J Med Ultrasonics (2006) 33:55–59
DOI 10.1007/s10396-005-0068-5
EDUCATIONAL NOTE
Nasima AKHTER · S.M. Moinul ISLAM
Saiyeeda MAHMOOD · Gazi Abul HOSSAIN
Ratan Kumar CHAKRABORTY
Prevalence of biliary ascariasis and its relation to biliary lithiasis
Received: April 15, 2005 / Accepted: July 25, 2005
Abstract Hepatobiliary ultrasound was carried out on 2224
consecutive patients at the Center for Nuclear Medicine
and Ultrasound and at one private diagnostic center in
Mymensingh for ultrasound examination of different
systems. The purpose of this study was to investigate the
prevalence of biliary ascariasis and its association with other
biliary diseases, specially biliary lithiasis. Data regarding the
presence of stone, worm or other diseases were recorded
accordingly in this prospective study. There were 952 male
and 1272 female patients with an age range of 5–90 years.
Biliary diseases were detected in 305 patients (13.71%), of
whom 97 were male (10.19%) and 208 were female
(16.35%). The most common biliary disease in both sexes
was cholelithiasis (11.87%), which was found in 84 male
patients (8.82%) and in 180 female patients (14.15%).
Other diseases found were choledocholithiasis in 14
patients (3 males, 11 females), gall bladder mass in 9
patients (3 males, 6 females), common bile duct mass in
7 patients (4 male, 3 female) and biliary ascariasis in 10
patients (3 male, 7 female). Overall prevalence of biliary
ascariasis was 0.45% ( 0.31% in male patients and 0.55% in
female patients), and age range of patients with the condi-
tion was 6–50 years. No case of biliary ascariasis was asso-
ciated with cholelithiasis or choledocholithiasis. Acute
cholecystitis was associated with 8 cases (80%) of biliary
ascariasis. Common sonographic findings in patients with
biliary ascariasis were a single long, linear or curved
echogenic structure within the bile duct, without acoustic
shadowing. Other findings were gall bladder distention with
sludge inside, an edematous wall and mildly dilated biliary
tree. Prevalence of biliary ascariasis in the study was 0.45%,
N. Akhter (*)
Center for Nuclear Medicine and Ultrasound, Dhaka Medical
College Hospital Campus, 158, Ramna, Dhaka-1000, Bangladesh
Tel. +81-76-221-0598; Fax +81-76-234-4257
e-mail: drnasimaakhter@yahoo.com
S.M.M. Islam · S. Mahmood · G.A. Hossain · R.K. Chakraborty
Center For Nuclear Medicine and Ultrasound, Mymensingh Medical
College Hospital Campus, Mymensingh, Bangladesh
© The Japan Society of Ultrasonics in Medicine 2006
with incidence being higher in female subjects (0.55%). No
correlation was found between biliary ascariasis and biliary
lithiasis. Most of the cases of biliary ascariasis were associ-
ated with acute cholecystitis. We concluded that a careful
search for biliary ascariasis should be considered for
patients with acute acalculus cholecystitis, especially in
areas in which ascariasis is endemic, such as Bangladesh.
Keywords acute cholecystitis · biliary ascariasis · cholelithi-
asis · ultrasonogram
Introduction
Ascariasis is a globally distributed helminthic infection, with
more than 1.4 billion people infected throughout the world.
The majority of infections occur in the developing countries
of Asia and Latin America. Of the 4 million people infected
in the United States, a large percentage are immigrants from
developing countries. Ascaris-related clinical disease occurs
in people with heavy worm loads: an estimated 1.2 to 2
million such cases, with 20,000 associated deaths, occur in
endemic areas every year. Ascariasis is a frequent cause of
biliary and pancreatic disease in endemic areas. It occurs in
adult women and can cause biliary colic, acute cholecystitis,
acute cholangitis, acute pancreatitis, hepatic abscess, and
recurrent pyogenic cholangitis.1–4 Ultrasonography, com-
puted tomography (CT), and magnetic resonance imaging
(MRI) are important not only in the diagnosis of parasitic
biliary diseases but also in follow-up and surveillance.5,6
Ultrasonography is a rapid and simple noninvasive proce-
dure that is very effective for the visualization of the worm
in the biliary tree and the follow-up of infected patients.6–9
Characteristic signs of biliary ascariasis in ultrasonography
are the “strip sign,”10 “spaghetti sign,”10 and “inner tube
sign”10,11 in longitudinal sections, and the “bull’s eye in the
triple O”10,12 in transverse sections. Using real-time ultra-
sonographic scanning, the motility of the worms in the
biliary tract can be confirmed, in addition to the character-
istic morphology.9 Onset of biliary lithiasis is related to
56

