Sandbox spinalcord: Difference between revisions

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__NOTOC__
{{CMG}}
==Overview==
'''Lower gastrointestinal bleeding''', commonly abbreviated '''LGIB''', refers to any form of bleeding in the [[lower gastrointestinal tract]].
==Causes==
==Causes==
Common causes of acute spinal cord compression include
*[[Coagulopathy]] - specifically a [[bleeding diathesis]]
*Trauma is a leading cause of acute spinal cord compression
*[[Colitis]]
*Primary or secondary metastatic spinal tumor
**[[ischaemic colitis]]
*Vertebral compression fractures due to osteomalacia, osteoporosis, corticosteroid therapy
**[[ulcerative colitis]]
*Intervertebral disk herniation
**[[infectious colitis]]
*Epidural abscess
***[[E. coli O157:H7]]
*Epidural hematoma
***[[Shigella]]
==Risk factors==
***[[C. difficile]]
Common risk factors in the development of spinal cord compression include
***[[Campylobacter jejuni]]
*Cervical spondylosis
*[[Hemorrhoids]]
*Atlantoaxial instability
*[[Angiodysplasia]]
*Congenital conditions (tethered cord)
*[[Neoplasm]] - cancer
*Osteoporosis
*[[Diverticular disease]] - diverticulosis, diverticulitis
*Ankylosing spondylitis
 
*Rheumatoid arthritis of the cervical spine
==Diagnosis==
Less common risk factors
The following suggest an LGIB:
*IV drug abuse
*[[Melena]] and a negative [[oesophagogastroduodenoscopy]]
*Immunocompromised
*[[Hematochezia]]
*[[Fecal occult blood]]
 
The following may suggest an LGIB:
*[[Anemia]]
 
==Related Chapter==
* [[Fecal occult blood]]
* [[Blood in stool]]
* [[Rectal bleeding]]
* [[Upper gastrointestinal bleeding]]
<small>
<div style="width: 55%;">
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{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | |!| | | | | | | | |!| | | |}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | O01 | | | | | | | O02 | |O01=Fever|O02=Rectal pain}}
{{familytree | | | | | | | | | | | | | | | |,|-|-|-|-|-|-|-|-|-|-|-|-|^|-|-|-|-|.| | | |!| | }}
{{familytree | | | | | | | | | | | | | | | P01 | | | | | | | | | | | | | | | | P02 | | |!|P01=Yes|P02=No}}
{{familytree | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | |!| | | |!| | }}
{{familytree | | | | | | | | | | | | | | | Q01 | | | | | | | | | | | | | | | | Q02 | | |`|-|-|.|Q01=H/O of constipation|Q02=H/O of constipation}}
{{familytree | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | |,|-|-|-|^|-|-|-|.| | |!||}}
{{familytree | | | | | | | | | | |,|-|-|-|-|^|-|-|-|.| | | | | | | | | B01 | | | | | | B02 | |!|B01=No|B02=Yes|}}
{{familytree | | | | | | | | | | R01 | | | | | | | R02 | | | | | | | | |!| | | | | | | |!| | |!| R01=No|R02=Yes}}
{{familytree | | | | | | | | | | |!| | | | | | | | |!| | | | | | | | | C01 | | | | | | C02 | |!|C01=Weightloss|C02=Diverticulosis}}
{{familytree | | | | | | | | | | S01 | | | | | | | S02 | | | | |,|-|-|-|^|-|-|-|.| | | | | | |!|S01=Hemodynamic status|S02=Diverticulitis| }}
{{familytree | | | | | | | | | | |!| | | | | | | | | | | | | | D01 | | | | | | D02 | | | | | |!|D01=No|D02=Yes}}
{{familytree | | | | | | |,|-|-|-|^|-|-|-|.| | | | | | | | | | |!| | | | | | | |!| | | | | | |!|}}
{{familytree | | | | | | T01 | | | | | | T02 | | | | | | | | | E01 | | | | | | E02 | | | | | |!|T01=Stable|T02=Unstable|E01=Polyps|E02=Colon cancer}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |!|}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |,|-|-|-|'|}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |!| | | | |}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |,|-|-|-|^|-|-|-|-|.|}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |!| | | | | | | | |!| |}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | X01 | | | | | | | X02 |X01=No|X02=Yes}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |!| | | | | | | | |!| |}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | U01 | | | | | | | U02 |U01=Weight Loss|U02=Anal fissure<br> External Hemmrhoids}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | |,|-|-|-|-|^|-|-|-|-|.| |}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | |!| | | | | | | | | |!| }}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | C03 | | | | | | | | C04 |C03=Yes|C04=No|}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | |!| | | | | | | | | |!| | }}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | D01 | | | | | | | | D02 |D01=Rectal cancer<br>Colon cancer|D02=Angiodysplasia<br>Polyps }}
{{familytree/end}}
</div>
</small>
 
== Management ==
 
=== Hepatic adenoma ===
Management of hepatic adenoma depends upon:
* Symptoms
* Size
* Number
* Location
* Certainty of the diagnosis
 
==== '''Asymptomatic woman on OCPs with a small adenoma''' ====
The European Association for Study of the Liver recommends
* Discontinuation of contraceptive medication
* Close observation of the lesion with repeated imaging and alpha fetoprotein.
** Contrast-enhanced magnetic resonance imaging at a six month interval to determine if there is regression of a large adenoma to less than 5 cm.
* Patients with hepatic adenomas that do not resolve or that enlarge after six months of observation should undergo treatment.
 
