대 한 방 사 선 의 학 회 지 1992; 28(5) : 744~748 Journal of Korean Radiological Society, September, 1992

Too Màny Ducts Sign:A Characteristic Cholangiographic Finding of Clonorchiasis?

Ki Soon Park, M.D.* , Jae Hoon Lim, M.D. , Kwan Sup Lee M.D.* , Pil Mun Yu, M.D.**

Departmeηt 0/ Diagnostic Radiology, Kyμηg Hee [}，낌ν'ersity Hospital

- Abstract-

Clonorchiasis produces diffuse dilatation of the small and medium sized intrahepatic bile ducts and its

cholangiogram shows visualization of many bile ducts , especially, tertiary , quaternary , and more peripheral

tributaries up to the 6th tributaries. In an attempt to clarify this cholangiographic si민1 quantitively, we counted

the visualized smaller bile ducts in clonorchiasis and compared the number of visualized ducts in normal

cholangiogram , recurrent pyogenic chlangitis and carcinoma of the extrahepatic ducts. In clonorchiasis the

number of visualized smaller bile ducts was considerably greater than in normal subjects and recurrent pyogenic

cholangitis, but there was no singnificant statistical differences in the number of visualized bile duct tributaries

between clonorchiasis and carcinoma of the bile ducts. Thus it is considered that too many ducts sign is

not a unique cholangiographic finding of clonorchiasis , but we believe that in the presence of this sign with

other well known cholangiographic findings , diagnosis of clonorchiasis is very easy.

Index Words: Liver, bile ducts 76

Liver , clonorchiasis 76 .2085

Bile ducts , cholangiography 76.122

INTRODUCTION

Numberous bile ducts are visualized in

cholangiogram of clonorchiasis , especially small

and medium sized intrahepatic ducts (i.e. , ter­

tiary , quaternary , and more peripheral

tributaries up to the 6th tributaries). They are

not seen normally or in other bile duct diseases

such as biliary stone. Lim et al( 1) called it “ too

many ducts sign' ’ and we presumed the signs

a unique and characteristic cholangiographic fin­

ding of clonorchiasis

* 한럼대학교 의과대학 방사선과학교실

In an attempt to clarify the cholangiographic

“ too many ducts sign' ’ quantitively, we counted

the visualized smaller bile ducts in clonorchiasis

and compared the number with those in normal

cholangiogram , recurrent pyogenic chlangitis

and carcinoma of the extrahepatic ducts.

MATERIALS AND METHODS

We analyzed the cholangiographic findings of

a total of 41 patients with clonorchiasis between

January 1985 and September 1991. Diagnosis

was made by stool examination for eggs or

* Deþartmeηt 01 Radiology, College 01 Mediciηe， Hallym Uηiversity

** 단국대학교 의과대학 방사선과학교실 ** Departmeηt 01 Radiology, Daηkμk University College 01 Medicine 이 논문은 1992년 3월 11일 접수하여 1992년 8월 1일에 채택되 었음. Received March 11 , Accepted August 1, 1992

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serologic test. There were 34 man and 7 women , 26-77 years old (mean ,48 years) . Patients with

concomitant bile duct stones or cancer were ex­

cluded (7 cases). For comparison , we perform­

ed the same work in 15 normal cholangiograms , 15 cholangiograms with stone disease and 15

cholangiograms with carcinoma of the ex­

trahepatic bile ducts. Cholangiograms with in­

adequate contrast filling were excluded.

To determine the degree of visulaized in­

trahepatic ducts we divided the main intrahepatic

ducts into three main ducts;anterior division and

posterior division of the right main hepatic duct

and the left main hepatic duct and secondary , tertiary , quaternary , and more peripheral

tributaries upto 6th tributaries (Fig. 1) and

counted the number of the visualized bile ducts.

We statistically analyzed the data by Kruskal-

、'"allis test and Mann-Whitney tes t.

