Bien AgNina Ian John “G” Rachel Mark Jocelle Edo Gienah Jho Kath Aynz Je Glad Nickie

Ricobear Teacher Dadang Niňa Arlene Vivs Paul F. Rico F. Ren Mai Revs Mavis Jepay Yana Mayi Serge Hung Tope

S4 L7: TREMATODES (LIVER FLUKES) by Maria Cielo B. Malijan, MD, DPPS, FPSDBP

Liver Flukes Clonorchis sinensis

Clonorchis sinensis Common Name: CHINESE LIVER FLUKE
Opistorchis felineus
Opistorchis viverinii Diseases
Fasciola hepatica Clonorchiasis
Fasciola gigantica Liver Cancer
Dicrocoelium dendriticum
Geographic Distribution
Life Cycle an important parasite of humans in the Far East
All trematodes follow the above cycle, EXCEPT Schistosoma sp. a parasite of fish eating mammals and humans in Japan, China,
Adult liver flukes that live in the biliary passages irritate the ducts. South Korea, Formosa and Vietnam
Adenomatous proliferation can result to partial obstruction.
Morphology
Flat, spatulate, aspinous, flabby, transparent gray worm tapering
anteriorly and somewhat rounded posteriorly
Measures 12 to 20 mm (10 to 25 mm) by 3 to 5 mm
Ventral sucker smaller than oral sucker
Long intestinal ceca extending to the posterior end
Large deeply lobulated or branched testes in tandem formation in
the posterior third of the body
Small, slightly lobate ovary anterior to the testes in the midline
Loosely coiled uterus arising from the ootype ending in the common
genital pore
Minutely follicular vitellaria in the lateral midportion of the body

Adult Trematodes
Flat, elongated, leaf-shaped
Ovoid, conical or cylindrical depending on state of contraction
Integument may be covered with spines, tubercles or ridges(partially
or completely)

Adult Trematodes (Prototype)

All trematodes are hermaphroditic EXCEPT the blood flukes
(Schistosoma sp.)

Ovum
Broadly ovoid, 29 x 16 u
Has a moderately thick, light
yellowish brown shell
At the smaller end is a distinct
convex operculum which fits into a
rimmed extension of the shell.
At the thicker posterior end is a small median protuberance.

Life Cycle

Trematode Egg (Prototype)

Contains a fertilized ovum
Shape, appearance and size – depending on the species
Contains a cap-like operculum, EXCEPT Schistosoma sp.

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 Praziquantel
o 25 mg/kg TID for 2 consecutive days or 75 mg/kg in 3
doses 4 to 6 hours apart
o no treatment failure and only mild side effects –
headache and dizziness
Heavy infections complicated by obstructive jaundice
o cholecystectomy with choledocholithotomy
o exploration of the common duct
o drainage procedure such as sphincteroplasty or
o choledochoduodenostomy

Prevention and Control

thorough cooking of all freshwater fish
sterilization of human feces by storage or by the addition of
ammonium sulfate
human and animal feces should not be disposed in bodies of water

Opistorchis felineus
Common Name: CAT LIVER FLUKE

Disease: Opistorchiasis felineus

Geographic Distribution
prevalent in eastern and southeastern Europe and Asiatic areas of
the former USSR
found in humans in the highly endemic areas of Poland and the
Dnieper, Donetz and Desna basins
Pathology
distal bile ducts are irritated mechanically and by its toxic secretions Morphology
slight leukocytosis and eosinophilia in early infection lancet in shape 7 to 12 mm by 2 to 3 mm
enlarged tender liver rounded posteriorly and attenuated anteriorly
bile ducts thicken and become dilated and tortuous thin and transparent; reddish bile colored
adenomatous proliferation of the biliary epithelium has a smooth integument
fibrosis and destruction of hepatic parenchyma two suckers equal in diameter; oral sucker subterminal
liver function is impaired although SGPT and SGOT are normal two testes lobed and situated obliquely to each other in the posterior
fourth of the worm
Symptomatology ovary small, oval or slightly lobed is median in position just in front of
Light infections the anterior end of the bladder
o produce only mild symptoms or go unnoticed vitellaria consist of numerous transversely compressed follicles
Moderate infections disposed in the lateral fields in the middle third of the body
o indigestion uterus – an intricately coiled tubule from the ootype that proceeds
o epigastric discomfort unrelated to meals anteriad
o weakness
o loss of weight
Heavy infections
o complicated by cholelethiasis and bouts of pyogenic cholangitis