==== Symptomatic patients and those with large adenomas ====
* Surgical resection is recommended for all symptomatic patients with hepatic adenoma and those with large lesions (>5 cm).
* Surgical options include :
** Enucleation
** Resection
** Liver transplantation
 
* Nonsurgical interventions include
** Transarterial embolization
** Radiofrequency ablation
 
=== Hepatic Hemangioma ===
* '''Asymptomatic patients'''
** Patients with lesions <1.5 cm, are reassured and observed.
** Follow-up imaging in patients with hemangiomas ≤5 cm in size is usually not recommended.
** Patients with rapid growth of a hemangioma  or with lesions >5 cm it is recommended to repeat imaging in 6 to 12 months.
** It is recommended not perform additional imaging if there is no change in the size of the lesion.  
* '''Symptomatic patients'''
** Patients who have pain or symptoms suggestive of extrinsic compression of adjacent structures should be considered for surgical options.
** Surgical options include 
*** Liver resection
*** Enucleation
*** Hepatic artery ligation
*** Liver transplantation
** Non-surgical techniques include
*** Hepatic artery embolization
*** Radiotherapy
*** Interferon alfa-2a 
 
=== Focal nodular hyperplasia ===
* Due to their benign nature of focal nodular hyperplasia, there is
 
* Follow-up studies at three and six months will often be sufficient to confirm the stability of the lesion and its benign nature, after which no long-term follow-up is required routinely.
* Surgery should be reserved for symptomatic FNH lesion.