RESULTS

N umber of visualized intrahepatic duct

tributaries are summarized in Table 1. On

cholangiograms of clonorchiasis, peripheral small

bile ducts were dilated and visualized up to the

far peripheray of the liver;usually to the 5th or

the 6th intrahepatic duct tributaries in the right

and left lobes . Number of the visualized ducts was much greater than that in normal or stone

disease patients , especially in the 5th and the 6th

tributaries (p<O.05)

The number of the visualized bile ducts in in-

Ki Soon Park, et al : Too Many Ducts Sign

Fig. 1. Schematic Diagrams of the Intrahepatic Bile Duct Tributaries 1. Right and left main hepatic ducts 2. Right anterior and posterior divisions

Left superior and inferior segmental ducts Ducts draining caudate lobe Ducts draining medial lobe of the left lobe

dividual duct from the tertiary to the 6th

tributary is summarized in Table 2-5.

There was no significant difference in the

number of the visualized ducts from the secon­

dary to the 6th intrahepatic duct tributaries be­

tween normal and stone disease (p>O.05)

N ormal cholangiogram or stone disease show­

ed smaller caliber of bile ducts to the 5th and

the 6th tributaries, and the number of these ducts

was smaller than that in clonorchiasis (p< O.05

respectively from 3rd to 6th tributary). Car­

cinoma of the extrahepatic bile ducts revealed

as many visualized intrahepatic ducts as clonor­

chiasis without significant statistical difference

in all of the small branches; 3rd , 4th , 5th and

6th tributaries (p>O.05 , respectively) . However, in the 3rd tributary carcinoma revealed no

statistical difference from normal or stone group ,

Table 1. Number of Visualized Tributaries of the Intrahepatic Ducts

Bile duct Right main duct Left main duct

Anterior division Posterior division

Disease III IV V VI III IV V VI 11 III IV V VI

Normal 2.2 4.9 2.7 0.7 2.4 5.3 2.7 0 .4 2.5 4.9 2.2 0.2 0 Stone 1.9 4.5 2.5 0.5 2.8 6.4 3.3 0.5 3.5 5.1 2.6 1. 1 0 Cancer 3.3 7.8 6.0 2.0 3.8 8.9 6.6 1.9 3.7 5.5 5.7 1.5 0 Clonorchiasis 2.4 6.8 6. 3 2.2 3.1 8.1 7.2 2.6 3.8 7.3 6.3 1.6 0.7

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Journa l of Korean Radi이ogica l Society 1992; 28(5) : 744~748

DISCUSSION and in the 4th and 6th tributary revealed no

statistical difference from normal (p>O.05 respec­

tively) Cholangiographic findings of clonorchiasis

Table 2. Number of Visualized T ertiary Intrahepatic Duct Tributaries

Number 1 - 5 6 - 10 11 - 15 16 - 20 > 20 Total Case

Normal 2 (13.3) 4 (26.7) 8 (53.3) 1 ( 6.7) 0 15 Stone 1 ( 6.7) 8 (53.3) 5 (33.3) 1 ( 6.7) 0 15 Cancer o ( 0) 5 (33.3) 5 (33.3) 5 (33.3) 0 15 Clonorchiasis 1 ( 2.9) 10 (29.4) 7 (20.6) 14 (41. 2) 2 (5.9) 34

p<0.05 Note.-Numbers in parentheses are percentages

Table 3. Numbers of Visuali zed Quaternary Intrahepatic Duct Tributaries

Number 0 1 - 10 11 - 20 21 - 30 >30 Total Case

Normal 1 (6.7) 4 (26 .7) 7 (46.7) 2 (13.3) 0 15 Stone 1 (6 . 7) 3 (20.0) 7(46.7) 4 (26.7) 0 15 Cancel o (0 ) o ( 0 ) 6 (40.0) 9 (60.0) 0 15 Clonorchiasis 1 (2.9) 6 (17.6) 5 (14.7) 10 (29.4) 12 (35.3) 34

