1976
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FEBRUARY,
BILIARY By
B. J. CREMIN
ASCARIASIS F.R.A.C.R.,
IN
CHILDREN
F.R.C.R.,* and R. M. FISHER, CAPE TOWN, SOUTH AFRICA
M.B.,
CH.B.,
D.M.D.R.t
ABSTRACT:
The ascaris is a common human parasite and has a world wide distribution. In areas where it is endemic, biliary complications are common. In our locality it occurs mainly in children, presenting with upper abdominal colicky pain usually without jaundice. We have analyzed the positive roentgenological findings of 67 cases which presented in one year. The findings on cholangiography are diagnostic. The worm is seen as a linear translucent filling defect in a dilated common bile duct. Usually it is only faintly outlined by thin tram lines and occasionally there may not be excretion of the contrast material. The attention of radiologists is brought to this condition and the appearances of ascariasis infestation of the intestines are also noted.
T
HE
( five
coides)
(o.
percent)
cases
(0.5
giant round worm (Ascaris lumbrithrives in a moist warm climate. It is particularly prevalent in Africa and the Far East 5,7,10,11,17 and is endemic unless efficient closed sewerage systems are utilized. In Africa it has been conservatively estimated that 6o million people harbor the parasite.5 The definitive hosts are man and the pig, and in man the adult ascarids mainly inhabit the small intestine.5’13 Their reproduction rate is formidable and the gravid female may lay up to 200,000 ova per day.’ The hardy ova can remain viable for many years, so that children are particularly liable to repeated infection from contaminated vegetables, water, and soil. In Africa, massive ascariasis in children is a common form of intestinal obstruction.5’10” The peak incidence of infestation is between four and eight years and at the Red Cross Children’s Hospital, Cape Town, Louw,” in 974, reported that during the period 1958 through 1974, 528 cases of acute abdominal conditions were caused or complicated by ascariasis. They constituted 10-I 5 percent of all acute abdominal emergencies and were second in frequency only to acute appendicitis. The breakdown of complications in these 528 cases was 351 cases (66 percent) of intestinal obstruction, 148 (25 percent) biliary lesions, 25 cases S
Professor
t
Senior
and Specialist,
Chairman, Red
Department Cross
Children’s
of Radiology, Hospital,
Groote Cape
Town,
percent)
of
pancreatitis,
of acute percent)
two
appendicitis,
cases
and
of primary
two
peritonitis.
At
t
FIG.
I.
Intravenous
cholangiogram,
40
minute
roent-
genogram, ascaris (black arrows) in a dilated common bile duct (white arrow). There is also a worm (arrowhead) in the right hepatic duct.
Schuur South 352
and Africa.
Red
Cross
Children’s
Hospitals,
Cape
Town,
South
Africa.
126,
VOL.
No.
Biliary
2
Downloaded from www.ajronline.org by Zeitschriftenabteilung/Med. on 04/20/15 from IP address 134.176.129.147. Copyright ARRS. For personal use only; all rights reserved
MATERIAL
AND
Ascariasis
in Children
353
METHOD
An analysis of the roentgenologic records cases referred from both medical and surgical services during the five year period, ‘968 through 3972, showed positive intravenous cholangiographic evidence of biliary ascariasis in I 54 cases. After we became more aware of the severity of this problem, the intravenous cholangiograms in children under twelve years of age from all service departments during the year i 974 were reviewed. There were i 26 cases referred because of possible biliary ascariasis. Fifty-nine were considered normal. Sixty-one (48 percent) showed a worm present in the ccmmon bile duct. Six (four percent) demonstrated nonfunction, which in conjunction with other clinical or roentgenological evidence of ascariasis infestation, was taken as positive evidence. Therefore a total of 52. percent of the children referred with colicky right upper abdominal pain showed roentgenological evidence of ascariasis. The sex incidence was approximately equal, and the cases of
consisted
of
five
European,
seven
African
and 6 of mixed parentage. It should be noted that less than ten percent of the children attending this hospital are European. All the proved cases had acute colicky
FIG.
