Indian Journal of Radiology and Imaging Indian Journal of Radiology and Imaging

: 2003  |  Volume : 13  |  Issue : 2  |  Page : 223--224

Radiological quiz - hepatobiliary imaging

NA Patel, HP Parekh, DP Vasavada 
 Dept of Radio-Diagnosis, M.P Medical College, Jamnagar, Gujrat, India

Correspondence Address:
N A Patel
D-6/A Medical Campus, M.P. Shah Medical College, Jamnagar -Gujarat

How to cite this article:
Patel N A, Parekh H P, Vasavada D P. Radiological quiz - hepatobiliary imaging.Indian J Radiol Imaging 2003;13:223-224

How to cite this URL:
Patel N A, Parekh H P, Vasavada D P. Radiological quiz - hepatobiliary imaging. Indian J Radiol Imaging [serial online] 2003 [cited 2019 Mar 21 ];13:223-224
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Full Text

A middle aged female from a lower socioeconomicclass presented with right hypochondriac pain and nausea. On examination she was anemic. Ultrasound images of the biliary tree are shown here. What is your diagnosis?

 View Answer

 Radiological Diagnosis

 Hepatobiliary Ascariasis

The roundworm Ascaris lumbricoides infests about one quarter of the world's populations and especially is common in parts of Asia, Africa and Central America. Children are often infested and about 10% of those with abdominal ascariasis have biliary ascariasis. 40% of whom may experience complications. In man adult worms live in the small intestine, and bile duct infestations usually occurs when the duodenum is heavily colonized. Usually only one or two worms are found but there may be more than 80 in the CBD[1] Other parasites like Clonorchis Sinensis, Opistorchis Viverrini, Fasciola Hepatica and Entamoeba have also been noted in the biliary tree.

Most of the patients present with uncomplicated biliary colic. Nausea, vomiting, fever and jaundice may be associated. Patients may present with acute cholecystitis, acute biliary obstruction and pancreatitis. But complications such as ascending cholangitis, worm-containing liver abscess, recurrent pyogenic cholangitis (Oriental cholangiohepatitis) and bowel perforation are rare. Most of the patients respond to anti-helminthic agents.

Five different signs have been described in characterizing the worms' sonographic appearance[2]. The strip sign occurs when the worm is as a long, thin linear, echogenic strip within the lumen of the duct or the gall bladder. When the worm, containing duct is viewed in cross-section a bull's-eye appearance of central specular echo within the duct is obtained. On occasion a central anechoic tube is seen within the worm (the inner tube sign), probably representing the worms digestive tract [Figure 1]. With heavier infestation and many biliary worms, multiple overlapping longitudinal interfaces may be present within the duct, the spaghetti sign [Figure 2]. Real time examination is useful in demonstrating worm motility; characteristic erratic, non-directional, zig-zag movements may be seen within the duct. Khuroo et al. has outlined the same sonographic appearance of the worms in the bile ducts[3].

USG is a non-invasive, cheap and accurate modality to diagnose and follow-up cases of hepatobiliary ascariasis[4]. It's also useful in confirming exit of the worms from the biliary tree. The disadvantage of USG is that it cannot visualize the more common duodenum ascariasis and there by miss half the cases of hepatobiliary ascariasis.


1R.G.Grainger, D.J.Allison. The biliary tract. In: Andreas Adam, Mary E. Roddie and N.B. Bowley, editors. Diagnostic Radiology. London: Churchill Livingstone,1997:1231.
2Arnold C Friedman, Abrahham H. Dechman. Parasitic Diseases. In: Abrahham H. Dechman, editors. Radiology of Liver Biliary tract and Pancrease. Mussouri: Mosby, 1994: 640-642.
3Khurro MS, Zargar SA, Yatoo GN, et al. Sonographic findings in gall bladder ascariasis. J clin ultrasound 1992;20:587-589.
4A Suri, M Bhatia, BN Chander, A Chaturvedi. Ind J Radiol Imag 2002 12 :2:221-223