Common Intestinal Parasites

CORRY JEB KUCIK, LT, MC, USN, GARY L. MARTIN, LCDR, MC, USN, and BRETT V. SORTOR, LCDR, MC,
USN, Naval Hospital Jacksonville, Jacksonville, Florida
Intestinal parasites cause significant morbidity and mortality. Diseases caused by Enterobius
vermicularis, Giardia lamblia, Ancylostoma duodenale, Necator americanus, and Entamoeba
histolytica occur in the United States. E. vermicularis, or pinworm, causes irritation and sleep
disturbances. Diagnosis can be made using the “cellophane tape test.” Treatment includes mebendazole
and household sanitation. Giardia causes nausea, vomiting, malabsorption, diarrhea, and weight loss.
Stool ova and parasite studies are diagnostic. Treatment includes metronidazole. Sewage treatment,
proper handwashing, and consumption of bottled water can be preventive. A. duodenale and N.
americanus are hookworms that cause blood loss, anemia, pica, and wasting. Finding eggs in the feces
is diagnostic. Treatments include albendazole, mebendazole, pyrantel pamoate, iron supplementation,
and blood transfusion. Preventive measures include wearing shoes and treating sewage. E.
histolytica can cause intestinal ulcerations, bloody diarrhea, weight loss, fever, gastrointestinal
obstruction, and peritonitis. Amebas can cause abscesses in the liver that may rupture into the pleural
space, peritoneum, or pericardium. Stool and serologic assays, biopsy, barium studies, and liver
imaging have diagnostic merit. Therapy includes luminal and tissue amebicides to attack both life-cycle
stages. Metronidazole, chloroquine, and aspiration are treatments for liver abscess. Careful sanitation
and use of peeled foods and bottled water are preventive. (Am Fam Physician 2004:69:1161–8. Copy-
right© 2004 American Academy of Family Physicians)

Intestinal parasites cause significant morbidity and mortality throughout the world, particularly in undeveloped
countries and in persons with comorbidities. Intestinal parasites that remain prevalent in the United States
include Enterobius vermicularis, Giardia lamblia, Ancylostoma duodenale, Necator americanus, and Entamoeba
histolytica.

E. vermicularis
E. vermicularis, commonly referred to as the pinworm or seatworm, is a nematode, or roundworm, with the
largest geographic range of any helminth.1 It is the most prevalent nematode in the United States. Humans are the
only known host, and about 209 million persons worldwide are infected. More than 30 percent of children
worldwide are infected.2

Adult worms are quite small; the males measure 2 to 5 mm, and the females measure 8 to 13 mm. The worms
live primarily in the cecum of the large intestine, from which the gravid female migrates at night to lay up to
15,000 eggs on the perineum. The eggs can be spread by the fecal-oral route to the original host and new hosts.
Eggs on the host's perineum can spread to other persons in the house, possibly resulting in an entire family
becoming infected.

Ingested eggs hatch in the duodenum, and larvae mature during their migration to the large intestine. Fortunately,
most eggs desiccate within 72 hours. In the absence of host autoinfection, infestation usually lasts only four to six
weeks.

Disease secondary to E. vermicularis is relatively innocuous, with egg deposition causing perineal, perianal, and
vaginal irritation.3 The patient's constant itching in an attempt to relieve irritation can lead to potentially
debilitating sleep disturbance. Rarely, more serious disease can result, including weight loss, urinary tract
infection, and appendicitis.4,5

Pinworm infection should be suspected in children who exhibit perianal pruritus and nocturnal restlessness.
Direct visualization of the adult worm or microscopic detection of eggs confirms the diagnosis, but only 5
percent of infected persons have eggs in their stool. The “cellophane tape test”(Figure 1) can serve as a quick
way to clinch the diagnosis.6,7

FIGURE 1.
“Cellophane tape test.” (Top) Affix the end of the tape near one end of the slide. Loop the rest of the tape over the end of the
slide so the adhesive surface is exposed. (Center) Touch the adhesive surface to the perianal region several
times. (Bottom) Smooth down the tape across the surface of the slide.
This test consists of touching tape to the perianal area several times, removing it, and examining the tape under
direct microscopy for eggs. The test should be conducted right after awakening on at least three consecutive days.
This technique can increase the test's sensitivity to roughly 90 percent.

FIGURE 2
Giardia lamblia cyst.
Reprinted from Centers for Disease Control and Prevention. Accessed November 15, 2003, athttp://phil.cdc.gov.

