Ascariasis

Ascariasis is due to infection with the Ascaris lumbricoides adult worm, and typically presents with gastrointestinal or pulmonary symptoms, depending on the stage of development. Epidemiology Ascaris lumbricoides is widely distributed in tropical and subtropical regions and in other humid areas. Approximately one-fourth of the world population infected at any given time. It is much less common in developed countries and relatively rare in the United States. Clinical presentation Clinical presentations vary according to the stage of the life cycle of infection (see parasitology below).
Gastrointestinal manifestations

Gastrointestinal manifestations are due to adult worms. Most common complication of ascariasis is mechanical small bowel obstruction caused by a large number of worms. A large worm bolus can also cause volvulus or intussusception. Infestation with Ascaris lumbricoides can cause a variety of other complications as well, including pancreatitis, acute cholecystitis, and liver abscess. Rare complications include cardiac tamponade and airway obstruction. Adult worms may be passed through the anus or through the mouth while vomiting.
Pulmonary manifestions

Pulmonary manifestations occur 5 -26 days following ingestion of viable eggs. Ascaris pneumonia may develop and consists of migratory, transient, localized intraalveolar inflammatory reactions. Pulmonary ascariasis is the most common cause of Loeffler syndrome, which is characterized by fever, cough, sputum, asthma, eosinophilia, and infiltrates seen at chest radiography. Parasitology Ascaris lumbricoides adult worm is typically 15 - 30 cm long and 3 - 6 mm thick. Humans are permanent hosts. The life cycle begins when embryonated eggs, shed by the adult worm, are passed in the feces of an infected individual. Eggs can then contaminate soil, water, or even food. Humans become infected after ingesting contaminated material. Gastric secretions then cause the eggs to hatch in the small bowel. The larvae penetrate the intestinal mucosa and are hematogenously transported to the lung. Pulmonary manifestations vary widely. The worms grow while in the alveoli, eventually travel up the airway to the epiglottis, and are swallowed again. Once they are back in the small bowel, the worms grow to lengths of up to 35 cm. The life span of an adult female worm is 6 months to 1 year. Radiographic features For a discussion of the pulmonary appearances of ascariasis please refer to simple pulmonary eosinophilia.
Plain film

Worms can often be seen on conventional abdominal radiographs as curvilinear soft-tissue-density cords. If bowel obstruction is present, the typical pattern of air-filled, dilated loops of small bowel with multiple air-fluid levels can be seen on an upright radiograph.
Fluoroscopy
Barium studies

Intestinal ascariasis appears as individual worms seen as longitudinal tubular structures on barium enema. If the alimentary tract of the worm is empty, the worm may appear as a filling defect. If its alimentary tract is distended, the worm appears as parallel bands. On transverse sections, the worm appears as a target sign with body wall and a central dot representing its gut 1.
Ultrasound

Ultrasound will depict the adult worm as a hypoechoic tubular structure with well-defined echogenic walls. During real-time evaluation, the worms can be seen making curling movements.
CT

The worms can usually be visualized within the bowel lumen at CT with soft-tissue windowing. Treatment and prognosis Treatment with oral administration of a single 400-mg dose of albendazole is usually successful. In the presence of bowel obstruction, surgery is usually indicated.

REFRENCES
1. DiSantis DJ, Ralls PW, Balfe DM, et al: The patient with suspected small bowel obstruction: imaging strategies. American College of Radiology. ACR Appropriateness Criteria. Radiology 2000 Jun; 215(suppl): 121-4 2. Lim JH, Kim SY, Park CM. Parasitic diseases of the biliary tract. AJR Am J Roentgenol. 2007;188 (6): 1596-603. doi:10.2214/AJR.06.1172 - Pubmed citation 3. Rodriguez EJ, Gama MA, Ornstein SM et-al. Ascariasis causing small bowel volvulus. Radiographics. 23 (5): 1291-3. doi:10.1148/rg.235025155 - Pubmed citation