By Dr Raghuram Y.S. MD (Ay) and Dr Manasa, BAMS
Amoebiasis is an infection caused by amoebas of the entamoeba group, mainly by Entamoeba histolytica. Only about 10-20% of people who are infected with E.histolytica become sick from the infection.(A)
With amoebic infection, the symptoms can vary from being mild to moderate to severe. The symptoms of amebiasis include abdominal pain, mild diarrhea, bloody diarrhea, severe colitis and perforation. Perforation may cause peritonitis, inflammation of the layers covering the intestines and abdominal viscera. Anemia also may develop due to loss of blood.
Read – Anemia: Ayurvedic Treatment, Medicines, Remedies
Other names –
- Amoebic dysentery
Amebiasis and infection of intestines –
When the intestinal lining is invaded with infection one may suffer from amoebic bloody diarrhea or amoebic colitis. The same parasites, on reaching the bloodstream enter into the liver causing amoebic liver abscesses.
The cysts of amoeba i.e. entamoeba survive for around one month duration in the soil when the infected faeces are soiled. They may remain for up to 45 minutes under the fingernails when the butts are washed with hands and when hands are not washed properly after voiding feces.
Read – Hand Foot and Mouth Disease Prevention Tips, Remedies
1. For preventing infection –
- When in endemic areas, you should avoid raw vegetables. They may have been fertilized using human feces.
- Boil drinking water. Alternatively use water treated with iodine tablets. Water filtration and boiling are more effective than chemical treatment of water.
- Food safety is very important. Uncooked fruits and vegetables should be washed thoroughly. The fruits should be peeled and vegetables should be boiled before consuming them. Food and drinks shall be protected from flies and cockroaches. Measures to control these insects should be taken.
- Avoid eating street foods, especially in public places.
Read – Prevention And Lifestyle Tips For Dysentery and Diarrhoea
2. To prevent the spread of the disease –
- Hand wash – People should wash their hands thoroughly with soap and hot running water for at least 10 seconds. This should be practiced and also advocated to be done after using toilet, changing baby’s diaper and before handling food.
- Clean the bathrooms and toilets, including toilet seats and taps as often as you can.
- Avoid sharing towels or face washers.
- Carriers who pass cysts and are involved in handling food at home or stalls or in catering establishments should be detected. They should be treated.
Other measures –
- Good sanitary practice – Safe disposal of human excreta coupled with sanitary practices of washing hand thoroughly after defecation and always before handling and consuming foods are important measures.
- Responsible sewage disposal / treatment
- Sedimentation and filtration of water
- Health education of public and also health personnel at all levels should be done regarding sanitation and food hygiene.
- Elementary hygienic practices should be propagated and reinforced in schools, health care units and homes often, through periodic campaigns using mass media.
- General social and economic development – implementation of individual and community preventive measures like hand washing, proper disposal of excreta etc should be included.
- Community surveys – to monitor local epidemiological situation
- Improvement of case management – quick diagnosis and adequate treatment of patients with invasive amoebiasis should be done at all the levels of health services.
- Surveillance and control of situations that encourage further spread of disease like refugee camps, contaminated public water sources etc should be done
Read – Sadvritta In Ayurveda – Code Of Conduct For Healthy Life
Amoebicides i.e. anti-amoebic drugs are used to destroy the disease and agent.
Nitroimidazoles, including metronidazole or tinidazole are generally used in the treatment of amoebiasis. This is followed by administration of luminal agents such as paromomycin or diloxanide furoate to prevent relapse.
Liver aspiration – if abscesses are large in size, abscess rupture is imminent, if the medicines have failed or if abscesses are present in the left lobe
Read – Ayurvedic Home Remedy For Liver Diseases
- The amoebas remain in the gastro-intestinal tract of the hosts in most cases of amoebiasis.
- In less than 16% cases, severe ulceration of gastrointestinal mucosa occurs.
- In fewer cases the parasite invades the liver.
- In rare conditions amoebomas i.e. masses leading to intestinal obstruction are formed.