2. Intravenous
genogram, common ent
in
cholangiogram,
40
minute
worm (black arrow) seen bile duct. Contrast material calyces
of
kidney
(white
arrowheads).
in
roent-
a dilated
is also
4 J ury.
..
FIG.
3. Intravenouscholangiogram,
genogram
mon
twelve
bile
is absent.
40
days
rant
minute
pain,
tenderness,
gallbladder
and
was
right
upper
vomiting.
present
A
in
roent-
a dilated
shows
duct (white arrow) but now No renal excretion was noted.
abdominal
upper
later,
‘I
25
the
comworm
quadpalpable
percent
of
cases.
Cholangiography intravenous infusion cent
iodipamide
five
percent
by
given
was performed by an consisting of o permeglumine* in o ml of a dextrose solution. This was
intravenous
drip
infusion
over
a
This method showed better results and was less likely to cause vomiting than a simple intravenous injection. Apart from nausea no complications were encountered. Roentgenograms were taken in the I 5#{176} prone oblique position at 20 minute intervals. A worm was usually seen as a large lucent filling defect contamed inside a dilated common bile duct (Fig. i). Identification in many cases was not always so obvious and a more frequent appearance was two parallel lines of contrast material outlining the worm (unfortunately too faint to reproduce photographically). Tomography was used only if the appearances were equivocal after the 40 minute film. With experience this was not usually necessary. The worms were frequently multiple and sometimes were also present in the major intrahepatic ducts. When a dilated duct containing a worm was period
of
ten
minutes.
forte
(Schering
presS
Biligrafin
A. G.)
20
ml
ampule.
Downloaded from www.ajronline.org by Zeitschriftenabteilung/Med. on 04/20/15 from IP address 134.176.129.147. Copyright ARRS. For personal use only; all rights reserved
J.
B.
354
Cremin
and
.,
.-
FIG.
4.
Intravenous
control
is seen
in
roentgenogram.
the biliary
Gas
tree.
seen, medical treatment was instituted and the intravenous cholangiogram repeated after one week. With successful treatment, the worm disappeared, although the duct frequently remained dilated (Fig. 2; and 3).
Fic.
g.
Barium
cholangiogram arrows) in the
meal
taken
during
demonstrating first part of the
an
intravenous
ascariasis duodenum.
(black
R.
M.
Fisher
FEBRUARY,
1976
In cases with a partial blockage of the duct by a worm, it was commonly noted that there was a more marked excretion of contrast material by the kidneys (Fig. 2) than when the worm had been passed (Fig. 3). The calyceal pattern of kidney excretion in the oblique roentgenograms may easily be confused with the faint biliary duct “tram lines” of worm obstruction. In one case of partial biliary obstruction, contrast material was seen in both alimentary tract and renal calyces three days after the initial injection. In none of the cases was an ascaris identified in the gallbladder. Infrequently gas was noted in the biliary system in the control roentgenogram (Fig. 4), and it was noted only once during this series. On six occasions when worms were seen in the common bile duct during the intravenous
barium In all
cholangiogram,
an
immediate
examination was performed. worms were present in the duodenum (Fig. ) and although the dilated common bile duct caused an indentation on the duodenum, the ascarid protruding through the ampulla of Vater was not visualized. This has, however, been noted on endoscopy (Fig. 6).
Fio.
meal cases
6. Photograph (straight arrow) protruding through
taken through endoscope showing worm (curved arrow) the ampulla of Vater.
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VOL.
126,
No.
2
Biliary
Ascariasis
in Children
355
The cases were treated primarily by medical methods that consisted of sedation, intestinal decompression, intravenous fluids, antispasmodics, and anthelminthics. Surgery was resorted to only when repeated intravenous cholangiograms showed a dilated common bile duct or the continued presence of worms. In these cases either duct stricture or death of an incarcerated worm was considered likely. Medical treatment of at least three weeks is advisable before surgery should be considered.” When massive infestation of worms or stricture were indications for surgery, operative cholangiography and postoperative T-tube cholangiography were employed. Figure 7 shows an operative cholangiogram in which 8o ascaris were removed at surgery. A subsequent T-tube cholangiogram
FIG.