==Pathophysiology==
===Anatomy===
*The spinal cord extends from the foramen magnum down to the level of the first and second lumbar vertebrae.
*At L2 level spinal cord transforms into spinal roots and forms a cone-shaped structure called conus medullaris.
*The cord is protected by the vertebral column, which is mobile and allows for movement of the spine.
*It is enclosed by the dura mater and the vessels supplying it.
*The cord floats in the cerebrospinal fluid which acts as a buffer to movement and early degrees of compression.
*The cord substance contains a gray area centrally and is surrounded by white matter communication tracts, both ascending and descending.
===Pathogenisis===
*The spinal cord and nerve roots depend on a constant blood supply to perform axonal signaling.
*Conditions that interfere, either directly or indirectly, with the blood supply will cause malfunction of the transmission pathway.
*Injury to the spinal cord or nerve roots arises from stretching or from pressure.
*It initiates a cascade of events in the gray matter and white matter, and results in hypoperfusion and eventually hemorrhagic necrosis.
*The extent of necrosis depends on the severity of the trauma, concomitant compression, perfusion pressures and blood flow, and administration of pharmacological agents.
*The tissue responses by gliosis, demyelination, and axonal loss.
*This results in injury to the white matter (myelinated tracts) and the gray matter (cell bodies) in the cord with loss of sensory reflexes (pinprick, joint position sense, vibration, hot/cold, pressure) and motor function.
*Rapid compression will result in the collapse of the venous system, resulting in vasogenic edema.
*Vasogenic edema exacerbates parenchymal pressure and may lead to rapid progression of dysfunction.
===Dissemination===
Hematogenous spread
===Genetic Factors===
===Associated conditions===
Lesions may develop gradually or acutely and be complete or incomplete. Incomplete lesions often present as distinct syndromes  as follows:
{| class="wikitable"
{| class="wikitable"
! colspan="2" |Parasitic Infection
! rowspan="2" |Mode of infection
!
!
!Sensory dysfunction
!Epidemiology
!Motor dysfunction
! rowspan="2" |'''Clinical manifestations''' 
!Sphincter dysfunction
! rowspan="2" |Diagnosis
! rowspan="2" |Treatment
|-
!Disease
!Parasite
!Incidence
!Geographic distrubution
|-
|-
|Central cord syndrome
|[[Ascariasis]]
|Sensory loss is very rare
|[[Ascaris lumbricoides|''Ascaris lumbricoides'']]
|Upper extremity weakness
|
distal muscles are involved more than proximal
* Ingestion of [[Ascaris infection|Ascaris]] eggs secreted in the feces of humans or pigs.<ref name="pmid10899534">{{cite journal| author=Permin A, Henningsen E, Murrell KD, Roepstorff A, Nansen P| title=Pigs become infected after ingestion of livers and lungs from chickens infected with Ascaris of pig origin. | journal=Int J Parasitol | year= 2000 | volume= 30 | issue= 7 | pages= 867-8 | pmid=10899534 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10899534 }}</ref>
* Ingesting uncooked pig or chicken liver with the larvae.
|
|
* Ascariasis affects at least 1 billion people worldwide and about 4 million people in the United States.<ref name="pmid24688073">{{cite journal| author=Betson M, Nejsum P, Bendall RP, Deb RM, Stothard JR| title=Molecular epidemiology of ascariasis: a global perspective on the transmission dynamics of Ascaris in people and pigs. | journal=J Infect Dis | year= 2014 | volume= 210 | issue= 6 | pages= 932-41 | pmid=24688073 | doi=10.1093/infdis/jiu193 | pmc=4136802 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24688073  }}</ref>
|
* Asia
* Africa
* South America
|
* [[Abdominal discomfort]]
* [[Anorexia]]
* [[Nausea and vomiting]]
* [[Diarrhea]]
* [[Intestinal obstruction]]
|
* [[Stool examination|Stool microscopy]]
* Peripheral [[eosinophilia]]
* [[Barium swallow]] 
|
* [[Albendazole]]
* [[Mebendazole]]
* [[Ivermectin]]
|-
|-
|Brown-Séquard syndrome
|[[Necatoriasis]]
|Ipsilateral position and vibration sense loss
| [[Necator americanus|''Necator americanus'']] 
Contralateral pain and temperature sensation loss
|Motor loss ipsilateral to cord lesion
|
|
* Skin contact
|
* Approximately 800 million people are infected with [[hookworms]] worldwide.<ref name="pmid28098526">{{cite journal| author=Bradbury RS, Hii SF, Harrington H, Speare R, Traub R| title=Ancylostoma ceylanicum Hookworm in the Solomon Islands. | journal=Emerg Infect Dis | year= 2017 | volume= 23 | issue= 2 | pages= 252-257 | pmid=28098526 | doi=10.3201/eid2302.160822 | pmc=5324822 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28098526  }}</ref>
|
* Brazil
* Texas
* Africa
* China
* Southwest Pacific islands
* India
* Southeast Asia
|
* '''Acute <ref name="pmid4451228">{{cite journal| author=Nawalinski TA, Schad GA| title=Arrested development in Ancylostoma duodenale: course of a self-induced infection in man. | journal=Am J Trop Med Hyg | year= 1974 | volume= 23 | issue= 5 | pages= 895-8 | pmid=4451228 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4451228  }}</ref>'''
** [[Nausea and vomiting|Nausea]] and  [[Nausea and vomiting|vomiting]]
** [[Diarrhea]]
** Epigastric pain
** Increased [[flatulence]] 
* '''Chronic<ref name="pmid28300694">{{cite journal| author=Chhabra P, Bhasin DK| title=Hookworm-Induced Obscure Overt Gastrointestinal Bleeding. | journal=Clin Gastroenterol Hepatol | year= 2017 | volume= 15 | issue= 11 | pages= e161-e162 | pmid=28300694 | doi=10.1016/j.cgh.2017.02.034 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28300694  }}</ref>'''
** [[Bloody stools]]
** [[Anemia]]
** [[Low birth weight|LBW]] in [[pregnant]] women
|
* Stool microscopy<ref name="pmid29016326">{{cite journal| author=McKenna ML, McAtee S, Bryan PE, Jeun R, Ward T, Kraus J et al.| title=Human Intestinal Parasite Burden and Poor Sanitation in Rural Alabama. | journal=Am J Trop Med Hyg | year= 2017 | volume= 97 | issue= 5 | pages= 1623-1628 | pmid=29016326 | doi=10.4269/ajtmh.17-0396 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29016326  }}</ref>
* Peripheral [[eosinophilia]]
|
* [[Albendazole]]
* [[Mebendazole]]<ref name="pmid1916173">{{cite journal| author=Genta RM, Woods KL| title=Endoscopic diagnosis of hookworm infection. | journal=Gastrointest Endosc | year= 1991 | volume= 37 | issue= 4 | pages= 476-8 | pmid=1916173 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1916173  }}</ref>
* [[Pyrantel pamoate]]<ref name="pmid27032297">{{cite journal| author=Serre-Delcor N, Treviño B, Monge B, Salvador F, Torrus D, Gutiérrez-Gutiérrez B et al.| title=Eosinophilia prevalence and related factors in travel and immigrants of the network +REDIVI. | journal=Enferm Infecc Microbiol Clin | year= 2017 | volume= 35 | issue= 10 | pages= 617-623 | pmid=27032297 | doi=10.1016/j.eimc.2016.02.024 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27032297  }}</ref>
|-
|-
|Anterior cord syndrome
|[[Giardiasis]]
|Loss of pin and touch sensation
|''[[Giardia lamblia]]''
|
* Ingestion of raw or undercooked food contaminated with [[cysts]].<ref name="pmid1500757">{{cite journal| author=Quick R, Paugh K, Addiss D, Kobayashi J, Baron R| title=Restaurant-associated outbreak of giardiasis. | journal=J Infect Dis | year= 1992 | volume= 166 | issue= 3 | pages= 673-6 | pmid=1500757 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1500757  }}</ref>
|
* Approximately, 15,223 cases were reported in the United States in 2012.<ref name="pmid23169940">{{cite journal| author=Muhsen K, Levine MM| title=A systematic review and meta-analysis of the association between Giardia lamblia and endemic pediatric diarrhea in developing countries. | journal=Clin Infect Dis | year= 2012 | volume= 55 Suppl 4 | issue=  | pages= S271-93 | pmid=23169940 | doi=10.1093/cid/cis762 | pmc=3502312 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23169940  }}</ref>
|
* Worldwide infection
* Among mountains hikers
|
* Asymptomatic<ref name="pmid6707812">{{cite journal| author=Pickering LK, Woodward WE, DuPont HL, Sullivan P| title=Occurrence of Giardia lamblia in children in day care centers. | journal=J Pediatr | year= 1984 | volume= 104 | issue= 4 | pages= 522-6 | pmid=6707812 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6707812  }}</ref>
* Acute
** [[Diarrhea]]
** [[Malaise]]
** [[Steatorrhea]]
** [[Abdominal cramps]]
** [[Bloating]]
** [[Nausea and vomiting|Nausea]]
** [[Weight loss]].
* Chronic
** Lose stools
** [[Malabsorption]]
** [[Steatorrhea]]
** [[Weight loss]]
** [[Fatigue]]
|
* Antigen detection assays 
** [[Fluorescein]]-tagged [[monoclonal antibodies]]
** Immunochromatographic assays<ref name="pmid8075266">{{cite journal| author=Lengerich EJ, Addiss DG, Juranek DD| title=Severe giardiasis in the United States. | journal=Clin Infect Dis | year= 1994 | volume= 18 | issue= 5 | pages= 760-3 | pmid=8075266 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8075266  }}</ref>
** [[ELISA test|Enzyme-linked immunosorbent assays]] 
* Nucleic acid amplification<ref name="pmid23711521">{{cite journal| author=Claas EC, Burnham CA, Mazzulli T, Templeton K, Topin F| title=Performance of the xTAG® gastrointestinal pathogen panel, a multiplex molecular assay for simultaneous detection of bacterial, viral, and parasitic causes of infectious gastroenteritis. | journal=J Microbiol Biotechnol | year= 2013 | volume= 23 | issue= 7 | pages= 1041-5 | pmid=23711521 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23711521  }}</ref>assays ([[NAAT]])
* [[Stool examination|Stool microscopy]]
|
* [[Tinidazole]]<ref name="pmid16507373">{{cite journal| author=Fung HB, Doan TL| title=Tinidazole: a nitroimidazole antiprotozoal agent. | journal=Clin Ther | year= 2005 | volume= 27 | issue= 12 | pages= 1859-84 | pmid=16507373 | doi=10.1016/j.clinthera.2005.12.012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16507373  }}</ref>
* [[Nitazoxanide]] 
|-
| [[Fasciolosis]] 
|''[[Fasciola hepatica|Fasciola Hepaticum]]''
|
|
|
* Central and South America
* Asia (China, Vietnam, Taiwan, Korea, and Thailand)
* Europe (Portugal, France, Spain, and Turkey)
* Africa
* The Middle East.
|
* Acute liver phase
** [[Fever]]
** [[Anorexia]]
** Nausea and [[vomiting]]
** [[Myalgia]]
** [[Cough]]
** Right upper quadrant pain
** [[Hematoma|Hematomas]] of the [[liver]]
** [[Jaundice]]
** [[Hepatomegaly]].<ref name="pmid2822181">{{cite journal| author=Chan CW, Lam SK| title=Diseases caused by liver flukes and cholangiocarcinoma. | journal=Baillieres Clin Gastroenterol | year= 1987 | volume= 1 | issue= 2 | pages= 297-318 | pmid=2822181 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2822181  }}</ref>
* Chronic [[biliary]] phase
** Asymptomatic<ref name="pmid18725803">{{cite journal| author=Marcos LA, Terashima A, Gotuzzo E| title=Update on hepatobiliary flukes: fascioliasis, opisthorchiasis and clonorchiasis. | journal=Curr Opin Infect Dis | year= 2008 | volume= 21 | issue= 5 | pages= 523-30 | pmid=18725803 | doi=10.1097/QCO.0b013e32830f9818 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18725803  }}</ref>
** [[Common bile duct]] obstruction
** [[Pancreatitis]]
|
* Microscopy<ref name="pmid1588869">{{cite journal| author=Prociv P, Walker JC, Whitby M| title=Human ectopic fascioliasis in Australia: first case reports. | journal=Med J Aust | year= 1992 | volume= 156 | issue= 5 | pages= 349-51 | pmid=1588869 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1588869  }}</ref>
** Stools
** Bile
** Duodenal aspiration