Epidemiology and History
Amoebiasis is present all over the world. Approximately about 480 million people are infected with E.histolytica. These result in the death of between 40,000 – 110,000 people every year. More infections are now ascribed to be E. dispar.
- The first documented case of amoebiasis was in 1875 in St Petersburg in Russia, near Arctic Circle.
- The disease was described in detail in 1891.
- The terms amoebic dysentery and amoebic liver abscess were also coined in 1891 along with the description of the disease.
- Further evidences that showed that amoebiasis would develop on ingestion of E. histolytica cysts were obtained from Philippines in 1913. Since 1897, it was known that at least one non-disease causing Entamoeba species existed.
- In 1997, WHO recognized that E. histolytica had 2 species (this was first proposed in 1925).
- Apart from the recently-recognized E. dispar, evidence shows that there are at least 2 other Entamoeba species that look identical in humans, namely E. moshkovskii and E. Bangladeshi.
- Approximately 70,000 people die each year, mostly from liver abscess or other complications caused by E.histolytica infections.
- Infections are more common in warmer areas. This is both because of poorer hygiene and parasitic cysts surviving for long duration in warm and moist conditions.
Read – Fatty Liver: Symptoms, Ayurvedic Treatment, Remedies, Tips
Other important points about Amoebiasis
- It is a common cause of diarrhoea in infants, especially in low-income countries.
- It is a rare cause of brain abscess.
Treatment of Amoebiasis in Ayurveda
Amoebiasis, as already discussed, will present with diarrhoea – bloody or otherwise, inflammation of peritoneum, colon and intestines, pain abdomen and perforation. Anaemia may develop in later stages due to severe loss of blood.
While dealing this condition through Ayurveda measures, the disease principles of the predominant complaint as explained shall be adopted.
Amoebiasis can be treated on the lines of treating –
1. Pravahika – The condition pravahika is often compared to dysentery. Amoebiasis is also called Amoebic dysentery. The treatment strategies including medicines and dietetic inclusions explained in the context of pravahika when included in treating dysentery have found to be very effective.
2. Atisara – Line of treatment of diarrhoea can be adopted since it is the chief symptom.
3. Raktatisara – Amoebiasis, when associated with more bleeding or diarrhoea with blood and abdominal pain, can be treated on the lines of treating Raktatisara. Rakta means blood, Atisara means diarrhoea. Raktatisara means bleeding diarrhoea.
4. Pittatisara – Pittatisara is diarrhoea caused by vitiated pitta. Diarrhoea caused by pitta and vitiated blood are often interrelated if not as a rule. Blood and pitta have a residence-resident relationship. Pitta aggravation causes vitiation of blood. High pitta also causes inflammatory changes in the intestines and colon. The consequent aggravation of blood as afflicted by vitiated pitta may lead to worsening of inflammation and also bleeding from the gastrointestinal tract and colon.
5. Krimi Roga – Since dysentery is caused by infection, adopting the principles of treating krimi i.e. worm infestations as explained in Ayurveda, especially right at the beginning of treating amoebiasis will be helpful.
6. Shoola Chikitsa – Shoola means pain. If it is not specified, the term is confined to abdominal colic. Most of the medicines explained in Shula combat vitiated doshas, mainly vata and pitta, cures inflammation and associated pain. When these complaints are predominant in amoebiasis at some stage, the principles of treating shoola should be adopted.
7. Pandu Roga Chikitsa – Treatment of pandu roga i.e. anemia is helpful when the symptoms of the same are found in amoebiasis associated with loss of blood leading to anemia. Rakta Prasadaka i.e. blood quantity enhancing medications and diet too should be included.
Herbs that act as Grahi – water absorbent
Lodhra – Symplocos racemosa – The important ingredient of medicine lodhrasava.
Cumin Seeds – help to improve digestion strength, improves re-absorption of water from colon.
Chitraka – Plumbago zeylanica – useful in improving digestion strength, but used with precaution in people with sensitive stomach.
