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Oswal, et al.: Hepato-biliary ascariasis

worms into the biliary tree is a well-known complication,


which may result in biliary colic, cholecystitis, cholangitis,
intrahepatic abscesses or pancreatitis.[4] After cholelithiasis,
it is the second most common cause of acute biliary
symptoms worldwide.[7]

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There is evidence to suggest that sphincterotomy predisposes


a patient to biliary ascariasis. Jaundice and elevated liver
enzyme may occur. The diagnosis is established by means
of microscopic identication of A lumbricoides eggs in fecal
samples. An A lumbricoides worm occasionally is identied
in stool or vomitus.[6] USG readily depicts the worm in the
bile ducts or gallbladder.[7,8] Mebendazole (three days of
twice daily oral therapy) or albendazole (a single oral dose
of medication) are the treatments of choice.[6]

Figure 3: Ascariasis. USG image of the porta hepatis shows a thick


echogenic stripe (arrows), with a central anechoic tube (black arrowhead) within the slightly dilated common hepatic duct - inner-tube
sign

References
1.

Cerri GG, Leite GJ, Simoes JB, Correia Da Rocha DJ, Albuquerque
FP, Machado MC, et al. Ultrasonographic evaluation of Ascaris in
the biliary tract. Radiology 1983;146:753-4.

duct, but no tumor has an appearance that simulates the


long, well-dened, tubular, constant-diameter, intraluminal
abnormality surrounded by bile that is present in this
case.[3,5]

2.

Schulman A, Loxton TA, Heydenrych JJ, Abdurahman EK. Sonographic diagnosis of biliary ascariasis. AJR Am J Roentgenol
1982;139:485-9.

3.

Bude RO, Bowerman RA. Biliary ascariasis. Radiology 2000;214:8447.

A lumbricoides infects approximately 1 billion people


worldwide.[6] It is distributed throughout the tropics and
subtropics and is also present in other humid regions such
as the rural southeastern United States.[6]

4.

Suri A, Bhatia M, Chander BN, Chaturvedi A. Images: Hepatobiliary ascariasis. Indian J Radiol Imaging 2002;12:221-3.

5.

Robledo R, Muro A, Prieto ML. Extrahepatic bile duct carcinoma:


US characteristics and accuracy in demonstration of tumors. Radiology 1996;198:869-73.

6.

Liu LX, Weller PF. Intestinal nematodes. In: Fauci AS, Braunwald
E, Isselbacher KJ, et al, editors. Harrisons principles of internal
medicine. 15th ed. McGraw-Hill: New York, NY; 1998. p. 1208-9.

7.

Mani S, Merchant H, Sachdev R, Rananavare R, Cunha N.


Sonographic evaluation of biliary ascariasis. Australas Radiol
1997;41:204-6.

8.

Khuroo MS, Zargar SA, Mahajan R. Hepatobiliary and pancreatic


ascariasis in India. Lancet 1990;335:1503-6.

The human infection life cycle begins by ingestion of an


egg, with the larvae hatching in the small intestine. The
larvae invade the small-bowel mucosa, migrate through the
circulatory system to the lungs, invade the alveoli, ascend
the tracheobronchial tree and then are swallowed into the
small intestine where they mature into adult worms.[6]
Ascarids may reach 40 cm in length with a width of 3-6 mm.
Intestinal infestation is often asymptomatic. Migration of

Th

Source of Support: Nil, Conflict of Interest: None declared.

COMMENTARY

Hepatobiliary ascariasis
Omar Shah

Dept. of Surgical Gastroenterology, SKIMS, Srinagar, Kashmir, India. E-mail: omarjshah@yahoo.com.

The authors [1,2] of the two articles in this issue have


demonstrated nicely that, using ultrasonography (USG),
radiologists can make a diagnosis of hepato-biliary
ascariasis.
Indian J Radiol Imaging / May 2007 / Vol 17 / Issue 2
78 CMYK

Ascaroids have a tendency to explore small openings


and once they are in the duodenum, enter the ampullary
orice, leading to biliary ascariasis. The worms may nd
their way into the ramications of the intrahepatic ducts,
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Shah Omar, et al.: Hepato-biliary ascariasis

especially those of the left lobe of liver. The liberated ova


either dead or live, as well as the disintegrated worms
provoke a non-specic foreign body reaction leading to
formation of chronic granulomatous lesions in the liver
parenchyma. Secondary infection of these lesions leads to
the development of hepatic abscesses. In a study conducted
by our group over a period of 10 years on 510 patients,
75 (14.5%) patients presented with liver abscess that was
causally related to ascariasis.[3]

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The inner tube or the double tube sign is due to the


visualization of the hypoechoic alimentary canal of the
parasite containing uid and possibly due to the adjacent
extra-intestinal fat. In case the digestive tract is collapsed
or contains air, it appears as a hyperechogenic line [Figure
1]. Sometimes due to incomplete distension, the central
lumen may not appear as an uninterrupted line. Rarely four
echogenic lines may be visible, the inner two representing
the walls of the distended intestinal tract [Figure 2].

