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Imaging Diagnosis

Most patients with hookworm infection show no radiographic abnormality on barium examination of the upper gastrointestinal tract. The earliest radiographic reports were by Krause and Crilly in 1943, who reported some abnormality of the small intestinal pattern in 40 of 44 patients with clinically significant hookworm disease. They described a deficiency pattern with coarsening and irregularity of the mucosal folds in the jejunum and, in some severe infections, obliteration of the folds, flocculation of the barium and segmentation. In most patients barium reached the cecum in one hour or less, but slow transit time and dilatation were seen in several severe cases.

Other early investigators found small bowel abnormalities in 60% of examined hookworm patients, with the changes generally being proportional to the severity of the patient's disease. Mucosal folds of the jejunum were described as irregular and two to three times normal thickness. The ileum was usually normal except that, in patients with marked jejunal changes, the ileal folds also appeared unusually prominent and wide. There was increased tone in several loops and the intestinal lumen was narrowed in the more advanced infections. Peristalsis was observed to be vigorous and rapid and the small intestine appeared constantly in motion and unable to relax.

Sheehy and Salem have also reported different series of patients with clinical hookworm disease and steatorrhea in which a malabsorption pattern was noted in the jejunum. Improvement in the small bowel pattern followed purgation. In several other large series of patients with hookworm disease reported independently by Gilles and Kotcher, no evidence of malabsorption or other significant small bowel changes were found on barium examination. These latter series were among African patients as opposed to the earlier series described primarily from Puerto Rico and India. Thus, the radiological findings are by no means consistent in various parts of the world. There is the further problem that, although the jejunal changes may subside in many patients after treatment of their hookworm disease and anemia, the therapy is usually associated with a period of better nutrition; it is therefore difficult to ascertain whether the original radiological findings reflected the patients' infection or their state of nutrition. Rowland, Cockshott and Middlemiss, and others thought that the malabsorption pattern described on barium studies of patients with hookworm disease was attributable to their hypoalbuminemia caused by protein loss and that the swelling of the small bowel mucosa and other barium findings were nonspecific. Further, metabolic studies on hookworm patients reported by DaCosta failed to demonstrate evidence of malabsorption.

Probably the classical and most reliable radiological investigation (though somewhat dated-1974) is that of Bhardwaj from New Delhi, who performed small bowel series with non-flocculating barium (Micropaque) on 42 adult male Indians suffering from hookworm disease associated with anemia (hemoglobin less than 8 gm/100 ml). There were 10 controls and 10 other patients who had anemia but no evidence of hookworm infection. Jejunal biopsies were done on all patients with hookworm disease and revealed irregularity of the musosal lining and stunting and flattening of villi with cellular infiltration of varying degrees from minimal to severe. The radiological changes in this large series are summarized as follows:


Sixty percent of patients had prominent mucosal folds in the greater curvature and fundus of the stomach and 19% also had pylorospasm.

Duodenal Bulb

Prominent mucosal folds were seen in 57% of patients, whereas 40% had an irritable and spastic duodenal bulb with serrated or spiked folds. A few patients had nodular filling defects from marked hypertrophy of the mucosal folds and Brunner's glands. One patient had a coincidental duodenal ulcer.

Duodenal C Loop

Sixty-seven percent of the patients showed an abnormal C loop with mucosal fold thickening, distortion and spiking, which was associated with a spastic, irritable and narrowed loop in 36% of the patients.

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Copyright: Palmer and Reeder by Springer


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