8. T-tube
tiple
cholangiogram still present
worms
one week later worms present.
(Fig.
8) still
after
showing mulsurgery.
showed
multiple
DISCUSSION
In our locality, ascaris infestation of the biliary tract is predominantly a disease of children, and during the year 1974 only one adult case was reported at the adjacent Groote Schuur Hospital. It may, however, affect any age group, and a peak incidence between 20-50 years with a slight female preponderance has been reported.7 The roentgenological appearances of biliary ascariasis,
FIG. 7. Operative cholangiogram showing multiple ascarids in a grossly dilated common bile duct ( black arrow). The contrast material has passed through into the dilated duodenum which also contains ascarids.
although
not
widely
known
radiologists, have been previously ported.2’4’5’ 10-12 Clinically,jaundice is not a feature condition, as the intermittent spasm sphincter
the
ofOddi
alimentary percent had
allows
tract. a raised
bile
to
escape
to
reof the of the into
In Louw’s’1 series, i6 serum bilirubin level
B.
Downloaded from www.ajronline.org by Zeitschriftenabteilung/Med. on 04/20/15 from IP address 134.176.129.147. Copyright ARRS. For personal use only; all rights reserved
356
J.
Cremin
duct
is we
FEBRUARY,
5976
in
During
the
year
unable to correlate this evidence with definite cases of pancreatitis. The reported complications indude acute cholangi tis, cholecysti tis, stricture with stone formation, perforation of the duct with biliary peritonitis, liver abscess, hepatitis, and 78101116 The occasional appearance of ascariasis during a gastrointestinal series is well known to radiologists, and the worm body may either be outlined by barium or show barium inside the lumen of its gut.’ In areas where ascariasis is endemic the plain roentgenographic appearances are typical. A report by Issacs9 from Florida, noted the whirlpool effect of massive infestation (Fig. 9). Obstructive fluid levels in the small intestine are also a feature, and a massive bolus may cause obstruction by its physical size, or may cause volvulus, inreview
Fisher
elevated.
9. “Whirlpool” effect of multiple ascarids in the small bowel (arrows). The fluid levels in the small intestine indicate obstruction.
under
M.
had raised serum amylase serum amylase level may the pressure in the pan-
.
FIG.
creatic
R.
tussusception or ileocecal spasm. The worm bolus also may cause necrosis of the bowel wall with resulting peritonitis. During this series one case of perforation leading to free intra-abdominal gas occurred. It is also possible to identify a single ascarid when it appears as a tubular density outlined by the gas in the distended small intestine ( Fig. io). An associated unreported feature is the swollen valvulae conniventes that give a “cog wheel” effect to the mucosa (Fig. I i). Recognition of these roentgenographic features is important, so that patients with upper abdominal pain may be examined by intravenous cholangiography to exclude biliary infestation. It should be noted that biliary ascariasis should not be confused’4 with an entirely different biliary parasite, the Clonorchis sinensis, a pin-like fluke whose host is fresh water fish, and which is endemic in areas such as Singapore and Hong Kong.2’6 It is only in the last i years that we have become aware of the frequency of biliary ascariasis in endemic areas. The purpose of this report is to draw the attention of clinicians to the value of intravenous cholangiography as a safe and diagnostic procedure. It may also serve as a warning that
W’;
and 26 percent levels. A raised occur whenever
and
were
these
arrivals
( Israel),’4 gon,’2
days
of
from
areas
Fic.
and
so. Single a dilated
transport, as
recent
Middle
the
(Japan,8 China,’7 and India’3’ 15),
Africa,”0’1’
“cholecysti
in
jet
such
Far East Phillipines,7
America3
plained
rapid
tis”
ascarid loop
who
have
wi thout
(black of small
arrow) bowel.
East SaiSouth unex-
3 aundice
seen
VOL.
326,
No.
Biliary
2
Ascariasis
in Children
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2.