Vibration, position sense preserved
* Peripheral [[eosinophilia]] may disappear.<ref name="pmid22171131">{{cite journal| author=Kaya M, Beştaş R, Cetin S| title=Clinical presentation and management of Fasciola hepatica infection: single-center experience. | journal=World J Gastroenterol | year= 2011 | volume= 17 | issue= 44 | pages= 4899-904 | pmid=22171131 | doi=10.3748/wjg.v17.i44.4899 | pmc=3235633 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22171131  }}</ref>
|Motor loss or weakness below the level of compression
 
* Serology
**[[Hemagglutination assay|Indirect hemagglutination]]
**[[Complement fixation test|Complement fixation]]
**[[Enzyme linked immunosorbent assay (ELISA)|Enzyme-linked immunosorbent assay]]
|
|
* [[Triclabendazole]]
* [[Bithionol]]
* [[Nitazoxanide]]
|-
|-
|Transverse cord syndrome
|[[Schistosomiasis]]
|Loss of sensation below level of compression
|
|Loss of voluntary motor function below the level of compression
* ''[[Schistosoma mansoni|S. mansoni]]''
|Sphincter control lost
* ''[[Schistosoma japonicum|S. japonicum]]''
* ''[[Schistosoma haematobium|S. haematobium]]''
|
Infection can occur by:
* Penetration of the human skin by [[cercaria]]
* Handling of contaminated soil
* Consumption of contaminated water or food sources (e.g, unwashed garden vegetables)
|
* Approximately 200 million people are infected annually with 200,000 deaths per year.
|Sub-Saharan Africa.<ref name="pmid23041540">{{cite journal| author=Gower CM, Gouvras AN, Lamberton PH, Deol A, Shrivastava J, Mutombo PN et al.| title=Population genetic structure of Schistosoma mansoni and Schistosoma haematobium from across six sub-Saharan African countries: implications for epidemiology, evolution and control. | journal=Acta Trop | year= 2013 | volume= 128 | issue= 2 | pages= 261-74 | pmid=23041540 | doi=10.1016/j.actatropica.2012.09.014 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23041540  }}</ref>
|Acute schistosomiasis syndrome <ref name="pmid17488923">{{cite journal| author=Jauréguiberry S, Ansart S, Perez L, Danis M, Bricaire F, Caumes E| title=Acute neuroschistosomiasis: two cases associated with cerebral vasculitis. | journal=Am J Trop Med Hyg | year= 2007 | volume= 76 | issue= 5 | pages= 964-6 | pmid=17488923 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17488923  }}</ref>
* [[Fever]] and [[chills]]
* [[Urticaria]]
* [[Angioedema]]
* [[Myalgias]]
* [[Arthralgias]]
* Dry [[cough]]
* [[Diarrhea]]
* [[Abdominal pain]]
* [[Headache|Headache.]]<ref name="pmid8599059">{{cite journal| author=Rocha MO, Rocha RL, Pedroso ER, Greco DB, Ferreira CS, Lambertucci JR et al.| title=Pulmonary manifestations in the initial phase of schistosomiasis mansoni. | journal=Rev Inst Med Trop Sao Paulo | year= 1995 | volume= 37 | issue= 4 | pages= 311-8 | pmid=8599059 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8599059  }}</ref>
Chronic schistosomias<ref name="pmid8254164">{{cite journal| author=Lucey DR, Maguire JH| title=Schistosomiasis. | journal=Infect Dis Clin North Am | year= 1993 | volume= 7 | issue= 3 | pages= 635-53 | pmid=8254164 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8254164  }}</ref><ref name="pmid23465781">{{cite journal| author=Stothard JR, Sousa-Figueiredo JC, Betson M, Bustinduy A, Reinhard-Rupp J| title=Schistosomiasis in African infants and preschool children: let them now be treated! | journal=Trends Parasitol | year= 2013 | volume= 29 | issue= 4 | pages= 197-205 | pmid=23465781 | doi=10.1016/j.pt.2013.02.001 | pmc=3878762 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23465781  }}</ref><ref name="pmid16416239">{{cite journal| author=Gabbi C, Bertolotti M, Iori R, Rivasi F, Stanzani C, Maurantonio M et al.| title=Acute abdomen associated with schistosomiasis of the appendix. | journal=Dig Dis Sci | year= 2006 | volume= 51 | issue= 1 | pages= 215-7 | pmid=16416239 | doi=10.1007/s10620-006-3111-5 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16416239  }}</ref><ref name="pmid27521443">{{cite journal| author=Mu A, Fernandes I, Phillips D| title=A 57-Year-Old Woman With a Cecal Mass. | journal=Clin Infect Dis | year= 2016 | volume= 63 | issue= 5 | pages= 703-5 | pmid=27521443 | doi=10.1093/cid/ciw413 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27521443  }}</ref>
* Intestinal schistosomiasis
* Hepatosplenic schistosomiasis<ref name="pmid3124648">{{cite journal| author=Homeida M, Abdel-Gadir AF, Cheever AW, Bennett JL, Arbab BM, Ibrahium SZ et al.| title=Diagnosis of pathologically confirmed Symmers' periportal fibrosis by ultrasonography: a prospective blinded study. | journal=Am J Trop Med Hyg | year= 1988 | volume= 38 | issue= 1 | pages= 86-91 | pmid=3124648 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3124648  }}</ref><ref name="pmid10441577">{{cite journal| author=Dessein AJ, Hillaire D, Elwali NE, Marquet S, Mohamed-Ali Q, Mirghani A et al.| title=Severe hepatic fibrosis in Schistosoma mansoni infection is controlled by a major locus that is closely linked to the interferon-gamma receptor gene. | journal=Am J Hum Genet | year= 1999 | volume= 65 | issue= 3 | pages= 709-21 | pmid=10441577 | doi=10.1086/302526 | pmc=1377977 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10441577  }}</ref>
* Pulmonary schistosomiasis<ref name="pmid3722898">{{cite journal| author=Sarwat AK, Tag el Din MA, Bassiouni M, Ashmawi SS| title=Schistosomiasis of the lung. | journal=J Egypt Soc Parasitol | year= 1986 | volume= 16 | issue= 1 | pages= 359-66 | pmid=3722898 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3722898  }}</ref>
* Genitourinary schistosomiasis 
|
* Stool microscopy<ref name="pmid7042854">{{cite journal| author=Mahmoud AA| title=The ecology of eosinophils in schistosomiasis. | journal=J Infect Dis | year= 1982 | volume= 145 | issue= 5 | pages= 613-22 | pmid=7042854 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7042854  }}</ref>
* Serologic tests include:
**[[Hemagglutination|Indirect hemagglutination]]
**[[Complement fixation]]
**[[Enzyme-linked immunosorbent assay]]
**[[PCR]]
|
* [[Praziquantel]]<ref name="pmid24955523">{{cite journal| author=Cioli D, Pica-Mattoccia L, Basso A, Guidi A| title=Schistosomiasis control: praziquantel forever? | journal=Mol Biochem Parasitol | year= 2014 | volume= 195 | issue= 1 | pages= 23-9 | pmid=24955523 | doi=10.1016/j.molbiopara.2014.06.002 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24955523  }}</ref>
* [[Oxamniquine]]
|-
|-
|Conus medullaris syndrome
|Strongyloidiasis
| rowspan="2" |Saddle anesthesia
|[[Strongyloides|''Strongyloidis Stercoralis'']]
 
