Low efficacy of metronidazole in the eradication of Blastocystis hominis in symptomatic patients: Case series and systematic literature review. / Escasa eficacia de metronidazol en la erradicación de Blastocystis hominis en pacientes sintomáticos: serie de casos y revisión sistemática de la literatura.

INTRODUCTION: Blastocystis hominis (B. hominis) is a protozoan commonly found in the gastrointestinal tract. There are doubts about its clinical significance. Metronidazole (MTZ) is the recommended first-line treatment. MATERIALS AND METHODS: A retrospective review was carried out between 2011 and 2012. A total of 151 samples were randomly selected from 383 samples positive for B. hominis. Inclusion criteria were: suggestive symptoms, treatment indication and microbiological follow-up. A systematic review was performed of all studies that evaluated the effect of MTZ on B. hominis infection. RESULTS: Forty-six patients met the inclusion criteria (64% women; age, 44.2±2 years). MTZ was used in 39 patients, 31 of whom obtained a clinical response (79.5%) but only 15 a microbiological response (48.4%). No dose-effect relationship was observed. Twenty patients with no initial microbiological response received a second round of treatment (MTZ, cotrimoxazole, paramomycin, others), with a microbiological response in 70%. Overall, B. hominis was cured in 72% (95% CI: 57%-83%). Of 54 treatments associated with a clinical response, a microbiological response occurred in 31 (57%), while in the remaining 12 with no clinical response, microbiological cure was observed in only 2 (17%) (P=.022). The eradication rate in the systematic review varied between 0% and 100%. CONCLUSIONS: There seems to be a relationship between the clinical and microbiological response to B. hominis treatment. The microbiological response to MTZ treatment is insufficient in our geographical setting. The systematic review shows that the response to MTZ is very variable.

Diffuse nodular duodenitis in a woman presenting with dyspepsia and weight loss.

Duodenal nodularity is an uncommon endoscopic finding charac-trized by numerous visible mucosal nodules in the duodenum. It is important to consider giardiasis in patients with symptoms include abdominal pain, nausea, anorexia, diarrhea, vomiting, weight loss and abdominal distension. It is also important to remind giardiasis in patients with duodenal nodularity.

Hydatid Cyst Diagnosed by Endoscopic Ultrasound.

A 69-year-old female with unremarkable past history underwent endoscopy for dyspepsia. She denied weight loss or anorexia. Upper endoscopy revealed a bulge in the lesser curvature and posterior wall of the stomach with 4-5 cm. Endoscopic ultrasound was performed which showed a heterogeneous lesion, anechogenic in the major part, with a floating membrane inside, the greatest diameter of 90.8 × 17.2 mm, originated in the left liver lobe. Surgical resection was performed. Pathologic examination revealed a cystic lesion with an acellular thick fibrous wall, surrounded by a conspicuous inflammatory reaction. The cyst wall revealed a characteristic lamellar pattern of the fibers. In the internal surface of the lesion, there were remains of membranous structures, amidst which a vestigial Protoscolex was noted. In the presented case, a floating membrane was observed, which is a pathognomonic feature, establishing the diagnosis of hydatid cyst type 3. Fine needle aspiration guided by ultrasound was not performed due to the certainty in the diagnosis. To the authors' knowledge, these are the first images by endoscopic ultrasound of hydatid cyst of liver presented as a bulge in the stomach with pathognomonic features, which allowed the definitive diagnosis with no need for further diagnostic tests.

Prevalence of Helicobacter pylori and parasites in symptomatic children examined for Helicobacter pylori antibodies, antigens, and parasites in Yemen.