CREMIN,
J. Biliary
B.
1969,
3.
357
J. Personal
B.
CREMIN,
I3th
parasites.
7. Radiol.,
Brit.
506-508.
42,
Rad.
mt.
Congress,
Communication Madrid,
at 1974,
the Oct.
15-20th. 4.
S.,
CYWES,
giography biliary
and KRIGE, H. and tomography ascariasis. C/in.
Intravenous
in Radio/.,
cholan-
diagnosis
of
1963,
14,
271-272.
5.
DAVEY,
E.
W. W. Companion & S. Livingstone,
23,
to Surgery
Ltd.,
in Africa.
Edinburgh,
1968,
221-227.
pp.
6. HARRISON-LEVY, A. drome of Chinese.
Biliary Brit.
obstruction
7. Surg.,
1962,
syn49,
674-685.
E. G., LIMBO, D. M., EUFEMIO, J. V., and GARCIA, A. H. Hepaascariasis. 7. Phiiipine M. A., 1964,
7. HORRILLENO, G. G., SILAO, tobiliary 40,40-77.
8. Hsu, F. H. Clinical observation on 110 cases of of ascaris invasion into biliary tract. Nagoya 7. Med. Sc., 1962, 24, 215-233. 9. ISAACS, I. Roentgenographic demonstration of intestinal ascariasis in children without using barium.
& 10.
may
be
suspected
of
having
biliary
I I.
B. J. Cremin, F.R.A.C.R. Department of Radiology Groote Schuur Hospital
Observatory, Cape Town,
12.
7925
South
Acknowledgment Figure 6 to Dr.
is given for the B. Novis (endoscopist)
for
8 to
ogist)
Cape
7 and
both Town.
from
Dr.
Groote
R.
Kottler
Schuur
use
of and
CHARTRES,
logical Tropical
William pp.
J. C.,
Hospital,
and
34.
1956,
J. H. Abdominal infestation
RAD.
THERAPY
76, 558-561. complications of ascaris in children. Brit.
7.
Surg., 1966,53, 510-521. LOUW, J. H. Biliary ascariasis in childhood. S. African 7. Surg., 1974, 12, 2 39-225. NGUYEN, D. H., LAM, T. V., and NGUYEN, T. L. Ascaridiose hepato-chol#{233}docienne diagnostign#{233}eradioloiquement. Letter. Presse Mid., Movement of adult Ascaris Brit. 7. Surg., i 972, 59, 437-442. PFEFFERMAN, R., FLOMAN, Y. Y., and R. R. Ascariasis of biliary system.
PAUL,
Arch. 15.
16.
P. Radioaspects of some parasitic diseases. In: Radiology. By Howard Middlemiss. Heinemann, Ltd., London, 396!, JO,
115-118.
ROENTGENOL.,
M.
lumbri-
coides.
(radiol-
REFERENCES I.
J. MED.,
1972,79,958.
Africa 13.
Figure
LOUW,
lumbricoides
asca-
riasis.
AM.
NUCLEAR
COCKSHOTT,
17.
Surg.,
1972,
105,
R0zIN,
A.M.A.
118-120.
C. R. R. M., LAKSHMIKANTHA, K., and REDDY, M. R. Biliary ascariasis. Indian 7. M. Sc., 1968, 23, 488-49 I. WRIGHT, R. M., DORROUGH, R. L., and DITmore, H. B. Ascariasis of biliary system. A.M.A. Arch. Surg., 1963, 86, 402-405. YANG, S. C. H., and LOUBE, P. Biliary ascariasis, report of 39 cases. Ann. Surg., 1946, 123, REDDY,
299-303.