G. lamblia
G. lamblia is a pear-shaped, flagellated protozoan (Figure 2) that causes a wide variety of gastrointestinal
complaints. Giardia is arguably the most common parasite infection of humans worldwide, and the second most
common in the United States after pin-worm.8,9 Between 1992 and 1997, the Centers for Disease Control and
Prevention (CDC) estimated that more than 2.5 million cases of giardiasis occur annually.10

Because giardiasis is spread by fecal-oral contamination, the prevalence is higher in populations with poor
sanitation, close contact, and oral-anal sexual practices. The disease is commonly water-borne because Giardia is
resistant to the chlorine levels in normal tap water and survives well in cold mountain streams. Because
giardiasis frequently infects persons who spend a lot of time camping, backpacking, or hunting, it has gained the
nicknames of “backpacker's diarrhea” and “beaver fever.”11

Food-borne transmission is rare but can occur with ingestion of raw or undercooked foods. Giardiasis is a
zoonosis, and cross-infectivity among beaver, cattle, dogs, rodents, and bighorn sheep ensures a constant
reservoir.12

The life cycle of Giardia consists of two stages: the fecal-orally transmitted cyst and the disease-causing
trophozoite. Cysts are passed in a host's feces, remaining viable in a moist environment for months. Ingestion of
at least 10 to 25 cysts can cause infection in humans.8,9 When a new host consumes a cyst, the host's acidic
stomach environment stimulates excystation. Each cyst produces two trophozoites. These trophozoites migrate to
the duodenum and proximal jejunum, where they attach to the mucosal wall by means of a ventral adhesive disk
and replicate by binary fission.

Giardia growth in the small intestine is stimulated by bile, carbohydrates, and low oxygen tension.7 It can cause
dyspepsia, mal-absorption, and diarrhea. A recent theory suggests that the symptoms are the result of a brush
border enzyme deficiency rather than invasion of the intestinal wall.9 Some trophozoites transform to cysts and
pass in the feces.

Clinical presentations of giardiasis vary greatly. After an incubation period of one to two weeks, symptoms of
gastrointestinal distress may develop, including nausea, vomiting, malaise, flatulence, cramping, diarrhea,
steatorrhea, and weight loss. A history of gradual onset of a mild diarrhea helps differentiate giardiasis or other
parasite infections from bacterial etiologies. Symptoms lasting two to four weeks and significant weight loss are
key findings that indicate giardiasis.

Chronic giardiasis may follow an acute syndrome or present without severe antecedent symptoms. Chronic signs
and symptoms such as loose stool, steatorrhea, a 10 to 20 percent loss in weight, malabsorption, malaise, fatigue,
and depression may wax and wane over many months if the condition is not treated.

Rarely, patients with giardiasis also present with reactive arthritis or asymmetric synovitis, usually of the lower
extremities.13 Rashes and urticaria may be present as part of a hypersensitivity reaction.

Cyst excretion occurs intermittently in both formed and loose stools, while trophozoites are almost only found in
diarrhea. Stool studies for ova and parasites (O&P) continue to be a mainstay of diagnosis despite only low to
moderate sensitivity. Examination of a single stool specimen has a sensitivity of 50 to 70 percent; the sensitivity
increases to 85 to 90 percent with three serial specimens.8,10 Because Giardia is not invasive, eosinophilia, and
peripheral or fecal leukocytosis do not occur.

Antigen assays use enzyme-linked immunosorbent assay (ELISA) or immunofluo-rescence to detect antibodies
to trophozoites or cysts. Sensitivities range from 90 to 99 percent, with specificities of 95 to 100 percent
compared with stool O&P.9 Despite the high yield of these studies, direct microscopy is still important, because
multiple diarrhea-causing infectious etiologies can be present simultaneously.

Duodenal aspirates and biopsies give a higher yield than stool studies but are invasive and usually not necessary
for diagnosis. Serology and stool cultures are generally unnecessary. Polymerase chain reaction (PCR) analysis,
while only experimental, may be effective for screening water supplies.9

A. duodenale and N. americanus

Two species of hookworm, A. duodenale and N. americanus, are found exclusively in humans. A. duodenale, or
“Old World” hookworm, is found in Europe, Africa, China, Japan, India, and the Pacific islands. N. americanus,
the “New World” hookworm, is found in the Americas and the Caribbean, and has recently been reported in
Africa, Asia, and the Pacific.

Until the early 1900s, N. americanus infestation was endemic in the southern United States and was only
controlled after the widespread use of modern plumbing and footwear. Even though the prevalence of these
parasites has drastically decreased in the general population, the CDC reports that in the United States,
hookworm infection is the second most common helminthic infection identified in stool studies.14

FIGURE 3.
Electron micrograph of teeth and cutting plate differences between (left) Ancylostoma duodenale and (right) Necator
americanus .
Reprinted from Centers for Disease Control and Prevention and Dr. Mae Melvin. Accessed November 15, 2003,
at http://phil.cdc.gov.
N. americanus ranges from 10 to 12 mm in length for females and 6 to 8 mm for males. It is distinguished from
its slightly larger European cousin by its semilunar dorsal and ventral cutting plates at the buccal cavity
compared with A. duodenale's two pairs of ventral cutting teeth (Figure 3). The eggs of both worms are 60 to 70
μm in length and bounded by an ovoid transparent hyaline membrane; they contain two to eight cell
divisions (Figure 4).