Bilva – Aegle marmelos – an important ingredient in many medicines like Dashamoola, Vilwadi Gulika.
Shyonaka – Oroxylum indicum – A member of Dashamoola group of 10 roots
Parpataka – Fumaria indica – Useful in relieving intestinal infection,helps in improving the quality of Rasa Datu and useful in fever.
Neem – useful in infection
Bactefar capsule, Syrup
Koshta Shuddhi Tablets
Entamoeba histolytica – Amoebiasis is caused by an amoeba named E. histolytica.
Most patients will have traveled to or resided in an endemic area in the previous 12 months.
It is more closely related to poor sanitation and socioeconomic status than to climate.
The use of night soil for agricultural is also responsible for the spread of the disease. Disease epidemics are usually associated with sewage seepage into the water supply.
- directly via faecal-oral route, either by person-to-person contact
- indirectly through contact with dirty hands or objects, by eating or drinking food or water contaminated with feces
- by anal-oral contact – sexual transmission by oral-rectal contact
- vectors such as flies, cockroaches and rodents
Read – Charaka Janapadoddhvamsaniyam Vimana: 3rd Chapter: Epidemic Diseases
Ingestion of the cyst form of the parasites causes spread of infection.
Incubation period – commonly 2-4 weeks, may also range from few weeks to years.
Contaminated water and food – Since amoebiasis is transmitted through contaminated food and water, it is often endemic in regions with limited modern sanitation systems, including Mexico, Central America, western South America, South Asia and western and southern Africa.
Amoebic dysentery is often confused with ‘traveller’s diarrhoea’ because of its prevalence in developing nations.
Pathogenesis, Signs and Symptoms
About 90% infected people don’t develop symptoms (asymptomatic). The infection can make the sufferer seriously ill and the infections often last for many years. Symptoms take from a few days to a few weeks to develop and get manifested. Usually it takes about 2-4 weeks.
- Acute Amoebiasis – can present as diarrhoea or dysentery, with frequent, small and often bloody stools.
- Chronic amoebiasis – can present with gastrointestinal symptoms associated with fatigue, weight loss and occasional fever.
- Extra-intestinal amoebiasis – can occur if the parasite spreads to other organs. It is caused most commonly in liver wherein it causes amoebic liver abscess. This condition presents with fever and pain in the right upper quadrant of the abdomen.
Read – Ayurveda Home Remedy For Fever
Symptoms include –
- Mild diarrhoea to severe dysentery with blood and mucus
- Invasion of other organs – In about 10% invasive cases, the amoeba enters the bloodstream and may travel to other organs in the body, mainly Liver.
- Onset time – is variable, average asymptomatic infection persists for over a year
- Abdominal tenderness and weight loss are common in amoebic colitis
- Upper quadrant pain – in amoebic liver abscess, may have preceding history of diarrhoea
Read – Ayurveda Ulcerative Colitis Diet Tips, Home Remedies
Asymptomatic infections –
In these cases, absence of symptoms vary with
- strains of amoeba,
- immune response to the host and
- associated bacteria and viruses
In these conditions, the amoeba lives by eating and digesting bacteria and food particles in the gut. Due to the protective mucus layer lining the gut, the amoeba doesn’t usually come in contact with intestine. Disease occurs when amoeba comes in contact with the cells lining the intestine. The amoeba then secretes enzymes that destroy cell membranes and proteins. This leads to penetration and digestion of human tissues. This results in flask-shaped ulcers in the intestine. E. histolytica ingests the destroyed cells by phagocytosis and is often seen with red blood cells inside when seen in stool samples.
A granulomatous mass known as amoeboma may form in the wall of the ascending colon or rectum due to long-lasting immunological cellular response. It is sometimes confused with cancer.
