Radiology

Pictorial Essay Australasian Radiology (2007) 51, 500–506

Imaging of ascariasis
CJ Das,1 J Kumar,2 J Debnath3 and A Chaudhry1
1
Department of Radiodiagnosis, All India Institute of Medical Sciences, 2Department of Radiodiagnosis, Maulana Azad Medical College
and Associated Hospitals, New Delhi and 3Department of Radiodiagnosis, Command Hospital (SC), Pune, India

SUMMARY

Ascaris lumbricoides is one of the most common parasitic infestations of the gastrointestinal tract worldwide. Dur-ing the
intestinal phase of the disease, the adult worms usually remain clinically silent, sometimes causing a variety of non-
specific abdominal symptoms. When present in large numbers, the worms may get intertwined into a bolus, causing
intestinal obstruction, volvulus or even perforation. Occasionally, the adult Ascaris worm may migrate into the Vater’s
ampulla and enter the bile duct, gall bladder or pancreatic duct, leading to a variety of complications such as biliary colic,
gallstone formation, cholecystitis, pyogenic cholangitis, liver abscess and pancreatitis. Imaging plays a significant role in
showing the presence of worms and possible complications in intestinal as well as hepa-tobiliary ascariasis. This pictorial
essay aims to illustrate various imaging features of ascariasis and its associated complications.

Key words: ascariasis; computed tomography; magnetic resonance imaging; ultrasonography.

INTRODUCTION
Ascaris lumbricoides is the most common helminthic
infestation affecting human race. At any given time,
approximately 25% of the world’s population is infested with
A. lumbricoides.1 The incidence of ascariasis is greatest
where warm temperature and high humidity allow the eggs to
embryonate throughout the year. Overpopulation, poor
sanitation and inadequate sew-age disposal play a key role in
the maintenance and propaga-tion of ascariasis. Children are
much more commonly and severely infected than adults.2
LIFE CYCLE
A human being acquires ascariasis by ingesting food, water or
soil contaminated with embryonated eggs (Fig. 1). Following
ingestion of the hatched eggs, larvae are released in the duo-
denum. The larvae migrate through the duodenal wall into the
bloodstream and then to the pulmonary circulation. They enter
the alveoli, pass up to the bronchi and trachea and are swal-
lowed again to reach the small intestine. Within the small intes-
tine, they become adults. Thousands of eggs laid daily are
passed in faeces, which contaminate the soil. Ingestion of
embryonated eggs completes the cycle.3
DIAGNOSIS
Definitive diagnosis of ascariasis depends on the
identification of the adult worms passed through the anus or
any other body orifice or identification of the eggs of A.
lumbricoides in the stool, vomitus, sputum or small bowel
aspirate under a micro-scope. Imaging plays a vital role in the
diagnosis of intestinal as well as hepatobiliary ascariasis as
the appearance of adult worm within the intestinal lumen and
hepatobiliary tree is characteristic.
Ascaris pneumonia
The pulmonary involvement is suspected in patients presenting
with fever and cough with eosinophilia and is confirmed by
identifying larvae in the sputum. Chest radiography and high
resolution CT show ground-glass attenuation (Fig. 2) because

CJ Das MD, DNB; J Kumar MD, DNB; J Debnath MD; A Chaudhry MD, DNB.
Correspondence: Dr Chandan Jyoti Das, Department of Radiology, All India Institute of Medical Science, 8/39, New Delhi 110029, India.
Email: dascj@yahoo.com
Conflict of interest: None.
Submitted 17 March 2006; accepted 20 December 2006.
doi: 10.1111/j.1440-1673.2007.01887.x

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IMAGING OF ASCARIASIS 501

Fig. 1. The life cycle of Ascaris lumbricoides.

of patchy alveolar infiltrates that characteristically clear within

10 days. Lobar consolidation and alveolar haemorrhage have
also been described.4

Intestinal ascariasis
During the intestinal phase of ascariasis, most patients are
asymptomatic and only a few patients experience non-specific Fig. 3. Barium meal follow through showing Ascaris within the jejunal
symptoms such as nausea, vomiting, vague abdominal discom- loop, seen as elongated filling defect.