Both species share a common life cycle. Eggs hatch into rhabditiform larvae, feed on bacteria in soil, and molt
into the infective filariform larvae. Enabled by moist climates and poor hygiene, filariform larvae enter their
hosts through pores, hair follicles, and even intact skin. Maturing larvae travel through the circulation system
until they reach alveolar capillaries. Breaking into lung parenchyma, the larvae climb the bronchial tree and are
swallowed with secretions. Six weeks after the initial infection, mature worms have attached to the wall of the
small intestine to feed, and egg production begins.

FIGURE 4.
Hookworm egg.
Reprinted from Centers for Disease Control and Prevention. Accessed November 15, 2003, athttp://phil.cdc.gov.
While larvae occasionally cause pruritic erythema or pulmonary symptoms during their migration to the
gut,15 hookworm infection rarely is symptomatic until a significant intestinal worm burden is established. A
transient gastroenteritis-like syndrome can occur because mature worms attach to the intestinal mucosa.

The greatest concern from infection is blood loss. Aided by an organic anticoagulant, a hookworm consumes
about 0.25 mL of host blood per day. The blood loss caused by hookworms can produce a microcytic
hypochromic anemia.16 Compensatory volume expansion contributes to hypoproteinemia, edema, pica, and
wasting. The infection may result in physical and mental retardation in children. Eosinophilia has been noted in
30 to 60 percent of infected patients.

While clinical history, hygiene status, and recent travel to endemic areas can give important clues, definitive
diagnosis rests on microscopic visualization of eggs in the stool.

E. histolytica
Amebiasis is caused by E. histolytica, a protozoan that is 10 to 60 μm in length and moves through the extension
of finger-like pseudo-pods.1 Spreading occurs via the fecal-oral route, usually by poor hygiene during food
preparation or by the use of “night soil” (crop fertilization with human waste), as well as by oral-anal sexual
practices. Spreading is frequent in persons who have a deficient immune system. Crowding and poor sanitation
contribute to its prevalence in Asia, Africa, and Latin America. Approximately 10 percent of the world's
population is infected, yet 90 percent of infected persons are asymptomatic.17 Of the roughly 50 million
symptomatic cases occurring each year, up to 100,000 are fatal.18 The stable reservoir of infective cases
complicates eradication. After malaria, it is likely that E. histolytica is the world's second leading protozoan
cause of death.19
Much like Giardia, the two stages in the E. histolytica life cycle are cysts and trophozoites (Figure 5). Infective
cysts are spheres of about 12 μm in diameter that have one to four nuclei and can be spread via the fecal-oral
route by contaminated food and water or oral-anal sexual practices. The pseudopodal trophozoite is about 25 μm
across, has a single nucleus, and may contain red blood cells of the host in various stages of digestion. Ingested
cysts hatch into trophozoites in the small intestine and continue moving down the digestive tract to the colon.
Also like Giardia, some ameba trophozoites become cysts that are passed in the stool and can survive for weeks
in a moist environment. However, trophozoites can invade the intestinal mucosa and spread in the bloodstream to
the liver, lung, and brain.

Amebiasis can cause both intraluminal and disseminated disease. In the intestinal lumen, E. histolyticacan
disrupt the protective mucus layer overlying the colonic mucosa. The resulting epithelial ulcerations can bleed
and cause colitis,20 usually two to six weeks after initial infection. Acute progression to malaise, weight loss,
severe abdominal pain, profuse bloody diarrhea, and fever can occur, often leading to a misdiagnosis of
appendicitis, especially in children. In chronic smoldering cases, inflammatory bowel disease can be
misdiagnosed, and treatment with steroids only exacerbates the infection.

FIGURE 5.
(Top) Entamoeba histolytica cyst and (bottom) trophozoite.
Reprinted from Centers for Disease Control and Prevention and Drs. L.L.A. Moore, Jr., and Mae Melvin. Accessed November
15, 2003, at http://phil.cdc.gov.
Rarely, a reactive collection of edematous granulation and fibrous tissue called an ameboma can grow into the
lumen, causing pain, obstruction and, possibly, intussusception. Toxic megacolon, pneumatosis coli (intramural
air), and peritonitis also may occur.17,19

Tissue penetration and dissemination are possible. Trophozoites that penetrate the intestinal wall spread through
the body via the portal circulation. Amebas are chemotactic, attracting neutrophils in the circulation. Amebic
liver abscesses form because of toxin release and hepatocyte damage, and usually develop within five months
after infection. Symptoms of a developing abscess include fever, dull pleuritic right upper quadrant pain radiating
to the right shoulder, and pleural effusions. Diarrhea is present in only one of three patients with abscess. Fever
is the presenting symptom in 10 to 15 percent of patients, and therefore amebic abscess should be considered in
patients with a fever of unknown origin. Abscesses may rupture into the pleural space, peritoneum, or
pericardium, requiring emergency drainage.

