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Year : 2019  |  Volume : 63  |  Issue : 1  |  Page : 89-90  

Toddy consumption and amoebic liver abscess in India: An unexplored link

1 Associate Professor, Department of Gastroenterology, All India Institute of Medical Sciences, Patna, Bihar, India
2 Additional Professor, Department of Radiodiagnosis, All India Institute of Medical Sciences, Patna, Bihar, India
3 Associate Professor, Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Patna, Bihar, India

Date of Web Publication12-Mar-2019

Correspondence Address:
Dr. Ramesh Kumar
Department of Gastroenterology, All India Institute of Medical Sciences, Patna, Bihar
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijph.IJPH_192_18

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How to cite this article:
Kumar R, Priyadarshi RN, Anand U. Toddy consumption and amoebic liver abscess in India: An unexplored link. Indian J Public Health 2019;63:89-90

How to cite this URL:
Kumar R, Priyadarshi RN, Anand U. Toddy consumption and amoebic liver abscess in India: An unexplored link. Indian J Public Health [serial online] 2019 [cited 2022 May 24];63:89-90. Available from:


Amoebic liver abscess (ALA) is the most common manifestation of invasive amoebiasis caused by Entamoeba histolytica (EH). Several studies from India have reported a strong link between consumption of toddy and the occurrences of ALA.[1],[2],[3] Toddy is a local alcoholic beverage consisting of fermented palm juice. It is commonly consumed by people belonging to low socioeconomic groups of rural India. According to the National Sample Survey Office consumption 2011–2012 data, toddy was the most commonly consumed alcoholic beverage by rural India. The data also revealed that Andhra Pradesh, Assam, Bihar, Jharkhand, Arunachal Pradesh, and Kerala were among the biggest toddy - drinking states of India. Furthermore, asymptomatic amebiasis is prevalent in India because of poor sanitation. In a study from India, examining 1260 fecal samples using DNA dot blot assay, 13.7% tested positive for EH.[4] Thus, the burden of amoebiasis and toddy consumption is considerable in India.

In early 90s, Hai et al. reported that 85% of 220 ALA patients had a history of significant consumption of toddy.[1] Furthermore, the incidence of ALA was highest during the toddy season. In another study from Bihar, where 80% of 95 ALA patients were toddy consumer, toddy drinkers had larger size of abscesses, greater complication rates, and delayed resolution of abscess.[2] In a recent study, Priyadarshi et al. have found that 95% of 117 patients with ruptured ALA had a history of toddy consumption.[3] A study published from Sri Lanka has also revealed a strong association between toddy consumption (79.2%) and ALA (n = 346).[5]

The association between toddy consumption and ALA has been described; however, this has never been explored comprehensively in the context of mechanistic pathogenesis. Because toddy is prepared and stored in unhygienic condition and consumers are usually economically poor, malnourished, and have an unhealthy lifestyle, the chances of parasitic contamination, transmission and infection remain high with toddy consumption. However Kannathasan et al. have failed to demonstrate EH cyst or trophozoites in toddy samples, refuting the presumption of toddy being source of amoebic infection.[5] Toddy might create some environmental changes in the gut of individuals with asymptomatic amoebiasis which in turn switch the pre-existing latent EH to virulence. Toddy could increase the virulence of EH by upregulating its alcohol dehydrogenase enzymes, causing intestinal dysbiosis and increasing intestinal permeability. Makkar et al. have suggested that high iron content of traditional fermented beverages and iron overload due to chronic alcoholism may predispose patients to invasive amoebiasis, leading to ALA.[6] A high parasitic burden due to poor sanitation and immunosuppressive effects of alcohol could render the host more vulnerable to invasive amoebiasis. Thus, both the host factors as well as contents of toddy may be responsible for the increased EH virulence. Although further studies would be required to establish a causal relationship between for toddy and ALA, the association appears to be strong, consistent, biologically plausible, and have a good temporal relationship. In addition, creating greater awareness about this association would be helpful to prevent the occurrence of ALA in amoebiasis endemic regions.

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   References Top

Hai AA, Singh A, Mittal VK, Karan GC. Amoebic liver abscess. Review of 220 cases. Int Surg 1991;76:81-3.  Back to cited text no. 1
Sinha CM. A retrospective study of amoebic liver abscess in North and East Bihar. Int J Sci Res 2017;6:122-3.  Back to cited text no. 2
Priyadarshi RN, Prakash V, Anand U, Kumar P, Jha AK, Kumar R. Ultrasound-guided percutaneous catheter drainage of various types of ruptured amebic liver abscess: A report of 117 cases from a highly endemic zone of India. Abdom Radiol (NY). 2018. doi: 10.1007/s00261-018-1810-y.  Back to cited text no. 3
Nath J, Ghosh SK, Singha B, Paul J. Molecular epidemiology of amoebiasis: A cross-sectional study among North East Indian population. PLoS Negl Trop Dis 2015;9:e0004225.  Back to cited text no. 4
Kannathasan S, Murugananthan A, Kumanan T, de Silva NR, Rajeshkannan N, Haque R, et al. Epidemiology and factors associated with amoebic liver abscess in Northern Sri Lanka. BMC Public Health 2018;18:118.  Back to cited text no. 5
Makkar RP, Sachdev GK, Malhotra V. Alcohol consumption, hepatic iron load and the risk of amoebic liver abscess: A case-control study. Intern Med 2003;42:644-9.  Back to cited text no. 6

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