fort, colicky pain and diarrhoea. However, when aggregated,

ascarids may form a bolus and cause intestinal obstruction,
volvulus or even intestinal perforation. Radiological appearan-ces
of intestinal A lumbricoides infestation and associated com-
plications have been described for plain radiography, barium
examinations, ultrasonography (US) and CT scan.2,5–7
Plain radiography of abdomen may be normal when the
ascarids are few in number. In case of heavy infestation, the
aggregated ascarids may be seen as a tangled group of thick
cords contrasted against the bowel gas.

Fig. 2. (a) Chest radiograph shows

areas of ground-glass opacity in the
right midzones and lower zones. (b)
High-resolution CT axial section shows
areas of ground-glass attenuation that
corres-ponds to the findings in ‘a’.

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502
Fig. 4. Barium meal follow through showing an Ascaris in the jejunal loop.
The worm shows ingested barium within its alimentary tract (arrow).
Fig. 5. Barium study showing clumps of ascarids are seen as filling
defects in the small bowel of a 6-year-old child.
On barium study, the ascarids appear as elongated, smooth,
cylindrical and often coiled radiolucent filling defects within the
barium-filled intestinal lumen (Fig. 3). Mostly, they are found in
the jejunum and ileum. In a fasting patient, Ascaris
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CJ DAS ET AL.
Fig. 6. With a high-frequency transducer, (a) the Ascaris (arrow) is seen as
four parallel echogenic lines on the longitudinal ultrasonography scan. (b)
The outer two lines (thick arrows) are the outline of the worm and the inner
two lines (thin arrows) are the worm gut. The same is seen on the
transverse section as a rounded structure.
Fig. 7. (a) Axial CT image showing linear filling defects within the
small bowel (arrow). (b) Section taken at lower level than ‘a’, showing
multiple nodular filling defects in the small bowel (black arrow).
Ingested barium is also seen in few of these worms (white arrow).
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IMAGING OF ASCARIASIS
Fig. 8. The CT image showing clumps of ascarids inside the small
bowel (white arrow) in a heavily infested child. Ascarids are seen as
nodular filling defect (black arrows).
may ingest barium, thereby outlining its alimentary canal as a
central thin white line (Fig. 4). In heavily infested individuals,
especially children, clumps of ascarids may be seen filling up
the lumen of the small bowel (Fig. 5).
Real-time US is also a good method to see the intestinal
worms. Mahmood et al.5 described, in detail, the sonographic
appearance of intestinal ascariasis in a series of 84 patients.
Sonographic findings depend on the orientation of the worm
relative to the probe, resolution of the transducer, presence or
absence of fluid around the worm, part of the worm imaged
(head or body) and whether the worm is dead or alive. When
using a relatively low-frequency transducer (@3.5–3.7 MHz),
the body of the worm shows two parallel echogenic lines sep-
Fig. 9. MRCP half Fournier acquisition turbo spin echo coronal image
shows hypointense, elongated tubular filling defect (arrow) against
hyperintense intestinal fluid.
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503
Fig. 10. Ultrasonography showing long echogenic structure with cen-
tral longitudinal echogenic tube (representing alimentary canal of the
Ascaris), without acoustic shadowing within the common bile duct.
arated by an anechoic central area representing fluid-filled ali-
mentary tract of the worm. This appearance is known as
‘triple line’ sign.8 On using a high-frequency transducer (@7.5
MHz), the body of the worm shows four parallel thin
echogenic lines on longitudinal US scan. The outer two lines
are the outline of the worm and the inner two lines are the
worm gut (Fig. 6). During the act of swallowing of intestinal
fluid by the worm, the anechoic alimentary canal becomes
transiently echogenic, which can be appreciated on real-time
scanning. Sometimes, active movements of the worm can be
seen during real-time scanning.
On CT, worms are seen as elongated or rounded (depend-ing
on the orientation of the worm) filling defects in the contrast filled
lumen of the intestine (Fig. 7). Occasionally, a trace of contrast
may be seen within the gut of the worm.7 Sometimes, especially
in heavily infested children, clumps of ascarids may
Fig. 11. Ultrasonography showing an Ascaris in the left hepatic duct as
long echogenic structure (small arrow). In addition, thickened gall
bladder wall (thick arrow) is also noted.
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Fig. 13. Ultrasonography showing an ascarid within the pancreatic