Traditional O&P stool testing for amebiasis should use at least three fresh samples to increase sensitivity.
However, this test has recently fallen out of favor18 because an E. histolytica stool antigen test with a sensitivity of
87 percent and a specificity of more than 90 percent has become available.19 Stool culture and PCR testing
modalities used in research are not yet sufficiently widespread to be clinically useful. Positive stool samples are
likely to be heme positive and to have low neutrophils but may contain Charcot-Leyden crystals, indicating the
presence of eosinophils. Biopsy of colonic ulcer edges may yield intramural trophozoites but carries with it the
risk of perforation.
FIGURE 6.

Computed tomographic scan showing liver abscess.

Reprinted with permission from Medscape. Accessed November 15, 2003,
athttp://www.medscape.com/content/2002/00/44/12/441223/artiim441223.fig4.jpg.
Serologic tests such as ELISA and agar gel diffusion are more than 90 percent sensitive, but these tests often
become negative within a year of initial infection. Approximately 75 percent of infected patients have
leukocytosis, but mucosal invasion does not cause eosinophilia. Liver function tests usually are normal but may
show minimal elevation of alkaline phosphatase, even in the presence of large abscesses. To avoid misdiagnosis,
patients with suspected ulcerative colitis must be tested for E. histolyticaantibodies before starting steroid
therapy.17

Intestinal barium studies may be useful in identifying possible amebomas, but biopsy is required to confirm the
diagnosis and rule out neoplasia. Liver imaging studies, such as ultra-sonography, computed tomography (Figure
6), magnetic resonance imaging, and nuclear medicine scans, can reveal abscesses as oval or round hypoechoic
cysts, usually in the right lobe of the liver.21

Risk of complications increases with cysts of more than 10 cm, multiple cysts, superior right lobe involvement,
or any left lobe involvement. Repeat studies may be confusing by showing larger abscesses in improving patients.
Although two thirds of abscesses resolve within six months, approximately 10 percent of abscesses persist for
more than a year.17

TABLE 1
Treatment and Prevention of Parasite Infections

Parasite Treatment Prevention

Enterobius Primary: Mebendazole (Vermox), 100 mg orally Treat household contacts.Clean
vermicularis onceSecondary: Pyrantel pamoate (Pin-Rid), 11 mg per bedrooms, bedding.
kg (maximum of 1 g) orally once; oralbendazole
(Valbazen), 400 mg orally onceIf persistent, repeat
treatment in two weeks.Do not give to children younger
than two years.

Giardia lamblia Adults: Metronidazole (Flagyl), 250 mg orally three times Use proper sewage disposal and water
daily for five to seven daysPregnant women with mild treatment (flocculation, sedimentation,
symptoms: consider deferring treatment until after filtration, and chlorination).Consume
delivery.Pregnant women with severe symptoms: only bottled water in endemic
paromomycin (Humatin), 500 mg orally four times daily areas.Water treatment options:Boil
for seven to 10 days; metronidazole is water for one minuteHeat water to 70 C
acceptable.Children: albendazole, 400 mg orally for five (158 F) for 10 minutesPortable camping
daysAsymptomatic carriers in developed countries: treat filterIodine purification tablets for eight
using regimen for adults or children.Asymptomatic hoursDaycare centers:Proper disposal
carriers in developing countries: not cost-effective to of diapersProper and frequent
treat because of high reinfection rate. handwashing

Ancylostoma Albendazole, 400 mg orally onceMebendazole, 100 mg Use proper and continued shoe wear.
duodenale, orally twice daily for three daysPyrantel pamoate, 11 mg Use proper sewage disposal.
Necator per kg (maximum of 1 g) onceIron supplementation is
americanus beneficial even before diagnosis or treatment
initiation.Packed red blood cells (as needed) can
Parasite Treatment Prevention
minimize risk of volume overload in severely
hypoproteinemic patients.Confirm eradication with
follow-up stool examination two weeks after
discontinuation of treatment.

Entamoeba Intestinal disease: use both luminal amebicide (for cysts) Use proper sanitation to eradicate cyst
histolytica and tissue amebicide (for trophozoites) carriage.Avoid eating unpeeled fruits
and vegetables.Drink bottled water.Use
Luminal: iodine disinfection of nonbottled water.
Iodoquinol (Yodoxin), 650 mg orally three times
daily for 20 days
or
Paromomycin, 500 mg orally three times daily for
seven days
or
Diloxanide furoate (Furamide), 500 mg orally
three times daily for 10 days (available from
CDC)
Tissue:
Metronidazole, 750 mg orally three times daily for
10 days
Liver abscess:
Metronidazole, 750 mg orally three times daily for
five days, then paromomycin, 500 mg three times
daily for seven days
or
Chloroquine (Aralen), 600 mg orally per day for
two days, then 200 mg orally per day for two to
three weeks (higher relapse rates)
Aspirate if:
Pyogenic abscess is ruled out; there is no
response to treatment in three to five days;
rupture is imminent; pericardial spread is
imminent

CDC = Centers for Disease Control and Prevention.

Information from references 1,2,5,7,9,17,19, and 22.

