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Imaging Diagnosis

The adult flukes measure 1-2 cm and may be visualized on an operative T-tube, endoscopic or transhepatic cholangiogram in the large and medium-sized intrahepatic ducts. They appear as small, curved or crescentic filling defects within dilated bile ducts or as semilunar mounds attached to the duct walls (Figs. 21.11, 21.12, 21.13, 21.14). In a heavy infection, the common bile duct may be dilated to 2.5 cm or more in diameter and may be packed with soft stones, biliary sand, pus, living or dead Clonorchis and occasionally other worms such as Opisthorchis, Fasciola and Ascaris. The resultant biliary stasis favors bacterial infection and may lead to cholangitis, with alternating strictures and dilatations of the biliary tree (Figs. 21.11, 21.12, 21.13, 21.14).

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Fig. 21.11 Clonorchiasis. A Operative T-tube cholangiogram in a 43-year-old Chinese woman with intermittent right upper quadrant pain, admitted with a diagnosis of cholecystitis. Exploration of the common duct revealed many Chinese liver flukes (Clonorchis sinensis). The cholangiogram shows poor filling of the distorted, irregular hepatic bile ducts and common duct, with multiple filling defects representing worms living in and partially occluding the ducts. B After vigorous irrigation of the bile ducts at surgery, satisfactory filling is obtained on a follow-up cholangiogram Note the long areas of slight stricture and distal ectasia involving many of the bile ducts, especially in the right lobe. A few tiny crescentic defects remain (arrows), probably representing residual Clonorchis in these radicles. The common duct now appears normal. (Courtesy of H. Woloshin: Application of the Radiologic Approach to Biliary Tract Disease and Medical Times).

Fig. 21.12. Endoscopic retrograde cholangiogram in an adult Korean with clonorchiasis shows marked dilatation of the intrahepatic bile ducts. These are numerous oval, elliptical or crescentic filling defects representing adult C. sinensis flukes in small and medium-sized bile ducts. Peripheral duct filling is partially interrupted by these filling defects. The contour of the bile ducts is ragged and irregular because of flukes abutting the margin of ducts. The extrahepatic ducts are only slightly dialted (13 mm). (Courtesy of Dr. Jae Hoon Lim, Seoul and AJR, 1990).

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Fig. 21.13 A,B Clonorchiasis in a 20-year-old Korean man who had eaten raw seafood all his life. A Frontal and B oblique views of a T-tube cholangiogram show innumerable 1- to 2-cm filling defects within the dilated bile ducts. The flukes can be identified by their typical comma-shaped or crescentic outlines; other filling defects may represent associated stones and biliary sludge. Short strictures and gross dilatations of the ducts are present as the result of chronic obstruction and cholangitis. C Cholangiogram in another patient showing multiple small 1- to 2-cm crescentic or oval filling defects from C. sinensis flukes (arrows) in large hepatic ducts and branches. (C courtesy of the late Prof. J. Ho, Hong Kong. Reprinted from W.P. Cockshott and J.H. Middlemiss: Clinical Radiology in the Tropics. Churchill Livingstone, Edinburgh, 1979).

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Fig. 21.14 A Clonorchiasis of the biliary tract as visualized by ERCP. There are innumerable Clonorchis flukes appearing as 1- 2-cm crescentic or oval filling defects throughout the dilated major intrahepatic bile ducts intermingled with pigmented lucent stones. There is slight dilatation of the common bile duct with an oval filling defect near the ampullary segment, which could be either a fluke or stone; probably the former. B A non-enhanced CT scan in the same patient shows hyperdense material within grossly distended major intrahepatic bile ducts, which on pathological examination was proven to be a combination of pigmented biliary stones and sludge and Clonorchis flukes. Several calcified stones can be seen in peripheral ducts on this CT study. The spleen is enlarged. (Courtesy of Dr. Joan Kendall).

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