OBJECTIVES: To estimate the prevalence of Helicobacter pylori (H. pylori) and parasites in symptomatic children examined for H. pylori antibodies, antigens, and parasites in Yemen. METHODS: A record-based study was carried out at Specialized Sam Pediatric Center in Sana'a, Yemen for 3 years between 2011-2013. Out of the 43,200 patients seen for different causes through that period, 1008 (2.3%) (females: 675 [67%]; males: 333 [33%]) had gastric complaints, and were subjected to an examination of blood and stool for H. pylori and parasites. Data regarding age and gender was also collected. RESULTS: The age of the patients ranged from 3-15 years. The prevalence of H. pylori among children examined for H. pylori was 65%, 30% of them were males, and 35% were females (chi square [I2]=142, p<0.01]). The prevalence in the 6-8 years age group was 83%, and it was 52% in the age group of 12-15 years. The prevalence of giardiasis was 10%, and amoebiasis was 25%. CONCLUSION: Prevalence of H. pylori infection among children was high, and was more prevalent in the age group of 6-8 years than in the other age groups. Females were more affected than males. Parasites (amoebiasis and giardiasis) infestation was less prevalent.

Molecular identification of giardia intestinalis in patients with dyspepsia.

BACKGROUND/AIMS: Giardia intestinalis triggers symptoms of functional dyspepsia. The aim of this study was to distinguish genotypes of G. intestinalis isolated from dyspeptic patients to evaluate their correlation with dyspeptic symptoms. METHODS: In total, 120 dyspeptic subjects were investigated by upper endoscopy, including gastric and duodenal biopsies for histopathological examination, and parasitological examination of their stools and duodenal aspirates was performed. The patients were classified into five groups: group I (G. intestinalis) included 19 patients, group II (Helicobacter pylori) included 36 patients, group III (coeliac disease) included 3 patients, group IV (mixed G. intestinalis and H. pylori infection) included 4 patients, and group V (unexplained aetiology) included 58 patients. Genotyping of G. intestinalis was performed for groups I and IV using PCR-RFLP. The urease test was performed for H. pylori. Serum anti-gliadin, anti-endomysial and anti-transglutaminase antibody estimation was performed for the diagnosis of coeliac disease. RESULTS: Genotype A of G. intestinalis was detected in the stool samples of 68.42% (13/19) and the duodenal aspirates of 42.1% (8/19) of dyspeptic patients harbouring the parasite. Genotype B was detected in 31.58% (6/19) of cases in stool samples and in 3 cases in duodenal aspirates. CONCLUSIONS: H. pylori, G. intestinalis and coeliac disease are common causes of dyspepsia. G. intestinalis genotype A demonstrated a greater association with dyspeptic symptoms.

Giardia intestinalis in patients with nonulcer dyspepsia.

BACKGROUND AND STUDY AIMS: Giardiasis may present with dyspeptic symptoms that may mimic other gastrointestinal and/or biliary disorders. The objective of this study was to determine the prevalence of giardiasis in stool and duodenal aspirate of patients with NUD, assess symptomatic benefit of therapy, and compare the diagnostic tools for giardiasis utilizing stool and duodenal aspirates microscopic evaluation versus ELISA testing. PATIENTS AND METHODS: 109 Patients with endoscopic diagnosis of NUD out of 278 consecutive patients with dyspepsia were included. The severity of dyspepsia and the quality of life were assessed utilizing Rome II criteria and SF-36 for Quality of Life and concomitant stool and/or duodenal aspirate samples were submitted for ELISA antigen test for Giardia intestinalis. Those who tested positive for giardiasis (Group 1) were assigned to receive Tinidazole 2.0g. single dose plus omeprazole for 4weeks and the remaining patients (Group 2) omeprazole alone for 4weeks. One month after therapy, both groups were reassessed and Stool ELISA antigen test for G. intestinalis for Group 1, was performed. RESULTS: ELISA testing of stool (19%) and duodenal aspirates (19%) had significantly better results than microscopic ones in stool (11%) or duodenal aspirates (7%). The two groups were well matched with respect to age, sex, initial results on the Glasgow Dyspepsia Severity Score, prevalence of previously prescribed antisecretory-drug therapy, prevalence of smoking, predominant symptom at presentation, and quality of life. The outcome of patients at 1month, on an intention-to-treat basis, showed that the symptoms were resolved (defined as a score of 0 or 1) in 17 of 21 patients (81%) in Group 1 as compared with 31 of 88 patients (35%) in Group 2 P<0.001. The scores in both groups were lower than those at base line and there was a highly statistically significant difference between both groups. CONCLUSION: G. intestinalis as a cause of dyspepsia should be considered in patients with negative endoscopy and in those who remain symptomatic in spite of adequate treatment for known upper G.I. disorders. NUD associated with the presence of Giardia, had better symptomatic benefit (81%) with specific treatment than controls (35%). ELISA testing of stool (19%) and duodenal aspirates (19%) had significantly better results than microscopic ones in stool (11%) or duodenal aspirates (7%).