Treatment and Prevention

Treatment and prevention strategies for parasite infections are summarized in Table 1.1,2,5,7,9,17,19,22 Amebicidal
agents available in the United States are compared in Table 2.22

TABLE 2
Advantages and Disadvantages of Amebicidal Agents
Amebicidal agent Advantages Disadvantages
Luminal amebicides
Paromomycin Seven-day treatment course; Frequent GI disturbances; rare ototoxicity and nephrotoxicity;
(Humatin) may be useful during expensive
pregnancy
Iodoquinol (Yodoxin) Inexpensive and effective 20-day treatment course; contains iodine; rare optic neuritis
and atrophy with prolonged use
Diloxanide furoate Alternative to paromomycin if Available in United States only from the CDC; frequent GI
(Furamide) unable to tolerate disturbances; rare diplopia; contraindicated in pregnant
women
For invasive
intestinal disease
only
Tetracycline, Alternative to metronidazole Not active for liver abscesses; frequent GI disturbances;
erythromycin (Flagyl) if unable to tolerate tetracycline should not be administered to children or
pregnant women; must be used with luminal agent
For invasive intestinal and extraintestinal
amebiasis
Metronidazole Drug of choice for amebic Anorexia, nausea, vomiting, and metallic taste in nearly one
colitis and liver abscess third of patients at dosages used; disulfiram-like reaction with
alcohol; rare seizures
Chloroquine Useful only for amebic liver Occasional headache, pruritus, nausea, alopecia, and
(Aralen) abscess myalgias; rare heart block and irreversible retinal injury

GI = gastrointestinal; CDC = Centers for Disease Control and Prevention.

Adapted with permission from Huston CD, Petri WA. Amebiasis. In: Rakel R, ed. Conn's Current therapy 2001. Philadelphia:
Saunders, 2001:64–5.

The Authors
CORRY JEB KUCIK, LT, MC, USN, currently serves as flight surgeon for Marine Fighter Attack Squadron 251, Marine Corps
Air Station, Beaufort, S.C. He received his medical degree from the Uniformed Services University of the Health Sciences,
Bethesda, Md., and completed an internship in family medicine at Naval Hospital Jacksonville, Jacksonville, Fla.
GARY L. MARTIN, LCDR, MC, USN, serves as 27th Group Surgeon, 2d Marine Air Wing, at the Marine Corps Air Station,
Cherry Point, N.C. He received his medical degree from the Uniformed Services University of the Health Sciences and
completed a residency in family medicine at Naval Hospital Jacksonville.
BRETT V. SORTOR, LCDR, MC, USN, is a senior resident in the family medicine residency program at Naval Hospital
Jacksonville. He received his medical degree from the Medical University of South Carolina, Charleston.
Address correspondence to Corry J. Kucik, LT, MC, USN, 1210 Brookwood Circle, Opelika, AL 36801. Reprints are not
available from the authors.
The authors indicate that they do not have any conflicts of interest. Sources of funding: none reported.
The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or
as reflecting the views of the U.S. Navy Medical Corps or the U.S. Navy at large.
The authors thank Anthony J. Viera, LCDR, MC, USNR, for constructive feedback and encouragement.

REFERENCES
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Mosby, 1997:1519.
3. MacPherson DW. Intestinal parasites in returned travelers. Med Clin North Am. 1999;83:1053–75.
4. Saxena AK, Springer A, Tsokas J, Willital GH. Laparoscopic appendectomy in children withEnterobius vermicularis.
Surg Laparosc Endosc Percutan Tech. 2001;11:284–6.
5. Dickson R, Awasthi S, Demellweek C, Williamson P. Anthelmintic drugs for treating worms in children: effects on growth
and cognitive performance. Cochrane Database Syst Rev. 2003;(2):CD000371.
6. Parija SC, Sheeladevi C, Shivaprakash MR, Biswal N. Evaluation of lactophenol cotton blue stain for detection of eggs
ofEnterobius vermicularis in perianal surface samples. Trop Doct. 2001;314:214–5.
7. Procop GW. Gastrointestinal infections. Infect Dis Clin North Am. 2001;15:1073–108.
8. Katz DE, Taylor DN. Parasitic infections of the gastrointestinal tract. Gastroenterol Clin North Am. 2001;30:795–815.
9. Leder K, Weller P. Giardiasis. In: Rose BD, ed. Infectious disease. Wellesley, Mass.: UpToDate, 2002. 10. Furness BW,
Beach MJ, Roberts JM. Giardiasis surveillance—United States, 1992–1997. MMWR CDC Surveill Summ. 2000;497:1–
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10. Furness BW, Beach MJ, Roberts JM. Giardiasis surveillance—United States, 1992–1997. MMWR CDC Surveill
Summ. 2000;49(7):1–13.
11. DuPont HL, Backer HD. Infectious diarrhea from wilderness and foreign travel. In: Auerback PS, ed. Wilderness
medicine: management of wilderness and environmental emergencies. 3d ed. St. Louis: Mosby, 1995:1028–59.
12. Glaser C, Lewis P, Wong S. Pet-, animal- and vector-borne infections. Pediatr Rev. 2000;21:219–32.
13. Steiger U, Weber M. Ungewöhnliche ursache von erythema nodosum, pleuraerguss und reaktiver arthritis:giardia
lamblia. [Unusual etiology of erythema nodosum, pleural effusion and reactive arthritis:Giardia lamblia. ] Schweiz
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14. Centers for Disease Control and Prevention. Publication of CDC surveillance summaries. MMWR Morb Mortal Wkly
Rep. 1992;418:145–6.
15. Kitchen LW. Case studies in international medicine. Am Fam Physician. 1999;59:3040–4.
16. Ali-Ahmad N, Bathija M, Abuhammour W. Index of suspicion. Case #2. Diagnosis: anemia from hookworm infestation.
Pediatr Rev. 2000;21:354–7.
17. Reed SL. Amebiasis and infection with free-living amebas. In: Harrison TR, Fauci AS, Braunwald E, et al., eds. Harrison's
Principles of internal medicine. 15th ed. New York: McGraw-Hill, 2001:1199–202.
18. Walsh JA. Problems in recognition and diagnosis of amebiasis: estimation of the global magnitude of morbidity and
mortality. Rev Infect Dis. 1986;8:228–38.
19. Petri WA Jr, Singh U. Diagnosis and management of amebiasis. Clin Infect Dis. 1999;29:1117–25.
20. Stanley SJ. Pathophysiology of amoebiasis. Trends Parasitol. 2001;17:280–5.
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Members of various family practice departments develop articles for “Practical Therapeutics.” This article is one in a series
coordinated by the Department of Family Medicine at Naval Hospital Jacksonville, Jacksonville, Fla. Guest editor of the
series is Anthony J. Viera, LCDR, MC, USNR.