p<0.05 Note.-Numbers in parentheses are percentages

Table 4. Numbers of Visualized 5th Intrahepatic Duct Tributaries

Number 0 1 - 10 11 - 20 >20 Total Case

Normal 3 (20.0) 9 (60.0) 3 (20 .0) 0 15

Stone 3 (20.0) 7 (46.7) 5 (33 .3) 0 15

Canrer o ( 0) 4 (26.7) 8 (53 .3) 3(20.0) 15

C lonorchiasis 5 (14.7) 3 ( 8.8) 10 (29.4) 16 (47.1) 34

p<005 Note.-Numbers in parentheses are percentages

Table 5. N umber of Visualized 6th Intrahepat ic Duct Tributaries

Numbel 0 1 . 5 6 - 10 >10 Total

Case

Normal 9 (60.0) 6 (40.0) 0 0 15

Stone 10 (66.7) 4 (26.7) 1 ( 6.7) 0 15

Cancer 6 (40 .0) 4 (26.7) 3 (20.0) 2 (13. 3) 15

C lonorchiasis 11 (32.4) 5 (14 .7) 6( 17.6) 12 (35.3) 34

p<0.05 Note.-Numbers in parenthessc are percentages

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have been well described (1-11) such as the

characteristic diffuse dilatation of peripheral

small bile ducts with no or minimal dilatation

of the large bile ducts.

The main factor in pathogenesis of clonor­

chiasis is mechanical obstruction of the smaller

bile ducts; tertiary , quaternary or more

peripheral tributary of the intrahepatic ducts by

f1uke itsel f. Thus the number of visualized small

and medium sized ducts are closely ralated to

the severity and stage of the disease. The severity

of the ductal dilatation depends on the number

of f1ukes present and the repetition and period

ofinfestation (4 ,8 ,12). Actually in mild infesta­

tion , few defects are scattered within the dilated

bile ducts. In severe infestation , the tributaries

of the biliary tree are obstucted , and peripheral

filling by contrast medium is interrupted. The

contour of the bile ducts is smooth or somewhat

irregular with or without obstruction according

the the actual stage ofthe disease (8 ,10 ,13). In

active stage of infestation peripheral ductal

obstruction by f1ukes and increased mucus secre­

tion may decrease the number of visualized

ducts . In inactive clonorchiasis Lim (14) sug

gestedthat dilated ducts are rather smooth and

contrast medium filled up to the far periphery

of the liver without obstruction , giving the ap­

pearance of “ too many ducts sign' ’ The “ too

many ducts sign " is not due to actual increase

in the number of the bile ducts but due to con­

trast filling all of dilated peripheral ducts .

In this study , cholangiograms in clonorchiasis

showed visualization of many bile ducts , especial­

ly small and medium sized intrahepatic duct (i.e ’

tertiary , quaternary , and more peripheral

tributariesup to the 6th tributary) in both right

and left lobe of the liver . The number of visualiz­

ed ducts in clonorchiais was much more than that

in normal cholangiograms and in patients with

stone disease. On the other hand carcinoma

revealed no statistica1 difference from normal and

stone group in the 3rd tributary and no difference

from normal group in the 4th and 6th tributary.

Ki Soon Park , et al : Too Many Ducts Sign

But there was no significant statistical difference

in number of the visualized bile duct tributaries

(from teritiary to 6th tributary) between

clonrochiais and carcinoma of the extrahepatic

bile ducts. With these results , it is considered that

“ too many ducts sign' ’ is not a unique but one

of characteristic cholangiographic findings of

clonorchiasis . We believe that in the persence of

this sign with other well known cholangiographic

findings clonorchiasis should be considered

We think that our statistical evaluation has

some limitations. In some of our clonorchiasis

cases , rather small number of biliary tributa ries

were visualized. It was considered as due to in

adequate contrast filling owing to obstruction by

f1ukes and increased mucus material within the

bile ducts , suggesting active stage with severe in­

festation (4 ,5,8). Insufficient amount of contrast

mediaum to visualize the dilated peripheral ducts

and poor mlxmg due to increased secretion

within the ducts may have played the additional

role. Larger number of cases are needed before

more accurate statistic evaluation between the

two grpups , clonorchiasis and extrahepatic bile

duct carcinoma.

REFERENCES

1. Lim]H , Ko YT , Lee DH , Lee KS , Suh S] , 씨fO

SK. Clonorhiasis and it s compli ca ti ons cholangiogram revisited.