Relative importance of abnormalities of CCK and 5-HT (serotonin) in Giardia-induced post-infectious irritable bowel syndrome and functional dyspepsia.

BACKGROUND: Post-infectious irritable bowel syndrome (PI-IBS) and functional dyspepsia (FD) have been described after both Campylobacter jejuni gastroenteritis and Giardia infection. After C. jejuni, there is increased rectal serotonin (5-HT)-containing EC cells and postprandial plasma 5-HT, while a pilot study suggested increased plasma cholecystokinin (CCK) after Giardia infection. AIM: To determine changes in plasma and duodenal mucosal 5-HT and CCK in Giardia-induced PI-IBS. METHODS: A total of 32 patients previously infected with Giardia and 19 who had recovered fully (controls) completed symptom questionnaires. Endoscopic duodenal biopsies were obtained from all subjects and immunohistochemically stained for CCK, 5-HT and CgA containing entero-endocrine cells and mast cells. 5-HT content was also assessed. Twenty-one of 32 patients and 19 controls consumed a high-carbohydrate meal, while fasting and postprandial plasma CCK and 5-HIAA were measured. RESULTS: Post-infectious irritable bowel syndrome patients had increased numbers of CCK cells (P = 0.02), but lower numbers of EC cells (P = 0.009). Plasma CCK did not differ significantly between the groups, but correlated significantly with postprandial dyspepsia scores (r = 0.5, P = 0.05). PI-IBS patients had significantly lower plasma 5-HIAA, before and after meal (P = 0.05) as well as more dyspepsia (P < 0.0001) compared with recovered subjects. CONCLUSIONS: Post-infectious bowel dysfunction following Giardia infection is associated with increased duodenal mucosal CCK. Postprandial dyspeptic symptoms correlate better with CCK than measures of 5-HT metabolism.

Development of functional gastrointestinal disorders after Giardia lamblia infection.

BACKGROUND: Functional gastrointestinal disorders (FGID) may occur following acute gastroenteritis. This long-term complication has previously not been described after infection with the non-invasive protozoan Giardia lamblia. This study aims to characterize persistent abdominal symptoms elicited by Giardia infection according to Rome II criteria and symptoms scores. METHODS: Structured interview and questionnaires 12-30 months after the onset of Giardia infection, and at least 6 months after Giardia eradication, among 82 patients with persisting abdominal symptoms elicited by the Giardia infection. All had been evaluated to exclude other causes. RESULTS: We found that 66 (80.5%) of the 82 patients had symptoms consistent with irritable bowel syndrome (IBS) and 17 (24.3%) patients had functional dyspepsia (FD) according to Rome II criteria. IBS was sub classified into D-IBS (47.0%), A-IBS (45.5%) and C-IBS (7.6%). Bloating, diarrhoea and abdominal pain were reported to be most severe. Symptoms exacerbation related to specific foods were reported by 45 (57.7%) patients and to physical or mental stress by 34 (44.7%) patients. CONCLUSION: In the presence of an IBS-subtype pattern consistent with post-infectious IBS (PI-IBS), and in the absence of any other plausible causes, we conclude that acute Giardia infection may elicit functional gastrointestinal diseases with food and stress related symptoms similar to FGID patients in general.

[The prevalence of Microsporidium among adult patients admitted to the parasitology laboratory at the Inonu University Turgut Ozal Medical Center]. / Inönü Universitesi Turgut Ozal Tip Merkezi Parazitoloji Laboratuvarina Gelen Eriskin Hastalarda Microsporidium Görülme Sikligi.

