BMS304

Lecture No: 1
Title: Introduction and trematodes
parasites of small intestine
Prof. Khalifa E. Khalifa Medicine and Surgery Program
Spring 2024
By the end of this lecture, you should be able to:
1. List and categorize parasites affecting GIT including helminth and protozoan parasites.
2. Recognize the study objectives of GIT parasites including; geographical distribution, hosts,
life cycle, mode of infection, infective and diagnostic stages, clinical manifestations,
diagnosis, treatment, prevention and control.
3. Describe the general clinical manifestations of GIT parasitoses .
4. Apply the proper diagnostic measures for GIT parasites.
5. Outline the general preventive and control measures of GIT parasites.
6. List trematodes’ parasites of small intestine.
7. Describe life cycle, mode of infection, diagnostic stages of small intestinal trematodiases.
8. Discuss the clinical manifestations of small intestinal trematodiases.
9. Interpret the finding of case studies of small intestinal trematodiases.
10. Outline treatment and preventive measures of intestinal trematodiases.
Introduction
and Revision
Helminths
Character Trematoda Cestoda Nematoda
Shape Leaf-like, Tape-like, Cylindrical,
Unsegmented segmented unsegmented
Sex Hermaphrodites, Hermaphrodit Separate
except Schistosomes es (unisexual)
Suckers Present Present Absent
Body cavity Absent Absent Present
Alimentary Present, incomplete Absent Present,
canal without anus complete with
anus
Protozoa
Class Organ of locomotion
Sarcodina Pseudopodia: extension of the ectoplasm followed by extension of
“Rhizopoda” the endoplasm at any point on the surface, e.g. Amoebae.
Mastigophora Flagella: thread-like cytoplasmic extension that arise in the endoplasm
from a kinetostome, e.g., Giardia, Trichomonas, Leishmania, and
Trypanosoma.
Ciliophora Cilia: hair-like threads that cover the whole surface, they arise from
basal granules, just below the cell surface, e.g., Balantidium coli.
Apicomplexa No apparent motor organelles: but they move by gliding and
(Sporozoa) twisting, by means of contractile microtubules, e.g., Plasmodium,
Toxoplasma, and Cryptosporidium, Cyclospora, Cystoisospora.
GIT Parasites
•Parasites of Small Intestine
•Parasites of Large Intestine
•Parasites of Liver and Biliary Tract
Parasites of Small Intestine
Trematodes Heterophyes heterophyes
Metagonimus yokogawai
Fasciolopsis buski
Cestodes Diphyllobothrium latum
Taenia saginata -Taenia solium
Hymenolepis nana- Hymenolepis diminuta
Dipylidium caninum
Nematodes Ascaris lumbricoides
Toxocara canis (Visceral Larva Migrans)
Hookworms
Strongyloides stercoralis
Capillaria philippinensis
Protozoa Giarida lamblia
Cryptosporidium parvum
Cystoisospora belli
Parasites of Large Intestine
Trematodes Schistosomes:
Schsitosoma mansoni
Schistosoma japonicum
Nematodes Enterobius vermicularis
Trichocephalus trichiurus

Protozoa Entamoeba histolytica

Balantidium coli
Parasites of Liver and Biliary Tract
Trematodes Fasciola gigantica (Biliary tract)
Fasciola hepatica (Biliary tract)
Clonorchis sinensis (Biliary tract)
Schistosoma mansoni, Schistosoma japonicum (Portal circulation and
liver granuloma)
Cestodes Echinococcus granulosus
Echinococcus multilocularis

Nematodes Ascaris Lumbricoides (Cholangitis, Pancreatitis, Liver Abscess)