|
Sensory loss may range from patchy to complete transverse pattern
* Infection is contracted via direct contact with contaminated soil during agricultural, domestic, and recreational activities
| rowspan="2" |Weakness may be of upper motor neuron type
|
| rowspan="2" |Sphincter control impaired
* Approximately 30–100 million infected persons worldwide
|
* Tropical and subtropical regions
|
* Hyperinfection syndrome
**[[Fever]]
**[[Nausea and vomiting]]
**[[Anorexia]]
**[[Diarrhea]]
**[[Abdominal pain]]
**[[Dyspnea]]
**[[Wheeze|Wheezing]]
**[[Hemoptysis]]
**[[Cough]]
|
* Aspiration of duodenojejunal fluid is sometimes used to detect<ref name="pmid7036430">{{cite journal| author=Carroll SM, Karthigasu KT, Grove DI| title=Serodiagnosis of human strongyloidiasis by an enzyme-linked immunosorbent assay. | journal=Trans R Soc Trop Med Hyg | year= 1981 | volume= 75 | issue= 5 | pages= 706-9 | pmid=7036430 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7036430  }}</ref> 
* Stool microscopy
* PCR, ELISA
|
* [[Ivermectin]]<ref name="pmid11957127">{{cite journal| author=Zaha O, Hirata T, Kinjo F, Saito A, Fukuhara H| title=Efficacy of ivermectin for chronic strongyloidiasis: two single doses given 2 weeks apart. | journal=J Infect Chemother | year= 2002 | volume= 8 | issue= 1 | pages= 94-8 | pmid=11957127 | doi=10.1007/s101560200013 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11957127  }}</ref>
* [[Albendazole]]<ref name="pmid8483992">{{cite journal| author=Archibald LK, Beeching NJ, Gill GV, Bailey JW, Bell DR| title=Albendazole is effective treatment for chronic strongyloidiasis. | journal=Q J Med | year= 1993 | volume= 86 | issue= 3 | pages= 191-5 | pmid=8483992 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8483992  }}</ref>
|-
|-
|Cauda equina syndrome
|Amoebiais
|}
|''[[Entamoeba histolytica|E. Histolytica]]''
|
* Transmitted by the fecal-oral route through contaminated drinking water or food.
* Direct contact with infected individuals.
|
* Annual incidence of amoebiasis is approximately 50 million cases.<ref name="pmid17716437">{{cite journal| author=Valenzuela O, Morán P, Gómez A, Cordova K, Corrales N, Cardoza J et al.| title=Epidemiology of amoebic liver abscess in Mexico: the case of Sonora. | journal=Ann Trop Med Parasitol | year= 2007 | volume= 101 | issue= 6 | pages= 533-8 | pmid=17716437 | doi=10.1179/136485907X193851 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17716437  }}</ref><ref name="pmid17437396">{{cite journal| author=van Hal SJ, Stark DJ, Fotedar R, Marriott D, Ellis JT, Harkness JL| title=Amoebiasis: current status in Australia. | journal=Med J Aust | year= 2007 | volume= 186 | issue= 8 | pages= 412-6 | pmid=17437396 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17437396  }}</ref><ref name="pmid19540361">{{cite journal| author=Ximénez C, Morán P, Rojas L, Valadez A, Gómez A| title=Reassessment of the epidemiology of amebiasis: state of the art. | journal=Infect Genet Evol | year= 2009 | volume= 9 | issue= 6 | pages= 1023-32 | pmid=19540361 | doi=10.1016/j.meegid.2009.06.008 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19540361  }}</ref>
|
* India
* Africa
* Mexico
* Parts of Central and South America
|
* Asymptomatic
* Mild [[diarrhea]] to severe [[dysentery]].
* Fulminant amebic colitis.
* [[Weight loss]]
* [[Amebic dysentery]]
|
* Stool microscopy
* Antigen testing
* PCR
|