Introduction:
There are two main types of intestinal parasites: helminths and protozoa. Helminths are worms with many
cells, and are generally visible to the naked eye in their adult stages. Tapeworms, pinworms, and
roundworms are among the most common helminths in the United States. In their adult form, helminths
cannot multiply in the human body. Protozoa have only one cell, and can multiply inside the human body,
which contributes to their survival and enables serious infections to develop. Transmission typically occurs by
fecal-oral route (for example, through contaminated food or water). In the U.S., the most common protozoa
are giardia and cryptosporidium.

Signs and Symptoms:

Parasites can live within the intestines for years without causing any symptoms. When they do, symptoms
include the following:
• Abdominal pain
• Diarrhea
• Nausea or vomiting
• Gas or bloating
• Dysentery (loose stools containing blood and mucus)
• Rash or itching around the rectum or vulva
• Stomach pain or tenderness
• Feeling tired
• Weight loss
• Passing a worm in your stool

What Causes It?:

The following factors put you at higher risk for getting intestinal parasites:
• Living in or visiting an area known to have parasites
• International travel
• Poor sanitation (for both food and water)
• Poor hygiene
• Age -- children and the elderly are more likely to get infected
• Exposure to child and institutional care centers
• Immune-compromised
• HIV or AIDS

What to Expect at Your Provider's Office:

Your health care provider will ask if you have traveled overseas recently and whether you have recently lost
weight. If your health care provider thinks you have an intestinal parasite, you will probably have one or
more of the following tests:
• Fecal testing (examination of your stool) can identify both helminths and protozoa. Stool samples
must be collected before antidiarrhea drugs or antibiotics are given, or x-rays with barium are taken.
Three (five for pinworm) stool samples are needed to find the parasite.
• The string test is used occasionally. For this test, you swallow a string that is then pulled back up.
Then samples of your stomach contents on the string are tested.
• The "Scotch tape" test identifies pinworm by touching tape to the anus several times, then examining
the tape under a microscope for eggs.
• Your health care provider may use x-rays with barium to diagnose more serious problems caused by
parasites, although this test is usually not required.
 Treatment Options:

Drug Therapies
Your health care provider will choose the drug that has the most effect against your intestinal parasite. Drug
treatment may occur in one dose or over a period of weeks. Be careful to take the medicine exactly as it is
prescribed, or it may not work.
Some examples of drug therapy include:
• Mebendazole (Vermox) -- roundworm, hookworm, pinworm
• Thiabendazole (Mintezol) -- threadworm, pork worm
• Metronidazole (Flagyl) -- giardiasis
• Nitazoxanide (Alinia) -- giardiasis, cryptosporidiosis

Complementary and Alternative Therapies

Generally, conventional medical treatments can eliminate parasites more quickly and with fewer side effects
than most alternative treatments. Alternative treatments may be helpful as supportive therapies. However,
your health care provider must find out what kind of organism is causing your problems before you start
treatment. The following nutritional guidelines will help keep organisms from growing. It is important to
maintain good bowel habits during treatment.