Fig. 12. Ultrasonography showing a curved structure in the gall blad-
der (arrow), with echogenic parallel lines enclosing an anechoic tube
within, representing the alimentary tract of the Ascaris (triple line
sign).
duct as echogenic parallel lines (arrow).
ascarid appears as a hypointense, elongated tubular filling defect
against the hyperintense intestinal fluid on half Fournier
acquisition turbo spin echo (HASTE) sequence (Fig. 9).

be seen inside the small bowel (Fig. 8). Axial CT images Hepatobiliary ascariasis
usually show small sections of the worm in multiple images. Biliary ascariasis is common in certain geographical areas of the
With the advent of multidetector CT and excellent multiplanar world endemic for ascariasis, like India. 9 During the late intestinal
recon-structions, worms may be seen in their entire length. phase of the parasite, especially in children, the adult worm may
However, CT is not the diagnostic imaging method of choice. enter the common bile duct (CBD), producing acute
The MRI appearance of hepatobiliary ascariasis has been uncomplicated biliary ascariasis. Once the worm gains entry
well described. However, no study has been carried out on the through the Vater’s ampulla, it may migrate into the CBD, hepatic
MRI imaging characteristics of intestinal ascariasis. Intestinal ducts, gall bladder and even pancreatic duct, resulting

Fig. 14. (a) Magnetic resonance imag-ing

turbo spin echo T1-weighted axial image
showing isointense Ascaris inside the
common bile duct (arrow). (b) The Ascaris
is hypointense (arrow) on T2-weighted
image surrounded by hyperin-tense bile,
which is distinctly different from the bile
flow artefact. In addition, thickened gall
bladder wall as a result of acute
cholecystitis is also noted (thick arrow). (c)
Coronal half Fournier acqui-sition turbo
spin echo image showing elongated filling
defect within the com-mon bile duct and
duodenum (small arrows). (d) Coronal
MRCP image show-ing a worm in the
duodenum (arrow) with thickened gall
bladder wall as a result of acute
cholecystitis (thick arrow).