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FEBRUARY,
BILIARY By
B. J. CREMIN
ASCARIASIS F.R.A.C.R.,
IN
CHILDREN
F.R.C.R.,* and R. M. FISHER, CAPE TOWN, SOUTH AFRICA
M.B.,
CH.B.,
D.M.D.R.t
ABSTRACT:
The ascaris is a common human parasite and has a world wide distribution. In areas where it is endemic, biliary complications are common. In our locality it occurs mainly in children, presenting with upper abdominal colicky pain usually without jaundice. We have analyzed the positive roentgenological findings of 67 cases which presented in one year. The findings on cholangiography are diagnostic. The worm is seen as a linear translucent filling defect in a dilated common bile duct. Usually it is only faintly outlined by thin tram lines and occasionally there may not be excretion of the contrast material. The attention of radiologists is brought to this condition and the appearances of ascariasis infestation of the intestines are also noted.
T
HE
( five
coides)
(o.
percent)
cases
(0.5
giant round worm (Ascaris lumbrithrives in a moist warm climate. It is particularly prevalent in Africa and the Far East 5,7,10,11,17 and is endemic unless efficient closed sewerage systems are utilized. In Africa it has been conservatively estimated that 6o million people harbor the parasite.5 The definitive hosts are man and the pig, and in man the adult ascarids mainly inhabit the small intestine.5’13 Their reproduction rate is formidable and the gravid female may lay up to 200,000 ova per day.’ The hardy ova can remain viable for many years, so that children are particularly liable to repeated infection from contaminated vegetables, water, and soil. In Africa, massive ascariasis in children is a common form of intestinal obstruction.5’10” The peak incidence of infestation is between four and eight years and at the Red Cross Children’s Hospital, Cape Town, Louw,” in 974, reported that during the period 1958 through 1974, 528 cases of acute abdominal conditions were caused or complicated by ascariasis. They constituted 10-I 5 percent of all acute abdominal emergencies and were second in frequency only to acute appendicitis. The breakdown of complications in these 528 cases was 351 cases (66 percent) of intestinal obstruction, 148 (25 percent) biliary lesions, 25 cases S
Professor
t
Senior
and Specialist,
Chairman, Red
Department Cross
Children’s
of Radiology, Hospital,
Groote Cape
Town,
percent)
of
pancreatitis,
of acute percent)
two
appendicitis,
cases
and
of primary
two
peritonitis.
At
t
FIG.
I.
Intravenous
cholangiogram,
40
minute
roent-
genogram, ascaris (black arrows) in a dilated common bile duct (white arrow). There is also a worm (arrowhead) in the right hepatic duct.
Schuur South 352
and Africa.
Red
Cross
Children’s
Hospitals,
Cape
Town,
South
Africa.
126,
VOL.
No.
Biliary
2
Downloaded from www.ajronline.org by Zeitschriftenabteilung/Med. on 04/20/15 from IP address 134.176.129.147. Copyright ARRS. For personal use only; all rights reserved
MATERIAL
AND
Ascariasis
in Children
353
METHOD
An analysis of the roentgenologic records cases referred from both medical and surgical services during the five year period, ‘968 through 3972, showed positive intravenous cholangiographic evidence of biliary ascariasis in I 54 cases. After we became more aware of the severity of this problem, the intravenous cholangiograms in children under twelve years of age from all service departments during the year i 974 were reviewed. There were i 26 cases referred because of possible biliary ascariasis. Fifty-nine were considered normal. Sixty-one (48 percent) showed a worm present in the ccmmon bile duct. Six (four percent) demonstrated nonfunction, which in conjunction with other clinical or roentgenological evidence of ascariasis infestation, was taken as positive evidence. Therefore a total of 52. percent of the children referred with colicky right upper abdominal pain showed roentgenological evidence of ascariasis. The sex incidence was approximately equal, and the cases of
consisted
of
five
European,
seven
African
and 6 of mixed parentage. It should be noted that less than ten percent of the children attending this hospital are European. All the proved cases had acute colicky
FIG.
2. Intravenous
genogram, common ent
in
cholangiogram,
40
minute
worm (black arrow) seen bile duct. Contrast material calyces
of
kidney
(white
arrowheads).
in
roent-
a dilated
is also
4 J ury.
..
FIG.
3. Intravenouscholangiogram,
genogram
mon
twelve
bile
is absent.