Nutrition and Supplements

• Avoid simple carbohydrates, such as those found in refined foods, fruits, juices, dairy products, and
all sugars, except honey.
• Eat more raw garlic, pumpkin seeds, pomegranates, beets, and carrots, all of which have antiworm
properties. Researchers found that a mixture of honey and papaya seeds cleared stools of parasites
in 23 out of 30 subjects. Drink a lot of water to promote good bowel elimination.
• Consume more fiber, which helps get rid of worms.

• Supplement your diet with probiotics, such as Lactobacillus acidophilus, Lactobacilus plantarum,
Saccharomyces boulardii (250 mg, one to two times per day between meals), andbifidobacteria, to
keep parasites from spreading.
• Digestive enzymes will help restore your intestinal tract to its normal state, which makes it
inhospitable to parasites. Papain taken 30 minutes before or after meals helps kill worms.
• Vitamin C (250 - 500 mg two times a day) or, if well-tolerated, much higher doses of up to 6,000 mg
per day in otherwise healthy adults and zinc (20 - 30 mg per day) support the immune system.
Lower vitamin C dose if diarrhea develops.

Herbs
As with any therapy, it is important to work with your health care provider on getting your problem
diagnosed before you start any treatment. You may use herbs as dried extracts (capsules, powders, teas),
glycerites (glycerine extracts), or tinctures (alcohol extracts). People with a history of alcoholism should not
take tinctures.
Many of the herbs used to treat intestinal parasites have toxic side effects. Use them only under the
supervision of a qualified practitioner. Your health care provider should treat you with the most gentle herb
that is effective for the type of parasite you have. A few of the herbs that your health care provider might
consider include:

• Garlic (Allium sativum)

• Barberry (Berberis vulgaris)

• Goldenseal (Hydrastis canadensis)

 • Oregon grape (Berberis aquifolium)

• Tea tree oil (Melaleuca alternifolia)

• Anise (Pimpinella anisum)

• Wormwood (Artemisia annua)

• Curled mint (Mentha crispa)

• Black walnuts (Juglans nigra)

Homeopathy
As with other treatments, your health care provider must first diagnose the kind of parasite you have. Before
prescribing a remedy, homeopaths take into account a person's constitutional type -- your physical,
emotional, and intellectual makeup. An experienced homeopath assesses all of these factors as well as any
current symptoms when determining the most appropriate remedy for a particular individual. The following
remedies may be used:

• Cina

• Cuprum oxidatum nigrum

• Indigo

• Teucrium

• Podophyllum

• Spigelia

• Sabadilla

• Stanum

Acupuncture
Can help general bowel health and increase immune function.

Massage
May help stimulate bowel function and elimination.

Following Up:
Your health care provider will retest your stool to be sure your parasite is gone, and will give you advice to
help you avoid reinfection. Follow these instructions carefully. Getting a parasite a second time can cause
more serious health problems.

Special Considerations:
The seriousness and length of illness varies with the specific intestinal parasite. Complications occur more
often in older people and in people who already have serious illnesses, such as AIDS.
Intestinal parasites can be more serious if you are pregnant. Your health care provider will tell you which
drugs are safe to take during pregnancy. Treatment for intestinal parasites during pregnancy should be
closely monitored by a qualified practitioner.
 Alternative Names:
Parasitic infection - intestinal
• Reviewed last on: 1/17/2008
• Steven D. Ehrlich, NMD, private practice specializing in complementary and alternative medicine,
Phoenix, AZ. Review provided by VeriMed Healthcare Network.

Supporting Research
Carr AC, Frei B. Toward a new recommended dietary allowance for vitamin C based on antioxidant and health
effects in humans. Am J Clin Nutr. 1999;69(6):1086-1107.
Choudhry VP, Sabir M, Bhide VN. Berberine in giardiasis. Indian Pediatr. 1972;9:143-6.

Constipation Intestinal Blockage Symptoms Causes

Constipation intestinal blockage symptoms causes stomach bloating, cramps,
abdominal bowel pain, dry hard bloody stool. Long term constipation results;
colon cancer, bacteria, parasites, yeast infection, poisonous toxins, stress,
vitamin mineral absorption.
Other constipation intestinal blockage symptoms include: allergy, appetite loss,
asthma, backache, bad breath, bad odor, concentration loss, depression,
eczema, fatigue, food craving, gingivitis, headache, hemorrhoids, indigestion,
insomnia, irritability, memory loss, menstrual problems, nausea, nervousness,
prostate problems, stomach pain, swelling, tension, weight problems.
Constipation can effect anyone at any age and another major health problem today. Constipation can result from
improper eating habits, digestive disorder, and other causes. Constipation effects over 4 million people yearly
in the USA. Proper eating habits and the intake of food is important but it is equally important to rid our
bodies of the waste.
If you eat daily you should have at least one bowel movement daily. Some think
that having only 2 or 3 bowel movements weekly are normal. When the food
waste moves to slow in the colon because of weak muscle contractions or
constipation, the waste tends to ferment or putrefy into poisons due to the
bacterial action during the putrefaction of foods. These toxins are then absorbed
into the blood stream and will eventually burden every vital organ and cell in the
body. In Europe, this condition is known as Alimentary Intestinal Toxemia or toxic
colon. Some have died from long term constipation if the colon ruptures.