Th

Thus, the USG appearance of the parasite is fairly typical


and an experienced sonologist especially in an endemic
area can make a condent diagnosis. USG is the imaging
modality of choice, as it is inexpensive, accurate, safe and
non-invasive. Besides being quick it has can be used along
the bedside of an acutely ill patient, to monitor the progress
of medical treatment and during pregnancy.[4] The authors[1]
have clearly demonstrated the echogenic non-shadowing
tubular structure with a relatively hypoechoic center
and echogenic walls. Besides various signs already welldescribed by the authors, worms may look like hyperechoic
pseudotumors, if densely packed within the duct. The
coexisting USG features may include dilatation of the bile
ducts, distention of the gall-bladder with edematous walls,
biliary calculi, swollen pancreas and liver abscess.

Figure 2: Sonogram of the gallbladder showing an edematous,distended


gall-bladder with an echogenic ribbon-like structure without acoustic
shadow, exhibiting a double tube sign corresponding to the digestive
apparatus of the worm.

False positive diagnoses may arise rarely when vague


echoes are observed in the bile duct due to blooming of
its wall or due to reverberations from more anterior tissue
interfaces. A curvilinear, angulated main duct along with
the proper hepatic artery and adjacent tissue interfaces
may mimic a strip or spaghetti sign. For a strip sign
to be positive, an unequivocal length of the main bile duct
lumen needs to be seen. Further, the spaghetti sign also
needs to be in a clear-cut intra-luminal situation within the
main bile duct.
False negative results may occur if the strip sign is not
recognized in an undilated main bile duct or if the duct
lumen is concealed due to its replacement by the spaghetti
appearance. Use of dynamic and static scanning with higher
resolution may minimize this. CT scan has a limited role in
biliary ascariasis, though it is of immense value in patients
having liver and pancreatic involvement. MRCP though
an excellent modality, is not cost-eective in developing
countries where the prevalence of ascariasis is quite high.
We recommend USG as the ideal imaging tool for the
diagnosis of biliary ascariasis. ERCP should be reserved
for suspected cases of biliary ascariasis in whom USG is
technically inadequate, is non-diagnostic or an endoscopic
therapeutic biliary procedure is planned [Figures 3, 4].

Figure 1: Hepatic sonogram showing an abscess cavity (black arrow)


with a ribbon-like hyperechogenic structure, representing a roundworm,
without acoustic shadowing (white arrow).
79

Ascariasis related acute pancreatitis is rarely seen and thus


adequate description of this clinical entity is lacking. This
is probably due to the narrowness of the pancreatic duct,
which hinders worm migration. We believe that in cases of
Indian J Radiol Imaging / May 2007 / Vol 17 / Issue 2
79 CMYK

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Shah Omar, et al.: Hepato-biliary ascariasis

Figure 3: Ballon occlusion ERCP revealing a linear filling defect due


to a roundworm, in the right hepatic duct (arrow).

Figure 4: Post-endoscopic extraction ERCP.

anomalous insertion of the pancreatic duct, such a separate


insertion may allow equal opportunity to the worm to
enter either the common bile duct or the pancreatic duct.
However, worm-induced pancreatitis may also occur due to
other mechanisms, such as a worm blocking the pancreatic
duct in biliary ascariasis or worm invasion of the pancreatic
duct as well as the bile duct.

pancreas are made. ERCP is not only an excellent modality


for diagnosis but also has a major therapeutic role. Upon
endoscopic removal of the worms from the pancreatic duct,
rapid relief of symptoms is usually noted.

1.

Oswal K, Agarwal A. Images: Hepato-biliary ascariasis. Indian J


Radiol Imaging 2007;17:(in current issue).

2.

Rajagopal KV, Vayalakshmi Devi B. Quiz: Pancreatic ascariasis.


Indian J Radiol Imaging 2007;17:(in current issue).

3.

Javid G, Wani NA, Gulzar GM, Khan BA, Shah AH, Shah OJ, et
al. Ascaris induced liver abscess. World J Surg 1999;23:1191-4.

4.

Shah OJ, Robanni I, Khan F, Zargar SA, Javid G. Management of


biliary ascariasis in pregnancy. World J Surg 2005;29:1294-8.

Source of Support: Nil, Conflict of Interest: None declared.

Th

Mild pancreatitis is observed in patients with isolated


pancreatic ascariasis. This is possibly due to incomplete
blockage of the duct of Wirsung and a patent Santorinis
duct. The combined biliary and pancreatic ascariasis
burden is usually severe in such situations and may be
associated with a high mortality. USG has a restricted role
in diagnosing pancreatic ascariasis due to its high false
negative rate. In our experience, delineation of the worm
in the pancreatic duct may be missed unless there is a
high index of suspicious and careful transverse scans of

References

Indian J Radiol Imaging / May 2007 / Vol 17 / Issue 2


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