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Imaging Diagnosis

The radiological findings in intestinal capillariasis have been well documented by Paulino and Wittenberg, based on their analysis of small bowel series performed on 14 patients at the Philippine General Hospital in Luzon in 1968-1969. Most of their patients were teenaged boys who represent the group at highest risk because they swim and fish in infected waters. It should be noted that the small bowel examinations were performed with 18 ounces of U.S.P. barium sulfate rather than the nonflocculating barium currently used in almost all Western countries. The following classical signs of a malabsorption pattern were identified in varying degrees in their patients.

1. Dilatation

Dilatation was present in slightly over half of the patients, usually involved only a short segment of bowel, and was rarely pronounced. As with other malabsorption syndromes, there was a changing pattern of dilatation of the loops during the examination.

2. Segmentation

In approximately one-third of the patients, delayed segmentation of the barium column was noted, most commonly in the ileum.

3. Fragmentation

Scattering or fragmentation of the barium column into numerous small clumps or globules was the most common radiographic abnormality. It was seen to at least some degree in all 14 patients. The changes ranged in severity from gross accumulations of barium, noted on every film and in most segments of the small intestine in a given patient, to the more characteristic delicate scattering of residual barium in the mid- and distal jejunum and proximal ileum of most patients. There was no particular association of segmentation and fragmentation in the same patients, as is characteristic of several other malabsorption syndromes.

4. Hypersecretion

Increased fluid in the small bowel, as manifested by the presence of diluted or flocculated barium (amorphous large clumps within a barium-filled loop), was noted in the majority of patients, but was usually of minimal degree and seen in only one or two loops.

5. Abnormal Fold Pattern

There was thickening of the valvulae conniventes of mild to moderate degree (folds wider than 1.5 mm) in all patients. Usually this pattern presented as a uniform thickening of the folds with normal contour, and was most extensive in the distal jejunum and proximal ileum. This finding may be related to the hypoalbuminemia universally present in these patients. Slight nodularity of the folds was seen in one-third of the patients and this finding, together with the segmentation and hypersecretion, permits differentiation from intestinal edema.

6. Moulage

Three patients showed transient moulage phenomenon (a dilated loop with a completely effaced fold pattern presenting as a smoothly contoured intraluminal barium collection) in a single short segment of ileum.

7. Transit Time

No abnormality of transit was noted in any patients in this series. The average transit time was 108 minutes.

It is noteworthy that in none of these patients did the severity of any one of these radiographic features correlate with the severity of the others. It is also of interest that all of the various abnormal radiographic signs of malabsorption, including the most consistent pattern of fragmentation of barium, were seen in the mid- and distal jejunum and proximal ileum (Fig. 14.4). This is the area of the small bowel in which the worm burden in capillariasis is highest and the associated histological changes are most advanced, thus providing a striking radiological-pathological correlation.

....

Fig. 14.4 A,B. Two films from a small bowel series taken at 30-minute intervals on a Filipino infected with Capillaria philippinensis. All the characteristic changes of a malabsorption pattern are present and probably some inflammatory component as well, judging from the marked thickening of the valvulae conniventes in the proximal and mid-jejunum (A) and the slight seperation of the loops and slight thickness of the bowel wall seen best in B. The malabsorptive changes include areas of slight dilatation over a short segment with a changing pattern seen between the two films, as well as moderate segmentation and fragmentation of the barium in the distal jejunum and ileum. There is evidence of slight hypersecretion, and multiple loops of mid-jejunum show a moulage phenomenon with a competely effaced mucosal pattern presenting as smoothly contoured collections of barium, seen best in B. The alternating and transient areas of dilatation give rise to the appearance of pseudostrictures in B, but comparison with A shows these areas of apparent narrowing are not persistent. They are due to changes in tone and peristalsis rather than fixation and stenosis of the loops, as would be present in a severe chronic inflammatory process. The radiological appearance of intestinal capillariasis may be indistinguishable from that of strongyloidiasis. Note that the changes are most marked in the jejunum and proximal ileum, corresponding to the area within the small bowel where the worm burden of capillariasis is highest.

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Copyright: Palmer and Reeder