Microsporidium can cause acute and self-restricted diarrhea cases among immunocompetent patients. The aim of this study was to investigate the presence of intestinal parasites and Microsporidium in patients presenting at the internal diseases polyclinic with some digestive system complaints but no immune suppressive problems, and to detect whether it has anything to do with the complaints. A total of 781 fecal samples were investigated for intestinal parasites and Microsporidium. Intestinal parasites were found in 16.11% and Microsporidium in 6.5%. A significant correlation was observed between the presence of intestinal parasites other than Microsporidium and dyspepsia, while in the case of Microsporidium, a significant frequency of dyspepsia and fatigue was observed. It was found that the presence of Microsporidium does not differ by age and gender. From the findings, it was concluded that patients with digestive system complaints should be examined for Microsporidium in addition to intestinal parasites, and the symptoms of dyspepsia and a lack of appetite should especially be given more careful attention.

Increased visceral sensitivity in Giardia-induced postinfectious irritable bowel syndrome and functional dyspepsia. Effect of the 5HT3-antagonist ondansetron.

In an outbreak of waterborne giardiasis where 1300 subjects were diagnosed, with Giardia lamblia, 139 continued to have abdominal symptoms of whom two of three had negative stool culture and microscopy. These were considered to have a postinfectious functional gastrointestinal disorder. We investigated visceral hypersensitivity in patients with persisting abdominal symptoms after Giardia infection and assessed the effect of 5HT(3)-antagonist ondansetron. Twenty-two patients with Giardia negative stools and 19 controls were included. A subset of patients (n = 15) had both irritable bowel syndrome (IBS) and functional dyspepsia (FD). All subjects underwent a satiety test with a soup combined with three-dimensional ultrasound. Fifteen of 22 patients underwent double-blind, randomized, placebo-controlled study with the 5-HT(3) antagonist ondansetron given orally. Drinking capacity was lower in patients than in controls (P < 0.01) and gastric emptying was reduced (P < 0.05). Patients had more symptoms both fasting and postprandially (P < 0.001) compared to controls. Ondansetron had no effect on these parameters except from less nausea postprandially (P < 0.05). In conclusion, patients with Giardia-induced gastrointestinal symptoms developed both IBS and FD. They exhibited gastric hypersensitivity with lower drinking capacity and delayed gastric emptying. The 5-HT(3) antagonist ondansetron did not improve drinking capacity, gastric emptying or symptoms except nausea.

Seropositivity to a major allergen of Anisakis simplex, Ani s 1, in dyspeptic patients with Helicobacter pylori infection: histological and laboratory findings and clinical significance.

Previous studies have demonstrated a high prevalence of seropositivity to the Ani s 1 protein in dyspeptic patients with Helicobacter pylori infection, but it is not known whether this represents episodes of anisakiasis misdiagnosis or previous exposure to the parasite without clinical relevance. To investigate the clinical significance of seropositivity to the Ani s 1 protein, a cohort study was performed with 87 consecutive dyspeptic patients who were treated for H. pylori infection. Fourteen (16.5%) patients were seropositive for the Ani s 1 protein, which was associated with the consumption of uncooked fish (p 0.0002). There were no differences in histological findings between subjects seropositive or seronegative for Ani s 1, but seropositive patients had increased eosinophil and basophil leukocyte counts (p < 0.05). Anti-Ani s 1 IgE was associated with a lack of improvement in the group of patients with non-ulcer dyspepsia after successful eradication of H. pylori (p 0.016). Thus, in at least a subset of patients with H. pylori infection, seropositivity to Ani s 1 could have clinical relevance. In addition, these data highlight that only anisakiasis associated with severe allergic or gastric symptoms is currently being diagnosed.

Giardia lamblia infection in patients with irritable bowel syndrome and dyspepsia: a prospective study.