40
days
rant
minute
pain,
tenderness,
gallbladder
and
was
right
upper
vomiting.
present
A
in
roent-
a dilated
shows
duct (white arrow) but now No renal excretion was noted.
abdominal
upper
later,
‘I
25
the
comworm
quadpalpable
percent
of
cases.
Cholangiography intravenous infusion cent
iodipamide
five
percent
by
given
was performed by an consisting of o permeglumine* in o ml of a dextrose solution. This was
intravenous
drip
infusion
over
a
This method showed better results and was less likely to cause vomiting than a simple intravenous injection. Apart from nausea no complications were encountered. Roentgenograms were taken in the I 5#{176} prone oblique position at 20 minute intervals. A worm was usually seen as a large lucent filling defect contamed inside a dilated common bile duct (Fig. i). Identification in many cases was not always so obvious and a more frequent appearance was two parallel lines of contrast material outlining the worm (unfortunately too faint to reproduce photographically). Tomography was used only if the appearances were equivocal after the 40 minute film. With experience this was not usually necessary. The worms were frequently multiple and sometimes were also present in the major intrahepatic ducts. When a dilated duct containing a worm was period
of
ten
minutes.
forte
(Schering
presS
Biligrafin
A. G.)
20
ml
ampule.
Downloaded from www.ajronline.org by Zeitschriftenabteilung/Med. on 04/20/15 from IP address 134.176.129.147. Copyright ARRS. For personal use only; all rights reserved
J.
B.
354
Cremin
and
.,
.-
FIG.
4.
Intravenous
control
is seen
in
roentgenogram.
the biliary
Gas
tree.
seen, medical treatment was instituted and the intravenous cholangiogram repeated after one week. With successful treatment, the worm disappeared, although the duct frequently remained dilated (Fig. 2; and 3).
Fic.
g.
Barium
cholangiogram arrows) in the
meal
taken
during
demonstrating first part of the
an
intravenous
ascariasis duodenum.
(black
R.
M.
Fisher
FEBRUARY,
1976
In cases with a partial blockage of the duct by a worm, it was commonly noted that there was a more marked excretion of contrast material by the kidneys (Fig. 2) than when the worm had been passed (Fig. 3). The calyceal pattern of kidney excretion in the oblique roentgenograms may easily be confused with the faint biliary duct “tram lines” of worm obstruction. In one case of partial biliary obstruction, contrast material was seen in both alimentary tract and renal calyces three days after the initial injection. In none of the cases was an ascaris identified in the gallbladder. Infrequently gas was noted in the biliary system in the control roentgenogram (Fig. 4), and it was noted only once during this series. On six occasions when worms were seen in the common bile duct during the intravenous
barium In all
cholangiogram,
an
immediate
examination was performed. worms were present in the duodenum (Fig. ) and although the dilated common bile duct caused an indentation on the duodenum, the ascarid protruding through the ampulla of Vater was not visualized. This has, however, been noted on endoscopy (Fig. 6).
Fio.
meal cases
6. Photograph (straight arrow) protruding through
taken through endoscope showing worm (curved arrow) the ampulla of Vater.
Downloaded from www.ajronline.org by Zeitschriftenabteilung/Med. on 04/20/15 from IP address 134.176.129.147. Copyright ARRS. For personal use only; all rights reserved
VOL.
126,
No.
2
Biliary
Ascariasis
in Children
355
The cases were treated primarily by medical methods that consisted of sedation, intestinal decompression, intravenous fluids, antispasmodics, and anthelminthics. Surgery was resorted to only when repeated intravenous cholangiograms showed a dilated common bile duct or the continued presence of worms. In these cases either duct stricture or death of an incarcerated worm was considered likely. Medical treatment of at least three weeks is advisable before surgery should be considered.” When massive infestation of worms or stricture were indications for surgery, operative cholangiography and postoperative T-tube cholangiography were employed. Figure 7 shows an operative cholangiogram in which 8o ascaris were removed at surgery. A subsequent T-tube cholangiogram
FIG.
8. T-tube
tiple
cholangiogram still present
worms
one week later worms present.
