les oreillons ou dans certains cas, cette maladie peut être héréditaire.La pancréatite chronique est principalement causée par la consommation chronique d'alcool chez les adultes ou par une fibrose kystique chez les jeunes.Dans certains cas, une pancréatite est génétique.L'obésité est un facteur de risque bien connu causant une pancréatite aiguë et sévère.« L'épidémie d'obésité » du monde occidental augmentera le nombre total de patients dans les prochaines décennies.Comment puis-je savoir si je souffre d'une pancréatite ?La pancréatite aiguë et chronique commence habituellement par des douleurs dans le haut de l'abdomen.Généralement, la douleur se propage directement vers le milieu du dos.Cette douleur survient après la consommation d'alcool ou à la suite d'un repas.Elle est souvent accompagnée de nausées et de vomissements.Elle s'aggrave quand le patient s'allonge sur le dos, à plat, et s'apaise lorsqu'on se penche vers l'avant.Dans les cas graves, la pancréatite peut entrainer COMPRENDRE LA PANCRÉATITE Overview Colon cancer is a disease where cancerous cells (tumours) are present in the wall of the large intestine (colon).A mix of genetic and environmental factors can cause cells in the lining of the bowel to turn cancerous.The first step in this transformation occurs when a collection of abnormal cells called a polyp forms.
www.CDHF.cale to dietary factors an e preventable through appears to increase iber, including vege vitamins called a amin D or the use o ance of getting colon c ncrease the risk of the use of aspirin/ ugs may decrease the tion (heredity) gr A close relative with co tor.It appears that nt in at least half of elatives affected, an with the disease, the loping colon canc ise from polyps.Thes usually do not cause all bulges from the b from the ground).Over time the nd, under appropriate conditions, turn er.If detected early, polyps can be easily olonoscopy, thereby eliminating the Since colon cancer typically arises from UNDERSTAN DING COLON CANCER What is colonoscopy?Colonoscopy is an examination of the large intestine (colon or large bowel) that is performed by a trained doctor.A slim flexible tube (colonoscope) is inserted into the anus and rectum and is advanced through the beginning of the colon (cecum) and sometimes higher into the small intestine (ileum).For the patient who has had a bowel operation with creation of an ostomy (colostomy, ileostomy) the scope can be placed directly into this opening directly into the gut.The colonoscope is used to see the lining of the gastrointestinal tract.The procedure usually takes 20-30 minutes but occasionally up to an hour.
Some medications (blood thinners, iron supplements) are stopped up to a week before the procedure to reduce complications or improve the view from the test .Be sure to ask your doctor about your medications well beforehand.You should arrange for an escort home as your judgment might be altered by medications given to relax you during the test.You must not drive.UNDERSTANDING COLONOSCOPYwww.CDHF.caHow do I prepare for colonoscopy?Your doctor will provide specific instructions on how to prepare for the procedure.The instructions will describe how to clean the bowel to provide the doctor with the best look at the colon as well as potential medications to avoid before or after the procedure to reduce the likelihood of complications.You will probably be asked to avoid solid food for 24 to 48 hours before the examination.A clear fluid diet is generally recommended for at least 24 hours (such as clear jello, broth, juices without pulp).You will also be required to take a laxative to purge the bowel of any stool.There are several different preparations and the type and timing may be chosen based your medical history.It is important that you follow the instructions carefully and take all the preparations to allow for a safe and thorough examination.Some medications (blood thinners, iron supplements) are stopped up to a week before the procedure to reduce complications or improve the view from the test .Be sure to ask your doctor about your medications well beforehand.You should arrange for an escort home as your judgment might be altered by medications given to relax you during the test.You must not drive.
jaundice (yellowness of the skin and eyes), abnormal liver tests or abdominal X-ray tests, unexplained abdominal pain or weight loss.These symptoms may be due to blockage or inflammation or leakage in the bile and pancreatic ducts (for example, stones, tumour, inflammation or postoperative problems).