AIM: To evaluate the prevalence of Giardia lamblia (G. lamblia) infection in patients with irritable bowel syndrome (IBS) and dyspepsia and to establish which is the most accurate test to diagnose the infection in this setting. METHODS: One hundred and thirty-seven patients who consecutively attended the Outpatient Gastroenterology Clinic for the first time between January 2002 and December 2003 due to symptoms of IBS and/or dyspepsia were recruited. All patients underwent clinical evaluation, first-step haematology and chemistry tests, serologic assays for celiac disease, lactose-H(2) breath test, abdominal ultrasonography, and esophagogastroduodenoscopy. Helicobacter pylori status was evaluated. In patients with symptoms of IBS older than 45 years, colonoscopy was also performed. In all patients, duodenal biopsies and stool samples were examined for trophozoites and cysts of G. lamblia by several methods. RESULTS: G. lamblia was identified in 9 patients. The following diagnoses were also made: IBS (100/137, 73%), functional dyspepsia (62/137, 45%), organic dyspepsia (33/137, 24%), and lactose intolerance (75/137, 55%). A significant association was found between giardiasis and H pylori infection (c2=6.632, OR=12.4, CI=1.5-68.1). There were no symptoms that reliably allowed the recognition of giardiasis. Direct search of the parasite in duodenal biopsy and stool sample examinations gave concordant results in all cases while histological examination of duodenal biopsies displayed a low sensitivity (e.g., 22.2%). CONCLUSION: In this consecutive series, diagnosis of G. lamblia infection accounted for 6.5% of patients with IBS and dyspepsia. Duodenal biopsies for diagnosis of giardiasis may be unnecessary if stool sample examination is performed.

Hookworm infection of the duodenum associated with dyspepsia and diagnosed by oesophagoduodenoscopy: case report.

Hookworm infection and peptic ulcer disease are common in subtropical and tropical countries. While hookworm infection is endemic where sanitary conditions are poor, peptic ulcer disease is associated with a high prevalence of Helicobacter pylori infection. Dyspepsia and epigastric pain are common presenting symptoms of patients with either hookworm infection or peptic ulcer disease. Consequently it is common practice at our healthcare facility to examine stool for ova or parasites before considering empirical gastric acid suppressive therapy or Helicobacter pylori eradication therapy. We describe a patient who presented with dyspepsia and epigastric pain whose stool examination showed no ova or parasites. The patient's symptoms did not improve with proton pump inhibitor therapy. Endoscopy revealed hookworms in the first part of the duodenum. We review published reports of hookworms at this location. In hookworm endemic areas, when empirical treatment for dyspepsia and upper abdominal pain with acid suppressive agents does not offer remedy, antihelminthic agents should be considered even when stool for ova or parasites is negative.

Giardiasis in patients with dyspeptic symptoms.

AIM: To investigate the prevalence of giardiasis in patients with dyspeptic symptoms. METHODS: Clinical records of consecutive patients who attended Gastroenterology Department at Aga Khan University Hospital from January 2000 to June 2003 and had esophagogastroduodenoscopy (EGD) with duodenal biopsies and international classification of diseases 9th revision with clinical modifications (ICD-9-CM) coded with giardiasis were studied. RESULTS: Two hundred and twenty patients fulfilled the above criteria. There were 44% (96/220) patients who were giardiasis positive, 72% (69/96) of them were males and 28% (27/96) of them were females. There were 65% (81/124) males and 35% (43/124) females who were giardiasis negative. The mean age of patients with giardiasis was 28+/-17 years, while that of giardiasis negative patients was 40+/-18 years (P<0.001). In patients with giardiasis, abdominal pain was present in 71% (68/96) of patients (P = 0.02) and diarrhea in 29% (28/96) (P = 0.005); duodenitis in 25% (24/96) on EGD (P = 0.006) and in 68% (65/96) on histopathology (P = 0.002). CONCLUSION: Giardiasis occurs significantly in young people with abdominal pain, while endoscopic duodenitis is seen in only 25% of giardiasis positive cases, which supports routine duodenal biopsy.

Unusual manifestations of Taenia solium infestation.

We present two rare cases of unusual manifestations of Taenia solium infestation. Taenia infestation usually causes abdominal pain and diarrhea in humans. But there have been no clinical reports of ascites, chronic diarrhea, and malabsorption due to Taenia solium without evidence of the ova or larvae of the parasites in stool examinations. Our first unusual case was in a 30-year-old woman with spontaneous pneumothorax, pleural effusion, and ascites; the second case was in a 67-year-old man with a 3-year history of diarrhea, weight loss, and indigestion. Both patients showed blood eosinophilia and positive serologic tests for Taenia solium. After antiparasitic agent administration, their symptoms resolved successfully.