nutritional, infectious, and parasitic factors. Ascariasis may Table 1. Age distribution of patients with biliary disease
play a determinant role in lithogenesis. There are several Age of patients Male Female
published reports regarding biliary lithiasis secondary s
to infestation with biliary ascariasis, and also the coexis- Normal Biliary Normal Biliary
tence of lithiasis and ascariasis in the biliary tree.13–22 To pathology pathology
our knowledge, there are no reports evaluating the rela- 0–10 28 1 28 2
tion between biliary ascariasis and biliary lithiasis in 11–20 102 6 99 8
Bangladesh. The aim of the present study was to investigate 21–30 169 13 321 51
the prevalence of biliary ascariasis and to determine if there 31–40 187 21 287 56
41–50 149 17 206 49
is any association between biliary ascariasis and other 51–60 116 26 40 28
biliary pathologies, especially biliary lithiasis. 61–70 73 7 46 11
71–80 24 6 7 3
81–90 7 0 0 0
Total 855 97 1064 208
Materials and methods

The subjects were consecutively selected from patients with

or without biliary symptoms who came to the Center for Table 2. Biliary diseases according to sex
Nuclear Medicine and Ultrasound (CNMU), Mymensingh,
Biliary pathology Male Female Total
or to a private diagnostic center in Mymensingh for ultra-
sound evaluation of the upper or whole abdomen. After Cholelithiasis 82 180 262
giving their verbal consent, each patient underwent ultra- Choledocholithiasis 3 11 14
sound examination of the hepatobiliary system. The main Gallbladder mass 3 6 9
Common bile duct mass 4 3 7
aim of the present study was to ascertain the prevalence of Acalculus cholecystitis 2 1 3
biliary ascariasis and to determine if there was any associ- Biliary ascariasis 3 7 10
ation with other biliary diseases, especially biliary lithiasis. Total 97 208 305
Each subject was examined by one or two experienced
sonologists from the CNMU (the authors of the present
paper), and by one sonologist in the private diagnostic
center (N. A.). A Sonoline SL 2 high-resolution real-time detected in 47 patients (17 male, 30 female) and acalculus
ultrasound (Siemens, Sonoline center, Franken, Germany) cholecystitis in 3 patients (2 male, 1 female). The prevalence
was used for this evaluation in the CNMU and a Just Vision of biliary ascariasis was 0.45% (0.31% in male patients and
400 (Toshiba, Tokyo, Japan) machine was used in the private 0.55% in female patients), and the age range of patients
center. The Sonoline machine was equipped with a 3.5-MHz with the condition was 6–50 years (Table 3). No case of
mechanical sector and 3.5-MHz linear array probes; the biliary ascariasis was associated with cholelithiasis or chole-
Toshiba machine was equipped with a 3.5-MHz convex docholithiasis. Acute cholecystitis was associated with eight
probe. Hepatobiliary ultrasound was performed in the cases (80%) and mild CBD dilatation with 7 cases (70%) of
supine and left lateral decubitus positions. Ultrasound find- biliary ascariasis. Common sonographic findings in patients
ings for all patients were recorded on a predesigned data with biliary ascariasis were single or multiple long, linear,
collection sheet. The presence of worms inside the biliary or curved echogenic structures within the bile duct or
tree was diagnosed by using the characteristic sonographic gallbladder, without acoustic shadowing. Other associated
features as described in the literature.8,10 sonographic findings were gallbladder distention, edema of
the gallbladder wall, sludge inside the gallbladder and a
mildly dilated biliary tree (Figs. 1–5).
Results

Between January 2002 and December 2003, 2224 patients Discussion

were enrolled in the present study (952 male, 1272 female).
The age range of the patients was 5–90 years (Table 1).
Biliary disease was detected in 305 patients (13.71%), of
whom 97 were male (10.19%) and 208 were female
(16.35%). The most common biliary disease in both sexes
was cholelithiasis (11.87%) (Table 2), which was found in
84 male patients (8.82%) and in 180 female patients
(14.15%). Other diseases found were choledocholithiasis in
14 patients (3 male, 11 female), gallbladder mass in 9
patients (3 male, 6 female), common bile duct (CBD) mass
in 7 patients (4 male, 3 female) and biliary ascariasis in 10
patients (3 male, 7 female). Calculus cholecystitis was
Ascariasis is the most common intestinal helminthiasis
worldwide. Heavily infected individuals are prone to
develop bowel obstruction or perforation, as well as biliary
disease. In areas where ascariasis is endemic, biliary com-
plications are common.1,2 In a study carried out in 1983 in
northern Bangladesh, the prevalence of ascariasis was 68%
among children aged between 6 months and 15 years. In
another study, carried out in 1999–2000 in the northern part
of Bangladesh on children between 5 and 13 years of age,
the prevalence rate of ascariasis was 36.2% after they used
a sanitary latrine and received health education for 4 years.