==Epidemiology and Demographics==
* [[Metronidazole]]
===Epidemiology===
* [[Tinidazole]] 
====Incidence====
*The annual incidence of spinal cord compression is estimated to be about 11,000 new cases/yr in the United States
*The worldwide incidence of spinal cord compression varies from 8 to 246 cases per million inhabitants per year.
====Prevelance====
*The global prevalence of spinal cord injury (SCI) has been reported to vary from 236 to 1,298 per million inhabitants.
*In United States the prevalence is estimated to be 171,000 persons.
===Demographics===
====Gender====
Spinal cord compression is more commonly seen in males than females
====Age====
It is more common in 40's
====Race====
No racial predilection


==Symptoms==
* [[Paromomycin]] 
Symptoms of spinal cord compression depends on the anatomic level involved in compression and can be discussed as follows
* [[Diloxanide furoate]] 
{| class="wikitable"
* [[Iodoquinol]] 
!Type of spinal
involvement
!Symptoms
|-
|-
|Cervical
|Taeniasis
|Headache
|
Neck, shoulder or arm pain
* ''[[Taenia saginata]]''  (beef [[Tapeworms|tapeworm]])


Loss of sensation over the upper extremities
* ''[[Taenia solium]]'', ( pork tapeworm).<ref name="pmid9798586">{{cite journal| author=Forrester JE, Bailar JC, Esrey SA, José MV, Castillejos BT, Ocampo G| title=Randomised trial of albendazole and pyrantel in symptomless trichuriasis in children. | journal=Lancet | year= 1998 | volume= 352 | issue= 9134 | pages= 1103-8 | pmid=9798586 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9798586  }}</ref>
|
* Consumption of undercooked beef
|
* Approximately 50 million human have cysticercosis.
|
* Europe
* Parts of Asia.
|
*Most human carriers are asymptomatic.
*Symptoms may include
*[[Nausea and vomiting|Nausea]]
*[[Anorexia]]
*[[Epigastric pain]]
|
* Stool microscopy


Motor weakness of neck, shoulder and arm
* Peripheral [[eosinophilia]]
* ELISA
* PCR
|
* [[Albendazole]]
|-
|-
|Thoracic
|Trichuriasis
|Pain in the chest and/or back
|''Trichuris trichiura''
Loss of sensation below the level of the compression
|
* Ingestion of [[Fertilised|embryonated]]<nowiki/>eggs from contaminated drinking water and food.
|
|
* [[Endemic (epidemiology)|Endemic]] in [[Tropical disease|tropical]] and subtropical countries.
*  Southern United States
* Incidence and prevalence rates are highest in children living in
** Sub-Saharan Africa
** Asia
** Latin America
** Caribbean
|
* Asymptomatic<ref name="pmid97985862">{{cite journal| author=Forrester JE, Bailar JC, Esrey SA, José MV, Castillejos BT, Ocampo G| title=Randomised trial of albendazole and pyrantel in symptomless trichuriasis in children. | journal=Lancet | year= 1998 | volume= 352 | issue= 9134 | pages= 1103-8 | pmid=9798586 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9798586  }}</ref>
* Loose stool which may contain [[mucus]] and [[blood]]
* Nocturnal stooling
* [[Rectal prolapse]]
|
* Stool microscopy
* [[Proctoscopy]]
** Demonstrates adult worms protruding from the bowel [[Mucous membrane|mucosa]].


Increased sensation above the level of the compression
* [[Eosinophilia]]
 
* [[Polymerase chain reaction]]
Muscle weakness
|
 
* [[Mebendazole]]<ref name="pmid6378109">{{cite journal| author=Rossignol JF, Maisonneuve H| title=Benzimidazoles in the treatment of trichuriasis: a review. | journal=Ann Trop Med Parasitol | year= 1984 | volume= 78 | issue= 2 | pages= 135-44 | pmid=6378109 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6378109  }}</ref>
Paralysis
** 500 mg PO q24h X 3 day '''(or)'''
 
** 100 mg PO q12h x 2 days
Positive Babinski reflex
* [[Albendazole]]<ref name="pmid21980373">{{cite journal| author=Steinmann P, Utzinger J, Du ZW, Jiang JY, Chen JX, Hattendorf J et al.| title=Efficacy of single-dose and triple-dose albendazole and mebendazole against soil-transmitted helminths and Taenia spp.: a randomized controlled trial. | journal=PLoS One | year= 2011 | volume= 6 | issue= 9 | pages= e25003 | pmid=21980373 | doi=10.1371/journal.pone.0025003 | pmc=3181256 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21980373  }}</ref>
 
** 400 mg POq24h
Bladder and bowel problems
 
Sexual dysfunction
|-
|-
|Lumbosacral
|Hymenolepiasis
|Low back pain that may radiate down the legs and/or perineal area
|''Hymenolepis nana''
Weakness in the legs and feet
|
 