Toxocara canis (Visceral Larva Migrans)
Protozoa Entamoeba histolytica (Amoebic Liver Abscess, Liver tissue)
Leishmania donovani (macrophage-phagocytic system)
Toxoplasma gondii (macrophage-phagocytic system, and liver tissue)
Trypanosma cruzi (macrophage-phagocytic system)
Study Objectives of GIT Parasites
▪ Geographical distribution
▪ Morphology
▪ Definitive host (DH): Carries adult stages or sexually reproducing forms.
▪ Intermediate host (IH): Carries larval stages or asexually reproducing forms.
▪ Reservoir host (RH): Carries the same parasite as DH, maintains the life cycle in nature and
act as a source of repassing infection to man.
▪ Habitat: Small intestine, large intestine, blood vessels (schistosomes), liver, bile duct
▪ Life cycle: Direct (monoxenous) or indirect (needs more than one hosts for completion of life
cycle (heteroxenous)
▪ Mode of infection: ingestion of contaminated food or drink, skin penetration.
▪ Infective stage: Egg, larva stage, cyst, oocyst.
▪ Diagnostic stage: Egg, larva stage, trophozoite, cyst, oocyst.
Study Objectives of GIT Parasites (cont.)
▪ Pathology and Clinical Manifestations: abdominal pain, nausea, vomiting, diarrhea,
dysentery, anemia, allergic manifestations, vitamins deficiency, intestinal obstruction, rectal
prolapse, pressure symptoms, other complications, etc.
▪ Diagnosis
- Clinical: Symptoms and signs
- Parasitological: repeated stool examination, stool concentration, stool culture, staining
techniques.
- Immunological: detection of antibodies or antigens by ELISA, IFAT
- Molecular: detection of parasites’ DNA by PCR.
- Imaging: X ray, CT, MRI, endoscopy
▪ Treatment: mostly, GIT trematodes and cestodes are treated with praziquantel, nematodes
are treated with albendazole, and protozoa are treated with metronidazole
▪ Prevention and Control: TTT of patients; Safe food and drinks and water supplies, and cut
source of infection
Study Objectives of GIT Parasites

Parasite Disease
1. Habitat 1. Epidemiology
2. Pathogenesis
2. Morphology
3. Clinical manifestations
3. DH, IH, RH 4. Diagnosis
4. Life cycle • Clinical
• Infective stage • Laboratory
• Imaging
• Mode of infection 5. Treatment
• Diagnostic stage 6.Prevention and Control
PARASITES OF SMALL INTESTINE
TREMATODS
General Characters of Trematodes
• Body is flattened unsegmented, except female
schistosomes (cylindrical).
• No body cavity.
• Digestive system is simple, no anus
• Organs of fixation in the form of suckers (oral,
ventral).
• Hermaphrodites except schistosomes.
• All trematodes need a snail intermediate host, so
part of the life cycle occurs in water (indirect life
cycle or heteroxenous).
Developmental Stages of Trematodes

Egg All eggs are operculated except those

of Schistosomes

Miracidium

Sporocyst
Absent in Schistosomes
Redia

Cercaria is formed of a body and a tail, the latter may

Cercaria be simple (leptocercus cercaria), surrounded by a
membrane (lophocercus) or forked (furcocercus).
Heterophyes heterophes
“Heterophyiasis”
• Distribution: Egypt (Nile Delta around Borolos and
Manzala lakes), Middle East, Far East
• Habitat: Small intestine, embedded between
villi.
• DH: Man, and fish-eating animals (dogs and
cats).
• IH: It requires two IH
1st: Brackish water snail (Pirenella conica) ,
2nd: Tilapia (Bolty) and Mugil (Boury) fish.
• RH: Dogs and cats.
Morphology
Pear-shaped,
unsegmented, 1-
1.7 mm, it has
three suckers: oral,
ventral and genital,
simple intestinal
caeca, one
spherical ovary
and 2 oval testes
beside each other
in the posterior
part. Vit. glands on
both sides of post.
half.
Heterophyes adult embedded in intestinal mucosa
Life Cycle of Heterophyes heterophyes
Mode of
infection

DH

IH
Intermediate hosts of Heterophyes heterophyes

1st: Pirenella conica 2nd: Fish

Encysted metacercaria in fish muscles (infective stage)
• Infective stage: Encysted metacercaria
• Mode of infection: Man acquires the infection by ingestion of
the encysted metacercaria (infective
stage) in insufficiently cooked or salted fish.
• Diagnostic stage: Eggs in stool
• Pathogenesis and clinical manifestations of heterophyiasis
1. Light infection: asymptomatic.
2. Heavy infection: inflammation of the intestinal mucosa where
adult attach, resulting in chronic intermittent mucous diarrhea,
abdominal pain.
3. Occasionally, egg emboli (due to the presence of genital sucker and
the small size of the eggs) may pass through the mesenteric
lymphatics and blood vessels to the heart, brain causing serious
complications
• Diagnosis of heterophyiasis
1. Clinical: abdominal pain and diarrhoea with a history of eating
insufficiently cooked or salted fish especially after Eastern or in a
patient coming from an endemic area.
2. Laboratory: finding the characteristic egg in repeated stool
examination by direct smear or after stool concentration.
• Treatment: Praziquantel
• Prevention and control
1. Proper diagnosis and treatment of patients.
2. Avoidance of eating insufficiently cooked or grilled fish.
3. Avoidance of feeding dogs and cats with raw fish especially in
endemic areas.
4. Snail control by molluscicides.
Heterophyes heterophyes Egg (diagnostic stage)