Constipation, Intestinal Blockage Causes

Some constipation or intestinal blockage causes are due to not chewing your
food, dehydration, insufficient fiber, fruit, vegetables and fluids in the diet,
irritable bowel syndrome, lack of exercise, side effect of drugs, or pregnancy.
Ignoring the call of nature to remove the bodies waste products, the muscular
action in the colon moves the bowel waste in reverse. This action causes the
building up or bulging of waste in the colon that weakens the walls. Eventually,
this or long term constipation may cause cancer, colitis, diverticula disease,
intestinal toxemia, over weight, prolapsed colon and ulcerations.
Obstructions or any blockage that causes the waste to back up due to weak
muscle contractions, undigested food, Crohn's, diverticulitis, hernia in the
smaller intestine, closure or narrowing, twisting or knotting of the colon, or worm
infestation. Other constipation causes include colon cancer, obstructions, scar
tissue, stricture, or tumors. Anything that causes the intestinal tract to narrow
down or restrict the flow may cause constipation or intestinal blockage.
Some medications that may cause constipation are antacids that contain
aluminum and calcium, anticonvulsants, antidepressants, antispasmodics, blood
pressure drugs, diuretics, iron supplements, and pain killer medications.
Constipation leads to mal-absorption that results in the deficiency of vitamins
and minerals. It creates an environment for unfriendly bacteria, parasites and
yeast infection. The build-up of poisonous toxins creates stress on the gall
bladder, liver, pancreas, pressure and stress on the upper gastrointestinal,
thinning of the intestinal walls, and muscle weakness in the colon. Stomach
bloating or lower abdominal pain is another common symptom of being
constipated.
When transit time is too long, feces are dry with hard lumps or clumps can
cause constipation. Usually caused by lack of fluids, lack of friendly bacteria,
essential oils, stress, excess mucosa, and not enough good fiber.
Mucosa is mucus formed to trap harmful substances and keep them from
penetrating into the body. The natural mucus is needed for lubrication in the
elimination of waste. Some processed foods create mucus that adds to the
propagation of bacteria or pathogens. An excess of mucosa in the stools causes
clumping of the feces and constipation. Colon dysfunction occurs when the
mucus becomes stagnant and putrefied which keeps building up layer upon
layer. It then becomes a source of infection, irritation, abscessed, and
ulcerations on the walls of the colon and the toxins created will be absorbed into
the blood. Eating processed foods with Crisco or hydrogenated oil will also build
up in layers on the inside of the intestinal walls, sometimes up to 1/2 inch thick
which narrows or restricts the flow. These conditions inhibits the absorption of
nutrients and water.

Some Laxatives May Cause Other Intestinal Tract Problems

Constipation usually leads some people to the dependence on laxatives.
Overuse of some drug store type laxatives for constipation can cause bleeding
in the intestinal tract with bloody stools, damaged nerves, muscles, and
damaged colon tissue. Most laxatives contain carbohydrates, sodium or sugar.
Some laxatives for constipation will list their inactive ingredients, some will not.
Glycerin is used in antifreeze, solvents and sweeteners. Sodium hydroxide is
used in chemical products and soaps. Stearic acid is used in pesticides and
listed as one possible carcinogen. Read the ingredients and think twice about
using these laxatives.
Health article called How To Be Always Well by, Dr. Robert G. Jackson, says;
Anything that lessens the functioning or working power of any one organ, cell or
part, automatically lessens the functioning power of every other organ, cell or
part, through the circulatory and nervous interrelations which obtain between all
the cells, organs and parts of our bodies.

Natural Constipation Intestinal Blockage Treatment Relief

Loosing our natural stimulus that induces normal bowel function because of
weak muscles, ozone colon irrigation tends to stimulate these muscles and
reduce stomach bloating. The herb Marjoram, strengthens stomach and
intestines, helps relieve abdominal cramps. Avoid alcohol, baking soda, cheese,
Crisco, hydrogenated oil, white dry poultry or other meat, and all products with
refined white flour, sugar, white rice and yeast.
Eating any diet of raw fruits, apples and vegetables, brewers yeast, yogurt,
whole grain cereals with lots of water, and wheat grass juice can be taken for
constipation. Balanced portions of all vitamins and minerals from plant derived
liquid dietary supplements and Oxy-Mega can benefit constipation or intestinal
blockage. Magnesium and potassium stimulates nerve impulses for muscle
contraction and builds the foundation for muscular tissues and elasticity.
Oxy-Mega super oxygenated colon cleanser is more gentle and better than
herbal cleansers for constipation or intestinal blockage relief. Oxy-Mega, the
heavy duty super duper pooper pill.

Those not seeking professional advice about long term constipation intestinal
blockage, if the colon ruptures your nearest of kin may be very busy making final
arrangements. Learn more on the importance and benefit of colon cleansing.