* Ingestion of infected eggs
Loss of sensation in the legs and feet
|
 
|Most common in temperate zones<ref name="pmid19456836">{{cite journal| author=Utzinger J, Botero-Kleiven S, Castelli F, Chiodini PL, Edwards H, Köhler N et al.| title=Microscopic diagnosis of sodium acetate-acetic acid-formalin-fixed stool samples for helminths and intestinal protozoa: a comparison among European reference laboratories. | journal=Clin Microbiol Infect | year= 2010 | volume= 16 | issue= 3 | pages= 267-73 | pmid=19456836 | doi=10.1111/j.1469-0691.2009.02782.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19456836  }}</ref>
Bladder and bowel problems
* South Europe
 
* Russia
Sexual dysfunction
* India
 
* US
Foot drop
* Latin America.
 
|
Decreased or absent reflexes in the legs
* Asymptomatic<ref name="pmid26535513">{{cite journal| author=Muehlenbachs A, Bhatnagar J, Agudelo CA, Hidron A, Eberhard ML, Mathison BA et al.| title=Malignant Transformation of Hymenolepis nana in a Human Host. | journal=N Engl J Med | year= 2015 | volume= 373 | issue= 19 | pages= 1845-52 | pmid=26535513 | doi=10.1056/NEJMoa1505892 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26535513  }}</ref>
* Heavy infections with >1000 worms can occur
** Crampy [[abdominal pain]]
** Diarrhea
** Anorexia
** Fatigue
** Pruritus ani
|
* Stool microscopy
** FLOTAC method<ref name="pmid22461006">{{cite journal| author=Steinmann P, Cringoli G, Bruschi F, Matthys B, Lohourignon LK, Castagna B et al.| title=FLOTAC for the diagnosis of Hymenolepis spp. infection: proof-of-concept and comparing diagnostic accuracy with other methods. | journal=Parasitol Res | year= 2012 | volume= 111 | issue= 2 | pages= 749-54 | pmid=22461006 | doi=10.1007/s00436-012-2895-9 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22461006  }}</ref>
|
* [[Praziquantel]]<ref name="pmid23618773">{{cite journal| author=Ohnishi K, Sakamoto N, Kobayashi K, Iwabuchi S, Nakamura-Uchiyama F| title=Therapeutic effect of praziquantel against Taeniasis asiatica. | journal=Int J Infect Dis | year= 2013 | volume= 17 | issue= 8 | pages= e656-7 | pmid=23618773 | doi=10.1016/j.ijid.2013.02.028 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23618773  }}</ref>
* Prompt family screening or empiric treatment<ref name="pmid1980572">{{cite journal| author=Pawłowski ZS| title=Efficacy of low doses of praziquantel in taeniasis. | journal=Acta Trop | year= 1990 | volume= 48 | issue= 2 | pages= 83-8 | pmid=1980572 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1980572  }}</ref>
|}
|}
 
<references />
==Laboratory findings==
Spinal cord compression is diagnosed based on clinical history and imaging studies. Other lab studies like CBC, CSF, clotting studies and electrolyte exam helpful in excluding infection as a cause.
*CBC shows increased neutrophil count in cases of infection.
*[[ESR]] and [[CRP]] are elevated
*Blood and CSF cultures are positive in case of an epidural abscess or osteomyelitis.
*Tumor biopsy positive for malignant cells if compression of spinal cord is due to malignancy
*Urodynamic studies reveal reduced bladder contractility and sphincter dysfunction.
==X-ray spine==
*Patients with acute spinal cord injury should be immobilized with a cervical collar and backboard/head strap while imaging.
*Plain radiographs are useful in assessing mechanical stability of the spine in trauma cases.
*Multidetector CT with sagittal and coronal reconstructions is supplanting the role of plain radiographs, especially in the setting of multiple trauma.
*Plain x-ray film is indicated in all patients presenting with chronic back pain as a initial symptom, if nondiagnostic MRI is ordered.
==CT Spine==
*MRI and CT imaging are preferred diagnostic modalities in confirming the diagnosis
*CT spine is preferred for detection of spinal canal abnormalities.
*Anteroposterior, lateral, views are required to show alignment of bone structures.
==MRI Spine==
*MRI is the study of choice when there is incomplete paralysis or under other circumstances where direct visualization of neural or ligamentous structures is clinically necessary.
*MRI is the best imaging method for evaluation of neural tissue.
*MRI has largely replaced CT scanning in the noninvasive evaluation of patients with painful myelopathy because of its superior soft-tissue resolution and multiplanar capability.   
*Urgent MRI is recommended for all patients who have new-onset urinary symptoms with associated back pain or sciatica.
*Patients who present with a tumor history should undergo CT- or MRI-enhanced imaging. 
*Plain radiographs of the entire spine should then be performed, followed by CT or MRI with and without contrast enhancement.
*CT-guided biopsy of suspected tumors can confirm the diagnosis.
*Epidural abscess is best detected by MRI.
*CT guidance may also allow for surgical aspiration and diagnosis of infection or drainage of an epidural abscess.
==Treatment==
The main goal of treatment is
*To prevent clinical deterioration
*To relieve pain and symptoms
*To restore functional ability.
The following patient groups can be considered in the treatment approach:
*Patients with acute, traumatic SCI
*Patients with intervertebral disk compression (cauda equina syndrome)
*Patients with malignant spinal cord compression (SCC)
*Patients with epidural abscess (infection)

Latest revision as of 19:19, 1 March 2018


Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Lower gastrointestinal bleeding, commonly abbreviated LGIB, refers to any form of bleeding in the lower gastrointestinal tract.