Shape : Oval
Shell: Thick
Size: 30 x 15 µm
Color: Yellow
Content: mature
Character: Operculated
A case study of heterophyiasis
A 33-year-old fisherman from Borolls area presented to the
hospital complaining of abdominal pain and diarrhea of 2
weeks duration. On examination the patient had slight abdominal
tenderness. As a fisherman, he used to eat semi-grilled fish while
in fishing trips. Stool examination revealed small operculated 30
x 15 µm eggs. Provisional diagnosis of heterophyiasis was done
for which the patient was treated with praziquantel. The patient
get improved and was advised not to eat improperly cooked or
salted fish.
Metagonimus yokogawi
“Metagonimiasis”
• Distribution: Far East. Russia, Spain
• Habitat: Small intestine, embedded between villi.
• DH: Man, and fish-eating animals (dogs, cats, pigs).
• IH: It requires two IH
1st: Fresh water snail (Semisulcospira libertine),
2nd: Cyprinoid and Salmon fish.
• RH: Dogs and cats.
• Life cycle, infective stage, diagnostic stage, clinical manifestations,
diagnosis and treatment as Heterophyes heterophyes.
Morphology
Pear-shaped,
unsegmented, 1-1.2
mm, it has two
suckers: oral ands
ventral sucker, the
latter is displaced to
one side. No genital
sucker. Simple
intestinal caeca, one
spherical ovary and 2
oval obliquely situated
testes posterior part.
Fasciolopsis buski
“Fasciolopsiasis”
• Distribution: Far East.
• Habitat: Small intestine, attached to intestinal mucosa.
• DH: Man.
• IH: Fresh water snail (Segmentina)
• RH: Pigs.
• Morphology: Largest intestinal trematode, 4-7 cm x1.5, ovate
body ventral sucker is larger than oral sucker
with simple wavy intestinal caeca. One branched
ovary in the middle of the body and 2 branched
testes in the posterior half with long cirrus sac.
Morphology
Ovate unsegmented4-7
x 1.5 cm it has two
suckers: oral and larger
basket shaped ventral
sucker. 2 simple wavy
intestinal caeca, one
branched ovary in the
middle and 2 branched
testes in front each
other in the post. Half,
Vit, glands along the
lateral field
Life Cycle of Fasciolopsis buski Mode of
infection

DH
IH
• Infective stage: Encysted metacercaria
• Mode of infection: Man acquires the infection by ingestion of
the encysted metacercaria (infective
stage) on raw or undercooked water plants.
• Diagnostic stage: Eggs in stool
• Pathogenesis and clinical manifestations of fasciolopsiasis
1. Light infection: asymptomatic or mild bouts of abdominal pain and
diarrhea due to inflammation and ulceration of intestinal mucosa
2. Heavy infection: severe inflammation and ulceration of mucosa
with toxic metabolites absorption leading to diarrhea, nausea,
vomiting, protein losing enteropathy.
3. Complication: hypoalbuminemia, fascial and generalized edema,
ascites, vitamin B12 deficiency, anemia, malnutrition, allergic
manifestations. Intestinal obstruction may occur.
• Diagnosis of fasciolopsiasis
1. Clinical: abdominal pain and diarrhea with a history of eating raw
aquatic plants patient coming from an endemic area.
2. Parasitological: finding the characteristic egg in repeated stool
examination by direct smear or after stool concentration.
3. Complete blood count CBC: eosinophilia and megaloblastic anemia
• Treatment: Praziquantel + ttt of hypoalbuminemia and anemia
• Prevention and control
1. Proper diagnosis and treatment of patients.
2. Avoidance of eating insufficiently cooked water plants.
3. Avoidance of using human and pig feces for fertilization of water
plants.
4. Snail control by molluscicides.
Fasciolopsis buski egg (diagnostic stage)

Shape : Oval
Shell: Thick
Size: 150 x 70 µm
Color: Yellow
Content: immature
Character: Operculated
In class assessment
A) Give Reason:
1. Cases of heterophyasis increase after Eastern
2. Cases of heterophyiasis is prevalent around Borolos and Manzala
lakes rather than around Naser’s lake south Egypt.
3. Cases of fasciolopsiasis may present by generalized edema.
B) Discuss the clinical manifestations of a small intestinal trematode
parasite prevalent in Egypt?
References:
1. Markell and Voge's Medical Parasitology: by John , Petri (Elsevier;
10th edition).
2. Diagnostic Medical Parasitology: by Garcia (American Society for
Microbiology; 6th edition, 2016).
3. Textbook of Medical Parasitology: by CK Jayaram Paniker (Jaypee; 8th
edition, 2017)
4. Human Parasites: Diagnosis, treatment, prevention: By Melhorn
(Springer, 2016)
THANK YOU