Diagnosis
Clinical Diagnosis
o suggestive in patients from endemic areas with:
 history of eating uncooked fish
 symptoms of biliary tract disease
 intermittent jaundice
 bouts of fever
 right upper quadrant pain
Laboratory Diagnosis
o finding the characteristic eggs in the feces or biliary Ovum
drainage or duodenal aspiration resembles Clonorchis sinensis but:
o eggs to be differentiated from opistorchid and heterophyid o is narrower and has more
flukes tapering ends
o a pointed terminal knob
Treatment o a less conspicuous
Chloroquine Diphosphate operculum
o 250 mg TID for 6 weeks elongate, ovoid in shape with an
o with treatment failure and side effects including optic operculum that fits into a thickened
neuropathy rim of the shell proper

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 light yellowish brown and are about three times as long as broad o loss of appetite as patient becomes toxic
a minute tubercular thickening at the posterior end o scar tissue around the bile ducts encroaches on liver cells
has a miracidium when laid and portal vessels  collateral venous circulation,
edema of the face and limbs and at times ascitis
Life Cycle
Diagnosis
Clinical Diagnosis
o suggestive in patients from endemic areas with:
 history of eating uncooked fish
 symptoms of biliary tract disease
 intermittent jaundice
 bouts of fever
 right upper quadrant pain

Laboratory Diagnosis
o finding the characteristic eggs in the feces or biliary
drainage or duodenal aspiration

Treatment
Praziquantel
Intermediate snail hosts are infected by feces deposited on sandy o 40 mg/kg body weight in a single dose after a meal
shores and washed into streams. o Side effects – abdominal pain, vomiting, diarrhea,
Definitive hosts – cats, dogs, fox, wolves, seals lassitude, myalgia, headache and rashes
Accidental final host – man
Can cause bile stones, destruction of the bile ducts and liver Prevention
thorough cooking of all freshwater fish
sterilization of human feces by storage or by the addition of
ammonium sulfate
human and animal feces should not be disposed in bodies of water.

Opistorchis viverinii
Disease: Opistorchiasis viverrini

Geographic Distribution
an important human parasite in northeastern Thailand and in the
northernmost province of Udorn

Morphology
It can be distinguished from Opistorchis felineus:
o greater proximity of its ovary and testes, both of which
are deeply lobulated
o aggregation of its vitellaria into a few clusters of glandular
material
o esophagus is elongated

Pathology
inflammatory and proliferative changes of the biliary epithelium
fibrosis of the distal biliary vessels
pathologic changes may extend to the proximal bile ducts and
gallbladder  periportal fibrosis

Symptomatology
Light infections
o asymptomatic
Moderate infections
o moderate, painful enlargement of the liver
o passive congestion of the spleen Ovum
o icterus Eggs are relatively
o local eosinophilia in the wall of the bile ducts short and broad,
Heavy infections 26.7 x 15 um.
o invade the pancreas with digestive disturbances
o bile stones may form around eggs as nuclei and cause
cholecystitis with colic

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Family Dicrocoellidae Diagnosis
small to medium-sized flukes that live in the bile or pancreatic ducts Clinical Diagnosis
of birds and mammals o suggestive in patients from endemic areas with:
elongate with well developed suckers  history of eating uncooked fish
notable feature – position of the testes anterior to the ovary  symptoms of biliary tract disease
eggs are small, with a thick brown shell and embryonated when laid  intermittent jaundice
 bouts of fever
Life Cycle  right upper quadrant pain
Laboratory Diagnosis
o finding the characteristic eggs in the feces or biliary
drainage or duodenal aspiration
o Ultrasonography to screen the presence of
cholangiocarcinoma

Treatment
Praziquantel
o 25 mg per kg body weight TID for two days

Prevention and Control

Natural definitive hosts - civet cat, cat, dog and other fish- eating
thorough cooking of all freshwater fish
mammals
sterilization of human feces by storage or by the addition of
Accidental host – man
ammonium sulfate
human and animal feces should not be disposed in bodies of water.