High prevalence of seropositivity to a major allergen of Anisakis simplex, Ani s 1, in dyspeptic patients.

Finding evidence of anisakidosis requires invasive methods. We have developed a serological assay based on the detection of an immunoglobulin E (IgE) specifically directed against Ani s 1 protein, a major parasite allergen of Anisakis simplex, which has shown a high level of accuracy in the diagnosis of anisakidosis. We used this tool to determine the prevalence of anti-Ani s 1 IgE in dyspeptic patients and to investigate if its seropositivity could be related to epidemiological factors other than raw fish consumption. A total of 174 dyspeptic patients who submitted to upper digestive tract endoscopy were studied. Specific IgE against Ani s 1 was determined by immunoblotting. Quantitative information on smoking, alcohol consumption, and fish consumption as well as a history of gastric surgery was recorded. Twenty-four (13.8%) patients were seropositive for Ani s 1 protein. The seroprevalence of anti-Ani s 1 IgE increased with age in patients who were less than 62 years old (P = 0.047). Seropositivity to Ani s 1 was associated with the consumption of fish in vinegar (P < 0.001), raw fish (P = 0.001), and smoked fish (P = 0.007). There was no relationship between anti-Ani s 1 IgE seropositivity and the number of cigarettes smoked (P = 0.098) or alcohol intake (P = 0.179). Five patients had undergone previous gastric surgery, and three of those patients were seropositive for Ani s 1 (P = 0.019). In multivariate analysis, the consumption of fish in vinegar (P = 0.006), raw fish (P = 0.017), and smoked fish (P = 0.002) and a history of gastric surgery (P = 0.005) were independent factors associated with anti-Ani s 1 IgE detection. In conclusion, at present, anisakidosis might frequently be underdiagnosed, and it might have a clinical role in patients with upper dyspeptic symptoms. Uncooked-fish ingestion and previous gastric surgery were associated with seropositivity for Ani s 1 protein.

Prevalence of intestinal parasites in Kenyans with dyspepsia.

Dyspepsia and intestinal worm infestation are both common clinical conditions in a developing country like Kenya and thus this study was designed to look at the correlation between the two in a referral gastroenterology clinic at Kenyatta National Hospital. One hundred and twenty five patients with dyspepsia had their stool, duodenal aspirate and duodenal biopsy analysed for evidence of intestinal parasites. Seven (5.6%) were found to have various types of intestinal parasites with giardia lamblia comprising 42.8% of worms isolated. 71.4% of patients with dyspepsia and worm infestation had their symptoms improved after deworming, but the low prevalence of intestinal parasite in dyspeptic patients makes routine deworming not cost effective. Stool examination had the best yield for intestinal parasites.

Dyspepsia in acute falciparum malaria: a clinico-pathological correlation.

Gastrointestinal symptoms are common in acute falciparum malaria. Dyspepsia often occurs in such patients and sometimes it is exceptionally severe. However, the pathogenesis of the dyspeptic symptoms in malaria has not been clearly defined. Upper gastrointestinal endoscopy was performed in 40 patients with acute falciparum malaria in order to correlate the dyspeptic symptoms with the macroscopic (endoscopic) and microscopic (histologic) pathology of stomach and duodenum. The patients were divided into a dyspeptic group (n = 20, male/female ratio = 17/3, age range 18-50 years, mean age = 28.85 + 9.14 years), and a non-dyspeptic group (n = 20, male/female ratio = 16/4, age range 15-47, mean age 26.05 + 9.98 years). The findings revealed that dyspepsia correlated with topographic endoscopic pangastritis (p = 0.0014), the category of endoscopic antral gastritis (p = 0.013), and the histologic severity of antral gastritis (p = 0.0434). The results suggested that gastritis should be considered in acute falciparum malaria patients presenting with dyspepsia.