(Fig.
8) still
after
showing mulsurgery.
showed
multiple
DISCUSSION
In our locality, ascaris infestation of the biliary tract is predominantly a disease of children, and during the year 1974 only one adult case was reported at the adjacent Groote Schuur Hospital. It may, however, affect any age group, and a peak incidence between 20-50 years with a slight female preponderance has been reported.7 The roentgenological appearances of biliary ascariasis,
FIG. 7. Operative cholangiogram showing multiple ascarids in a grossly dilated common bile duct ( black arrow). The contrast material has passed through into the dilated duodenum which also contains ascarids.
although
not
widely
known
radiologists, have been previously ported.2’4’5’ 10-12 Clinically,jaundice is not a feature condition, as the intermittent spasm sphincter
the
ofOddi
alimentary percent had
allows
tract. a raised
bile
to
escape
to
reof the of the into
In Louw’s’1 series, i6 serum bilirubin level
B.
Downloaded from www.ajronline.org by Zeitschriftenabteilung/Med. on 04/20/15 from IP address 134.176.129.147. Copyright ARRS. For personal use only; all rights reserved
356
J.
Cremin
duct
is we
FEBRUARY,
5976
in
During
the
year
unable to correlate this evidence with definite cases of pancreatitis. The reported complications indude acute cholangi tis, cholecysti tis, stricture with stone formation, perforation of the duct with biliary peritonitis, liver abscess, hepatitis, and 78101116 The occasional appearance of ascariasis during a gastrointestinal series is well known to radiologists, and the worm body may either be outlined by barium or show barium inside the lumen of its gut.’ In areas where ascariasis is endemic the plain roentgenographic appearances are typical. A report by Issacs9 from Florida, noted the whirlpool effect of massive infestation (Fig. 9). Obstructive fluid levels in the small intestine are also a feature, and a massive bolus may cause obstruction by its physical size, or may cause volvulus, inreview
Fisher
elevated.
9. “Whirlpool” effect of multiple ascarids in the small bowel (arrows). The fluid levels in the small intestine indicate obstruction.
under
M.
had raised serum amylase serum amylase level may the pressure in the pan-
.
FIG.
creatic
R.
tussusception or ileocecal spasm. The worm bolus also may cause necrosis of the bowel wall with resulting peritonitis. During this series one case of perforation leading to free intra-abdominal gas occurred. It is also possible to identify a single ascarid when it appears as a tubular density outlined by the gas in the distended small intestine ( Fig. io). An associated unreported feature is the swollen valvulae conniventes that give a “cog wheel” effect to the mucosa (Fig. I i). Recognition of these roentgenographic features is important, so that patients with upper abdominal pain may be examined by intravenous cholangiography to exclude biliary infestation. It should be noted that biliary ascariasis should not be confused’4 with an entirely different biliary parasite, the Clonorchis sinensis, a pin-like fluke whose host is fresh water fish, and which is endemic in areas such as Singapore and Hong Kong.2’6 It is only in the last i years that we have become aware of the frequency of biliary ascariasis in endemic areas. The purpose of this report is to draw the attention of clinicians to the value of intravenous cholangiography as a safe and diagnostic procedure. It may also serve as a warning that
W’;
and 26 percent levels. A raised occur whenever
and
were
these
arrivals
( Israel),’4 gon,’2
days
of
from
areas
Fic.
and
so. Single a dilated
transport, as
recent
Middle
the
(Japan,8 China,’7 and India’3’ 15),
Africa,”0’1’
“cholecysti
in
jet
such
Far East Phillipines,7
America3
plained
rapid
tis”
ascarid loop
who
have
wi thout
(black of small
arrow) bowel.
East SaiSouth unex-
3 aundice
seen
VOL.
326,
No.
Biliary
2
Ascariasis
in Children
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W. W. Companion & S. Livingstone,
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B. J. Cremin, F.R.A.C.R. Department of Radiology Groote Schuur Hospital
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7925
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for
8 to
ogist)
Cape
7 and
both Town.
from
Dr.
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