Fasciola hepatica
Common Name: SHEEP LIVER FLUKE

Diseases
Fascioliasis hepatica
Sheep Liver Rot
Pharyngeal Fascioliasis or Halzoun

Geographic Distribution: has a cosmopolitan distribution and prevalent in

sheep raising countries

Morphology
Large size, 20 to 30 mm by 8 to 13 mm
Flat, leaf shaped with characteristic shouldered appearance from its
cephalic cone
Oral and ventral suckers of equal size on the cephalic cone
Intestine with numerous diverticula
Highly dendritic testes in tandem formation
Diffusely branched vitellaria in lateral and posterior portions of the
body
Short convoluted uterus

Pathology
dilatation and thickening of bile duct walls
presence of stones and sludge in the gallbladder
hyperplastic biliary epithelium from presence of worms
further stimulated by nitrosamines in local fermented foods or by
nitrosocompounds produced by activated
macrophages in chronically affected tissues
striking association with cholangiocarcinoma

Symptomatology
mild to moderate infections
o few symptoms
heavy infections Ovum
o abdominal distress large, oval, yellowish brown operculated egg
o epigastric pain measures 130-150 u x 63-90 u
o generalized malaise unsegmented at oviposition

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Life Cycle o Heavy infections
 erosion of the epithelium
 young worms wander back into the liver to
produce abscess pockets and to seed the vital
liver tissue with their eggs

Symptomatology
colic and obstructive jaundice
coughing and vomiting
generalized abdominal rigidity
acute epigastric pain and tenderness
urticaria
early leukocytosis and eosinophilia
irregular fever
more or less persistent diarrhea
Natural definitive hosts - herbivorous animals like sheep marked anemia
o Herbivorous or ominivorous animals acquire the infection hemoglobinuria
in low, damp pastures, where the vegetation is infested cholelithiasis – common complication
with metacercaria.
Accidental host – man PHARYNGEAL FASCIOLIASIS OR HALZOUN
Goes to the liver and bile duct, causing destruction due to ingestion of infected raw sheep and goat livers
Adult worm lodges temporarily in the pharyngeal mucosa causing:
o edematous congestion of the soft palate, pharynx, larynx,
nasal fossae, Eustachian tube  suffocation
o dyspnea
o deafness
o asphyxiation

Diagnosis
Clinical Diagnosis – based on:
o biliary symptoms
o moderate to high eosinophilia
o eating watercress as a green salad (metacercaria in
vegetation)
Laboratory Diagnosis
o recovery of the eggs in the patient’s stool or from
duodenal or biliary tract drainage
o Serodiagnosis – helpful but not adapted for routine
diagnosis

Differential Diagnosis
acute hepatitis of other etiology
cholecystitis
cholelithiasis
cirrhosis resulting from other causes

 False fascioliasis – due to ingestion of infected livers with passage of

Pathology eggs in the feces
Acute or Invasive Phase  Keep the patient on a liver free diet for 3 days or more
o period during which the fluke migrates from the intestine o False fascioliasis – eggs no longer seen
to the liver and its burrowing through the liver o True fascioliasis – eggs can still be seen
parenchyma
o no significant change from the intestine to the liver Treatment
o parasite may wander or be carried by blood after bithionol (dichlorophenol)
penetrating a blood vessel to ectopic sites such as lungs, o 30 to 50 mg/kg per
subcutaneous tissues, brain and the orbit  abscesses o body weight on alternate days to complete 10-15 doses
or fibrotic lesions
dehydroemetine hydrochloride
o Migration to the liver parenchyma
o 1 mg per kg daily intramuscularly for 10 days
o traumatic and necrotic lesions
emetine hydrochloride
Chronic or Latent phase
o 30 mg daily for 17 or 18 days intramuscularly or 40 mg
o period when the parasite has already reached the bile
daily to a total of 5 mg per kg body weight
ducts
hexachloroparaxylene
o obstruction in the vessel
o favorable results as reported from Russia
o inflammatory and adenomatous changes of the biliary
epithelium praziquantel
o fibrosis of the ducts o probably effective as in other liver fluke infections
o pressure atrophy of the liver parenchyma
o intensive periductal fibrosis