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IMAGING OF ASCARIASIS 505

in various manifestations of hepatobiliary ascariasis like biliary

colic, recurrent pyogenic cholangitis, cholecystitis, pancreatitis,
hepatic abscesses and even septicaemia. 2,10 Once inside the bile
duct, normally the worm migrates back into the duodenum within
a period ranging from 24 h to 2 weeks.1,11
Biliary ascariasis does not have any characteristic labora-
tory and clinical features. Hence imaging, especially US,
plays an important role in the diagnosis by morphological
identifica-tion of the parasite within the biliary tree.
Ultrasonography is a simple, rapid, accurate and non-invasive
method for diagnosis and follow up of patients with hepatobiliary
ascariasis. The US imaging features of a worm in the bile duct
are similar to those of it in the small bowel. It is seen as a long
echogenic structure with central longitudinal echogenic tube
(representing alimentary canal of the Ascaris), without acoustic
shadowing within the CBD (Fig. 10). Khuroo et al. 12 described the
sonographic findings in 28 patients of biliary ascariasis as follows:
(i) dilatation of bile duct; (ii) presence of long, linear or curved
echogenic structures in bile duct; (iii) characteristic movements
shown by these echogenic structures in the bile duct; (iv) gall
bladder distension, oedema of the gall bladder wall or presence
of sludge within the gall bladder; (v) multiple liver abscesses; (vi)
oedematous pancreatitis; and (vii) normal sonographic
appearance. Ultrasonography can identify more than 85% of
cases of biliary ascariasis. All cases with two or more worms
within the bile duct show characteristic sono-graphic findings.
However, with a single worm in the bile duct, the diagnosis may
be missed in 50% cases. 12 Rarely, worms may be seen within the
intrahepatic biliary tree (Fig. 11), gall bladder (Fig. 12) and even
within the pancreatic duct (Fig. 13). Ultrasonography is not only
the imaging method of choice in the diagnosis of biliary
ascariasis, but also commonly used to monitor the spontaneous
exit of worms from the bile duct.
The role of CT scan is usually complementary as it can be
used to show the worms inside the bile ducts and more
import-antly to depict the extent of possible complications like
cholan-gitis and hepatic abscesses. On non-contrast CT, the
worms appear as relatively hyperattenuating tubular
structures sur-rounded by less attenuating bile. The worm
within the dilated bile duct may give rise to a ‘bulls-eye’
appearance on trans-verse section.13
The MRI features of biliary ascariasis have been scarcely
documented. The worm within the biliary tree appears as iso-
intense structures on turbo spin echo T1-weighted images and
hypointense on T2-weighted images (Fig. 14a,b).14,15 At mag-netic
resonance cholangiopancreatography (MRCP), especially on
coronal oblique HASTE images, the worm appears as elon-gated
filling defect within the CBD against the background of Fig. 15. (a) Endoscopic retrograde cholangiopancreatography show-
hyperintense bile (Fig. 14c). Occasionally, the fluid-filled diges- ing biliary Ascaris as linear filling defect in the common bile duct. (b)
The Ascaris was removed by endoscopy.
tive tract may cause hyperintensity inside the worm on T2-
weighted and MRCP images.15 Like US and CT, MRI also can
show presence of Ascaris in the intrahepatic biliary tree and

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 506
associated changes in the liver and gall bladder. Biliary Ascaris
can cause acute cholecystitis (Fig. 14b,d). Magnetic resonance
imaging can also suggest the possibility of intrapancreatic asca-
riasis. MRCP provides 3-D maximum intensity projection of the
biliary tree resembling endoscopic retrograde cholangiopan-
creatography (ERCP), without the risks of invasiveness and
iodine contrast allergy. MRCP has become a unique non-inva-
sive technique for showing ascariasis in the biliary tree clearly
and has the potential to replace ERCP in situations where
immediate endoscopic worm removal is not indicated.15
Endoscopic retrograde cholangiopancreatography is a
very useful diagnostic tool to delineate worms in the biliary
tree. With the advent of high-resolution US, CT scan and
MRI, the use of ERCP for diagnostic purpose has rapidly
declined. Besides being invasive, ERCP is often difficult to be
carried out in a sick patient. At ERCP, biliary Ascaris appears
as a linear filling defect (Fig. 15a). At present, ERCP is
reserved for already diag-nosed cases in which an
endoscopic removal of worms is attempted (Fig. 15b) or for
those cases when US is technically inadequate.
CONCLUSION
Ascariasis is the commonest parasitic infestation of human race.
Clinical manifestations of ascariasis are often vague and non-
specific. Morphological identification of Ascaris by vari-ous
imaging methods helps in the diagnosis as well as follow up. For
intestinal ascariasis, the mainstay of diagnosis is barium studies
and US. Computed tomography scan and MRI can sup-plement
barium and US studies. Ultrasonography is the imag-ing method
of choice for diagnosis as well as follow up of hepatobiliary
ascariasis. Computed tomography scan is valu-able in showing
the extent of possible complications of biliary ascariasis.
Magnetic resonance imaging and MRCP with 3-D MIP of the
biliary tree are excellent non-invasive means of showing biliary
ascariasis. Endoscopic retrograde cholangio-pancreatography
may be mainly used for endoscopic removal of worms in an
already diagnosed case.
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ACKNOWLEDGEMENT
We thank Mr Kalyan Bania MSc, geologist at GAIL India Ltd,
New Delhi, for his help in preparation of this manuscript.
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