2. Ameres ]P , Levine MP , DeB lash HP Acalculous clonorchiasis obstructing the co m­mon bile duct: a case report and review of the literature. Am Surg 1976 ;42: 170-172

3. Chan PH , T eoh TB. The pathology of Clonor­chis sinensis infestat ion 0 1' the pancreas . ] Pathol BacterioI1967 ;93 :1 85 -1 89

4 이순형， 심태섭， 이상운， 지제근. 간흡충증감염 백서간

의 병리학적 변화 기생충학잡지 1978 : 16 : 148-155

5. Okuda K , Em ura T , Mor아<uma K , Kojima S,

Yokagawa M . C lonorchias is studied by per­cutaneous cholan giography and a therapeutic trial of tolu ene-2 , 4-dii so -thiocya na te Gastroenterology 1973;65 :457 -461

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Journal of Korean Radi이ogical Society 1992 ; 28 (5) : 744~ 748

6. Clemett AR. The interpretation of the direct

cholangiogram. In: Berk RN , Clemett AR , eds

Radiology of the gallbladder and bile ducts

Philadelphia : Saunders , 1977 ;285-330

7. 이정일， 유지홍， 임규성， 이창홍， 민영일， 임재훈. 간

홉충증 환자의 내시경적 역행성 담도조영술 소견. 대한

소화기내시경학회잡지 1981 : 1 : 29-32

8. 강익원 서홍석， 임동란， 연경모. 간흡충의 방사선학적

소견. 대한방사선의학회지 1980 : 15: 159-162

9. Choi TK, Wong KP, WongJ. Cholangiographic

appearance in clonorchiasis . Br J Radiol 1984;

57:681-684

10. Lim JH. R adiologic findings of clonorchiasis.

〈국문 요약〉

AJR 1990;155 :1001-1008 11. Lim JH , Ko YT. Clonorchiasis of the pancreas.

Cl inical Radiology 1990; 41 : 195-198

12. Rim HJ. The current pathobiology and

chemotherapy of clonorchiasis . Korean J

Parasitol 1986;24 (suppl): 7-20 13 . Ameres JP , Levine MP , DeBlash HP

Acalculous clonorchiasis obstructing the com­

mon bile duct: a case report and review of the

literature . Am Surg 1976 ;42: 170-172

14 임재훈， 고영태， 이동호. 비활동성 간홉충증 · 담도조영

술. 대한방사선의학회지 1990 : 26 : 996-999

다관증후 (Too Many Ducts Sign)

한림대학교* 경희대학교， 단국대학교** 의과대학 방사선과학교실

박 기 순* • 임 재 훈 • 이 관 섭 * . 유 필 문**

이미 알려진 간홉충증의 담도조영소견 외에 많은 수의 중간 및 세답관이 조영되어 관찰되는 다관증후(too many

ducts sign) 소견이 간홉충증의 또다른 특징적인 담도조영 소견으로， 이는 정상 또는 다른 간외담도 질환에서는 보

이지 않는 독톡한(유일한) 소견임을 알아보기 위해 본 연구를 시도하였다.

41명의 간홉충증 환자에서 시행한 담조조영 (cholangiogram)상 조영되어 관찰되는 간내 담관을 해부학적으로 6번

째 세담관(6th trlbutary) 까지 나누고 그 보이는 간내담관의 숫자를 세어 각각 15례의 정상 및 간외 담도결석， 간외

담도암 환자와 비교하였다.

간홉충층의 경우 담도조영상 간내 담관이 중간 크기 담관과 주변부 세담관들이 5번째나 6번째 분지까지 뚜렷이 관

찰되며 그 숫자도 정상 또는 간외담도 결석에서 보다 월등히 많았다. 간외 담관암의 경우 중간 크기의 3번째， 4번째

분지가 특히 많이 관찰되며 5번째나 6번째의 세담관 분지에서는 그 숫자가 간홉충증보다 비교적 적었으나 간홉충증

과 통계학적 차이는 없었다.

결론적으로 담도조영술상 관찰되는 다관증후 (too many ducts sign) 소견은 간홉충증에서만 나타나는 유일한 소견

만은 아니나 이미 알려진 간홉충증의 다른 소견들과 같이 관찰되면 간홉충증의 진단에 도움이 된다고 사료된다.

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