Year : 2005 | Volume
: 15 | Issue : 1 | Page : 139--140
Radiological quiz - chest
SK Sethi, RS Solanki
Lady Hardinge Medical College, New Delhi, India
S K Sethi
CP-109, Pitampura, Maurya Enclave, Delhi - 110088
|How to cite this article:|
Sethi S K, Solanki R S. Radiological quiz - chest.Indian J Radiol Imaging 2005;15:139-140
|How to cite this URL:|
Sethi S K, Solanki R S. Radiological quiz - chest. Indian J Radiol Imaging [serial online] 2005 [cited 2019 Jun 24 ];15:139-140
Available from: http://www.ijri.org/text.asp?2005/15/1/139/29190
A 20-year-old woman presented with history of abdominal pain, nausea and fatigue for a year. Abdominal pain was more serious in last 15 days. Clinically she was pale and jaundiced. Abdominal US was performed. Representative gray scale images [Figure 1][Figure 2] are provided.
What is the diagnosis?
[Figure 1] shows a coiled echogenic, non-shadowing round worm (mobile on real time sonography) with a thin, longitudinal, anechoic tube inside the worms' body (representing worm's digestive tract). [Figure 2] shows a dilated, sludge filled common bile duct, which is an indirect evidence of biliary ascariasis. A diagnosis of biliary ascariasis was made; patient was put on antihelminthic treatment multiple ascaris worms were seen in the stools within 10 days.
Parasitic disease of the biliary tract, particularly ascariasis, occur frequently in tropical and subtropical areas and cause high morbidity and mortality. In general neither the clinical presentation nor the general laboratory findings are sufficiently unique to raise the possibility of a biliary infestation in the mind of the clinician. . Biliary ascariasis is common in India. The diagnosis of biliary ascariasis has been difficult in the past because of non-specific symptomatology. Now, ultrasonography can detect ascariasis in the biliary tree accurately. 
The adult Ascaris Lumbricoides roundworm infests the small intestine of 25% of the world's population. The worms tend to crawl from the duodenum into the biliary system. These worms are very mobile and can readily migrate back into the duodenum spontaneously or under the influence of vermifuges. 
The main causes of presentation of such patient to the hospital include obstructive jaundice,colicky upper abdominal pain, multiple intrahepatic abscesses, acute pancreatitis, acute cholecystitis, subphrenic abscess etc. 
Sonographic findings of biliary asarasis can be divided into direct and indirect signs depending on the ability to demonstrate the roundworms themselves or the consequences of the visceral involvement. Main direct signs include the "STRIP" sign which is defined as a single linear or coiled echogenic, non shadowing mobile or static structure and the "INNER TUBE" appearance characterized by a thin, longitudinal, anechoic tube or line inside the ascaris body (this represents worms digestive tract). Aggregates of worms may have appearance like spaghetti (SPAGHETTI sign) The main indirect findings are: dilatation of the intra and extra hepatic bile ducts, pneumobilia, gall bladder thickening, pancreatic edema, main pancreatic duct dilatation, intrahepatic abscess and ascites. 
In developing countries like ours, where ascariasis has a high prevalence, it should be kept in mind that it may be the cause of biliary or pancreatic obstructive diseases. Conversely, hepatobiliary and pancreatic complications of ascariasis should be suspected when patients infected by this worm have abdominal pain, distension, vomiting, or a combination of thereof at presentation.
Present case highlights the sonographic findings in biliary ascariasis. Ultrasonography is an imaging method readily available in most of the hospitals, which can not only readily diagnose biliary ascariasis but is also helpful in follow up and surveillance. Ultrasound is safe, non-invasive, accurate, rapid and cheap and in most instances it is the only diagnostic modality required.
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