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Fig. 21.15 Ultrasound study in a Korean patient with severe Clonorchis infection shows multiple echogenic areas simulating nodules, but actually representing marked fibrous thickening of bile duct walls. The hepatic parenchymal echotexture is coarse. Note dilated small bile ducts (arrows) in the center of the thick echogenic duct walls. (Courtesy of Dr. Jae Hoon Lim, Seoul, Korea and AJR, 1990).

Fig. 21.16 CT scan in a Korean with clonorchiasis shows diffuse uniform dilatation of small and medium-sized intrahepatic ducts in the liver periphery. There are numerous tiny hyperdense foci within these dilated ducts, apparently caused by aggregates of Clonorchis flukes. The extrahepatic duct was mildly dilated. (Courtesy of Dr. Jae Hoon Lim, Seoul, Korea and AJR, 1990).

 

 

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Biliary stasis, sludge and stones associated with dilatation and constriction of the bile ducts can be demonstrated by ultrasound, CT and MRI. Ultrasound is usually the first modality utilized, given its high sensitivity in detecting biliary stones and dilatation. However, because the stones and sludge in clonorchiasis or Oriental cholangiohepatitis are isoechoic relative to the liver and do not shadow, they can be missed on ultrasound. Ultrasound is particularly useful in the detection of bile duct dilatation and fibrous thickening of the duct walls with increased wall echogenicity (Fig. 21.15), and nonshadowing, discrete, echogenic stones in the gallbladder lumen.

CT demonstrates intra- and extrahepatic ductal dilatation, abscesses, atrophy, and hyperattenuated stones or sludge (Figs. 21.14B and 21.16). A diffuse, uniform dilatation of the intrahepatic bile ducts, particularly in the periphery of the liver, with disproportionately less extrahepatic biliary dilatation, should raise suspicion for clonorchiasis. MRI shows findings that parallel CT, though it may be useful in detecting subtle cases of cholangiocellular carcinoma.

Hepatic abscess or cholangiocarcinoma (either of which may develop in patients with advanced clonorchiasis) may both present as a mass in the liver. Depending on geographic availability and user preference, an ultrasound study, CT or MRI scan, hepatic arteriogram, or radioisotope scan may demonstrate the mass, and will usually help to differentiate carcinoma from abscess.

Rarely, pulmonary infiltrates have been described in clonorchiasis; they are nonspecific in appearance.

Treatment

Praziquantel is utilized in milder forms of clonorchiasis. However, the bile duct dilatation, irregularities and ductal proliferation persist despite eradication of the parasite. When fulminant cholangiohepatitis prominent, surgery is the usual course of action. If the disease is isolated to a single hepatic segment or lobe, partial hepatectomy may be curative. A biliary-enteric anastomosis is often necessary in those cases with diffuse involvement. Stone removal may be performed by the interventional radiologist via a percutaneous route as well.

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