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Imaging Diagnosis

Considering the frequency of Trichuris infection, it is surprising that the radiological diagnosis has not been made more often. Case reports in the literature are rare. Radiology should really play no significant role in the diagnosis, but the worms may well be found as part of an investigation of rectal bleeding or other colonic disease. The radiographic appearance of the colon in trichuriasis was first described in 1968 from the findings on barium enema examination of a 7 year-old San Salvador boy (Fig. 17.10).

A routine barium enema may be unremarkable or may show a granular mucosal pattern throughout the colon. An air contrast barium enema is the definitive imaging study and will demonstrate the wavy radiolucent outlines of numerous small trichurids against the air-barium background of the colon and rectum (Figs. 17.9, 17.10,17.11). The characteristic uncurled curvilinear pattern or S-shaped configuration of the female worm and the tightly coiled "pinwheel" or "target" pattern of the male worm will be recognized. The outlined posterior portions of the trichurids are slightly over 1-cm in length, with the longer, slender anterior two-thirds of the worms lying uncoated by barium within the colonic mucosa.


Fig. 17.9. Trichuriasis of the colon in a South African child. (A) Air contrast barium enema reveals the outline of innumerable small trichurids on the erect view. (B) Magnification of the rectosigmoid colon shows the tightly coiled outlines of multiple male parasites and the semilunar or whiplike configuration of numerous female trichurids contrasted against the air-barium background. (Courtesy of Prof. Bryan J. Cremin, Capetown).



Fig. 17.10 A-D Trichuriasis in a 7 year-old San Salvador boy with profuse rectal bleeding. Innumerable whipworms were seen attached to the rectal mucosa at proctoscopy. (A) Postevacuation film from a routine barium enema examination shows flocculation of barium and poor mucosal coating, probably due to excessive mucous secretions surrounding the numerous whipworms. (B) The definitive air contrast study reveals the radiolucent outlines of many small trichurids as they cling to the colon mucosa by their slender anterior ends. (C) A magnified view of the rectosigmoid colon from the same air contrast barium enema shows the outlines of many small whipworms attached to the mucosa with their posterior portions either tightly coiled (males) or unfurled in a semilunar or curvilinear configuration (females). The composite picture suggests a "target" or "pinwheel" appearance of the mucosal pattern. (D) A follow-up air contrast barium enema after hexylresorcinol enemas shows that the colon has been cleared of the parasites. The child required numerous blood transfusions for treatment of profound anemia but was later discharged greatly improved. AFIP 67-9998-4, 1, 3 and 2. (Courtesy of Dr. Julio Astacio, previously from San Salvador, now in McAllen, Texas).


Fig. 17.11. (A) Massive Trichuris infestation in a Brazilian child. Air contrast examination of the colon, including the spot film of the rectosigmoid colon shown here, identifies the typical wavy outlines of innumerable trichurids; some are tightly coiled in a "target" pattern typical of male parasites, whereas others are unfurled in the curvilinear configuration of female trichurids. (B) Magnification of the sigmoid colon from an air contrast barium enema of another Brazilian child with trichuriasis shows the wavy radiolucent outlines of numerous whipworms. This appearance is pathognomonic of trichuriasis. (Courtesy of Dr. Antonio Filho, Sao Paulo).

Differential Diagnosis

If the disease is remembered in areas of high prevalence and poor socioeconomic and sanitary conditions, it is not likely to be confused with any other entity. Specific diagnosis is easily made in the laboratory or occasionally by air contrast barium enema, and is often confirmed by direct inspection of the rectum.

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