Causes

Diagnosis

The following suggest an LGIB:

The following may suggest an LGIB:

Related Chapter

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Blood in stools
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Abdominal pain
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Fever
 
 
 
 
 
 
Rectal pain
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
H/O of constipation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
H/O of constipation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Weightloss
 
 
 
 
 
Diverticulosis
 
 
 
 
 
 
 
 
 
 
 
 
Hemodynamic status
 
 
 
 
 
 
Diverticulitis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Stable
 
 
 
 
 
Unstable
 
 
 
 
 
 
 
 
Polyps
 
 
 
 
 
Colon cancer
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Weight Loss
 
 
 
 
 
 
Anal fissure
External Hemmrhoids
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Rectal cancer
Colon cancer
 
 
 
 
 
 
 
Angiodysplasia
Polyps

Management

Hepatic adenoma

Management of hepatic adenoma depends upon:

  • Symptoms
  • Size
  • Number
  • Location
  • Certainty of the diagnosis

Asymptomatic woman on OCPs with a small adenoma

The European Association for Study of the Liver recommends

  • Discontinuation of contraceptive medication
  • Close observation of the lesion with repeated imaging and alpha fetoprotein.
    • Contrast-enhanced magnetic resonance imaging at a six month interval to determine if there is regression of a large adenoma to less than 5 cm.
  • Patients with hepatic adenomas that do not resolve or that enlarge after six months of observation should undergo treatment.

Symptomatic patients and those with large adenomas

  • Surgical resection is recommended for all symptomatic patients with hepatic adenoma and those with large lesions (>5 cm).
  • Surgical options include :
    • Enucleation
    • Resection
    • Liver transplantation
  • Nonsurgical interventions include
    • Transarterial embolization
    • Radiofrequency ablation

Hepatic Hemangioma

  • Asymptomatic patients
    • Patients with lesions <1.5 cm, are reassured and observed.
    • Follow-up imaging in patients with hemangiomas ≤5 cm in size is usually not recommended.
    • Patients with rapid growth of a hemangioma or with lesions >5 cm it is recommended to repeat imaging in 6 to 12 months.
    • It is recommended not perform additional imaging if there is no change in the size of the lesion.  
  • Symptomatic patients
    • Patients who have pain or symptoms suggestive of extrinsic compression of adjacent structures should be considered for surgical options.
    • Surgical options include 
      • Liver resection
      • Enucleation
      • Hepatic artery ligation
      • Liver transplantation
    • Non-surgical techniques include
      • Hepatic artery embolization
      • Radiotherapy
      • Interferon alfa-2a 

Focal nodular hyperplasia

  • Due to their benign nature of focal nodular hyperplasia, there is
  • Follow-up studies at three and six months will often be sufficient to confirm the stability of the lesion and its benign nature, after which no long-term follow-up is required routinely.
  • Surgery should be reserved for symptomatic FNH lesion.
Parasitic Infection Mode of infection Epidemiology Clinical manifestations  Diagnosis Treatment
Disease Parasite Incidence Geographic distrubution
Ascariasis Ascaris lumbricoides
  • Ingestion of Ascaris eggs secreted in the feces of humans or pigs.[1]
  • Ingesting uncooked pig or chicken liver with the larvae.
  • Ascariasis affects at least 1 billion people worldwide and about 4 million people in the United States.[2]
  • Asia
  • Africa
  • South America
Necatoriasis  Necator americanus 
  • Skin contact
  • Approximately 800 million people are infected with hookworms worldwide.[3]
  • Brazil
  • Texas
  • Africa
  • China
  • Southwest Pacific islands
  • India
  • Southeast Asia
Giardiasis Giardia lamblia
  • Ingestion of raw or undercooked food contaminated with cysts.[9]
  • Approximately, 15,223 cases were reported in the United States in 2012.[10]
  • Worldwide infection
  • Among mountains hikers
 Fasciolosis  Fasciola Hepaticum
  • Central and South America
  • Asia (China, Vietnam, Taiwan, Korea, and Thailand)
  • Europe (Portugal, France, Spain, and Turkey)
  • Africa
  • The Middle East.
  • Microscopy[17]
    • Stools
    • Bile
    • Duodenal aspiration
Schistosomiasis

Infection can occur by:

  • Penetration of the human skin by cercaria
  • Handling of contaminated soil
  • Consumption of contaminated water or food sources (e.g, unwashed garden vegetables)
  • Approximately 200 million people are infected annually with 200,000 deaths per year.
Sub-Saharan Africa.[19] Acute schistosomiasis syndrome [20]

Chronic schistosomias[22][23][24][25]

  • Intestinal schistosomiasis
  • Hepatosplenic schistosomiasis[26][27]
  • Pulmonary schistosomiasis[28]
  • Genitourinary schistosomiasis 
Strongyloidiasis Strongyloidis Stercoralis
  • Infection is contracted via direct contact with contaminated soil during agricultural, domestic, and recreational activities
  • Approximately 30–100 million infected persons worldwide
  • Tropical and subtropical regions
  • Aspiration of duodenojejunal fluid is sometimes used to detect[31] 
  • Stool microscopy
  • PCR, ELISA
Amoebiais E. Histolytica
  • Transmitted by the fecal-oral route through contaminated drinking water or food.
  • Direct contact with infected individuals.
  • Annual incidence of amoebiasis is approximately 50 million cases.[34][35][36]
  • India
  • Africa
  • Mexico
  • Parts of Central and South America
  • Stool microscopy
  • Antigen testing
  • PCR
Taeniasis
  • Consumption of undercooked beef
  • Approximately 50 million human have cysticercosis.
  • Europe
  • Parts of Asia.
  • Stool microscopy
Trichuriasis Trichuris trichiura
  • Ingestion of embryonatedeggs from contaminated drinking water and food.
  • Endemic in tropical and subtropical countries.
  •  Southern United States
  • Incidence and prevalence rates are highest in children living in
    • Sub-Saharan Africa
    • Asia
    • Latin America
    • Caribbean
  • Stool microscopy
  • Proctoscopy
    • Demonstrates adult worms protruding from the bowel mucosa.
Hymenolepiasis Hymenolepis nana
  • Ingestion of infected eggs
Most common in temperate zones[41]
  • South Europe
  • Russia
  • India
  • US
  • Latin America.
  • Asymptomatic[42]
  • Heavy infections with >1000 worms can occur
  • Stool microscopy
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