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Imaging Diagnosis

Prior to 1968, reports of roentgenographic changes in giardiasis were rare. In 1944, Welch described irritability of the duodenal cap with coarsening of the mucosal pattern in 22 of 29 patients with giardiasis. Later, Peterson described a deficiency pattern in patients with Giardia infestation, which consisted of pronounced segmentation, a moderate degree of dilatation of small bowel loops, and coarsening of the mucosal folds in the mid-portion of the small bowel. Since 1968, Marshak, Reeder and others have reported radiographic changes of an inflammatory nature, usually localized to the duodenum and jejunum, in patients with giardiasis. The proximal ileum is rarely involved; the lower ileum and the colon appear normal.

The mucosal changes can be quite marked with thickening, blunting, distortion and spiking of the folds. Concomitant with these mucosal changes there is marked spasm and irritability of the bowel, resulting in rapid change in configuration of the valvulae conniventes. There is fast transit of barium through the affected area, and narrowing of the bowel lumen from spasm (Figs. 9.6, 9.7, 9.8, 9.9, 9.10, 9.11). The movement of barium through the duodenum and proximal jejunum may be so rapid (with to-and-fro motion and reverse peristalsis which can be dramatic at times) that multiple fluoroscopic spot films and a considerable quantity of barium are often necessary to adequately visualize mucosal detail in the involved areas. There are usually increased secretions present, causing dilution of the barium and making exact definition of the mucosa difficult due to blurring and indistinctness of the folds, with occasional fragmentation and segmentation of the barium column.

Fig. 9.6 Giardiasis. There is marked spasm and irritability of the duodenum and jejunum with resultant poor filling of the duodenal C-loop and proximal and mid-jejunum. There is marked thickening, edema, and spiking of mucosal folds throughout the proximal small bowel . Increased secretions are present. The loops appear widely separated and the lumen appears narrow in many segments due to the combination of irritability and edema. The barium column is segmented and flocculated from spasm and increased fluid within the upper small bowel. This combination of mucosal edema, irritability, rapid transit of barium through the proximal small bowel, abnormal clumping of barium with evidence of increased secretions, narrowing of the bowel lumen, and localization of the pathological features to the duodenum and jejunum is typical of giardiasis and highly suggestive of the diagnosis. (Courtesy of the late Dr. Richard Marshak, New York City).

Fig. 9.7 Giardiasis. There is marked irregularity of the second portion of the duodenum and considerable spasm within the C- loop and proximal jejunum. These loops are poorly filled due to irritability and are separated one from another. The mucosal folds are thickened and edematous and increased secretions are present. There is slight rigidity and narrowing of the bowel lumen. The changes suggest actual inflammation rather than a malabsorption pattern. They disappeared after Atabrine therapy . This patient from New York City also had hypogammaglobulinemia with numerous tiny, uniform filling defects within the jejunum due to nodular lymphoid hyperplasia. Giardiasis has been a common finding in patients with hypo- or dysgammaglobulinemia. (Courtesy of the late Dr. Richard Marshak).

Fig. 9.8 Giardiasis. There is marked spasm and irritability in the duodenal C-loop and jejunum associated with narrowing of the bowel lumen. Valvulae conniventes are thickened, distorted and fragmented. These intense inflammatory changes in the duodenum and jejunum can be seen in giardiasis in severely infected and susceptible individuals. (Courtesy of the late Dr. Richard Marshak).

Fig. 9.9 Giardiasis. Note the similarity to the previous cases with spasm and irritability of the proximal small bowel and a normal appearing ileum. Mucosal folds in the duodenum and jejunum are thickened and spiked and there is segmentation and fragmentation of the barium column due to the combination of irritability, mucosal edema, and increased secretions. (Courtesy of the late Dr. Richard Marshak).

Fig. 9.10 Giardiasis in a 61-year-old white man with diarrhea and 15 pound weight loss of 10 weeks duration. He had recently been to France and also had a camp in Maine on a lake from which he drank untreated water. There is marked irritability of the duodenal C loop and proximal jejunum with distortion and thickening of the valvulae conniventes. The ileum appears normal as it does in the vast majority of patients with giardiasis. (Courtesy of Dr. Joseph Metz, Augusta, Maine).

Fig. 9.11 Giardiasis. There is such intense spasm in the duodenal C- loop that there is a string sign present in the second portion of the duodenum. The transit of barium through the duodenum and proximal jejunum is so rapid that these loops were poorly filled throughout the examination. The lumen of the proximal small bowel is narrowed and there is edema of the valvulae conniventes. There are also innumerable tiny 2 mm round radiolucent filling defects within the small bowel secondary to nodular lymphoid hyperplasia in this patient with hypogammaglobulinemia.

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