Read – Cancer- Ayurvedic Understanding And Hopeful Treatment Modalities
- Bloody diarrhoea
- Pericolic abscess
- Pericaecal abscess
Complications of hepatic amoebiasis / amoebic liver abscess –
- Sub-diaphragmatic abscess
- Perforation of diaphragm to pericardium and pleural cavity
- Perforation to abdominal cavity – amoebic peritonitis
- Perforation of skin – amoebiasis cutis
- Intra-peritoneal, intra-thoracic or intra-pericardial rupture,
- Dissemination and formation of brain abscess
Read – Liver Diseases: Causes, Symptoms, Treatment, Home Remedies
Complications of amoebic colitis –
- Fulminant or necrotizing colitis
- Recto-vaginal fistula
- Toxic megacolon
Complications due to Pulmonary amoebiasis – can occur from liver lesion. This happens through haemotogenous spread and also by perforation of pleural cavity and lungs. It causes –
- Abscess of lungs
- Pulmo-pleural fistula
- Broncho pleural fistula
Read – Fistula In Ano Ayurvedic Understanding And Effective Treatment
Complications related to brain – The disease can reach the brain through circulation and cause amoebic brain abscess and amoebic meningo-encephalitis.
Other complications –
- Skin complications – Cutaneous amoebiasis
- Urogenital tract amoebiasis – can cause amoebic vulvo-vaginitis, recto-vesicle fistula and recto-vaginal fistula
- Stunted growth
- Bowel perforation
- Gastrointestinal bleeding
- Stricture and intussusception
Read – Gastro intestinal Bleeding Causes, Symptoms, Differential Diagnosis
Usually the diagnosis of amoebiasis is confirmed by detection of E.histolytica antigen or DNA in stool or antibodies against the parasite in the serum.
Microscopy – Microscopic detection of cysts and trophozites in the stool is the common method for diagnosis. But it is not accurate in diagnosis of amoebiasis as other reliable tests are available. Microscopy comprises of distinguishing E.histolytica cyst from other cysts of non-pathogenic intestinal protozoa. Differentiation is based on morphologic characteristics of the cysts and trophozites. According to directions from WHO, the infections diagnosed by microscopy alone should not be treated if they are asymptomatic. Typically the organism cannot be found in feces once the disease goes extra-intestinal.
E.histolytica trophozites can be identified in aspirates or biopsy samples obtained during colonoscopy or surgery.
Serology – It is useful in detecting E.histolytica infection if the organism goes extra-intestinal. It is also used in excluding the organism from diagnosis of other disorders. Serological tests exist and most individuals will test positive for the presence of antibodies. The levels of antibody are much higher in individuals with liver abscesses. Serology gives positive results only about 2 weeks after infection. Off late we have kits that detect the presence of amoeba proteins in the faeces and another that detects amoeba DNA in faeces.
Colonoscopy – helps in detecting small ulcers between 3-5 mm
Stool examination – Asymptomatic human infections are diagnosed by finding cysts shed in the stool.
Read – Stool Examination In Ayurveda
Various flotation or sedimentation procedures help in recovering cysts from faecal matter. Stains help to visualize the isolated cysts for microscopic examination. Cysts are not shed constantly. Therefore a minimum of 3 stools should be examined. In symptomatic cases, the motile form of amoeba i.e. trophozite can be seen in fresh faeces.
Immunodiagnosis – Antibody detection –
- EIA i.e. Enzyme immunoassay is useful in those having extra-intestinal disease i.e. amoebic liver disease, when the organisms are not generally found on stool examination
- IHA – Indirect Hemagglutination
Molecular Diagnosis – Conventional PCR (Polymerase Chain Reaction) is a method of choice from discriminating the pathogenic species i.e. E. histolytica and the non-pathogenic species i.e. E.dispar.
Other tests –
- O&P test – An Ova and Parasite test
- E.histolytica fecal antigen assay
- Radiography, Ultrasonography (USG), Computed Tomography (CT) & Magnetic Resonance Imaging (MRI) – for detection of liver abscess, cerebral amoebiasis
- Recto-sigmoidoscopy & colonoscopy – for diagnosis of intestinal amoebiasis
Read – Roga, Rogi Pareeksha: Examination Of Disease And Patient