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Prevention and Control Dicrocoelium dendriticum
thorough washing or cooking of vegetables Common Name: LANCET FLUKE
boiling of water in areas where the infection is endemic
(metacercaria in vegetation) Disease: Dicrocoeliasis
elimination of the snail intermediate hosts
killing the parasites in the reservoir hosts by chemotherapy Geographic Distribution: has a cosmopolitan distribution in sheep and other
herbivors in Asia, Africa, Europe and North and South America

Fasciola gigantica Morphology

Common Name: GIANT LIVER FLUKE slender, lancet shaped, flat transparent, aspinous body 5-15 mm x
1.5-2.5 mm
Disease: Fascioliasis gigantica acetabulum lies at the beginning of the second fifth of the body
two large, slightly lobed testes situated obliquely to each other
Geographic Distribution: parasite of herbivorous mammals particularly anterior to the small subglobose ovary just behind the ventral sucker
camels, wild hogs, cattle and water buffalo in Africa, Asia and Hawaii voluminous uterine coils in the posterior thirds of the worm
subglobose ovary lies to the right of the midline and somewhat
Differences from Fasciola hepatica anterior to the equator of the worm
more elongated or lanceolate discrete vitelline follicles occupy lateral fields in the middle of the
cephalic cone is shorter and less prominent body
ventral sucker is larger
testes are more anterior in position
shoulders are practically lacking
eggs are larger

Ovum
deep golden-brown thick shelled, distinctly
operculated, measuring 38 to 45 u by 22 to
Family Opistorchiidae 30 u containing a fully developed miracidium.
parasites of the bile ducts and gall bladder
small to medium-sized, usually elongate and relatively delicate with
weakly developed suckers Life Cycle
testes located posteriorly may be branched or lobed
ovary is near midbody
coiled uterus fills the area between the ovary and ventral sucker
eggs are small and are fully embryonated

Life Cycle

1. Principal definitive host – sheep and other herbivorous mammals

2. Accidental final host – man

Natural definitive hosts - Cattle, buffaloes, camels, wild hogs and

other herbivores
Accidental host - man

Pathology
Symptomatology same as
Treatment Fasciola hepatica
Prevention and Control

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 o enlarged liver
o systemic toxemia less pronounced that in fascioliasis

Laboratory Diagnosis
finding the eggs consistently in the feces and duodenal drainage
eliminate spurious infections from eating livers containing the eggs

Treatment – same as Clonorchis sinensis

Praziquantel – 25 mg per kg TID for 2 consecutive days

Prevention and Control

no effective measures of control
fresh herbs collected from grazing areas for use as food for humans
should be washed to remove the ants.

-----------------------------------------END OF TRANS-----------------------------------------

Pathology – same as Fasciola hepatica

in animals
o enlargement of the bile ducts
o hyperplasia of the biliary epithelium
o formation of the periductal fibrous connective tissue
o atrophy of the liver cells
o portal cirrhosis in heavy infections
in humans --Ayna Due
o hepatic changes are less pronounced

Symptomatology
in humans
o digestive disturbances Ang trans na ito ay inihahandog ng...
o flatulence MiCrObIoMaN
o vomiting
o biliary colic
o chronic constipation or diarrhea

Scientific CN Morphology Ovum Infective Diagnostic 1st IH 2nd IH Final Host AFH
Name Stage Stage
Clonorchis Chinese Highly dendritic or deeply Rimmed, With Metacercaria Embryonated Snail Freshwater Man
sinensis Liver lobulated testes in tandem small ova Fish
Fluke protuberance
Opistorchis Cat Liver Testes are lobed and Rimmed, With Metacercaria Embryonated Snail Freshwater Cat, Dog, Fox, Man
felineus Fluke oblique to each other small ova Fish Wolf, Seal
protuberance
Opistorchis Testes are lobed and Rimmed, With Metacercaria Embryonated Snail Freshwater Civet cat, Cat, Man
viverinii oblique to each other small ova Fish Dog, other
protuberance Fish-eating
mammals
Fasciola Sheep Cephalic cone, Oval Metacercaria Unembryonated Snail Aquatic Herbivorous Man
hepatica Liver (+)Shoulder, Dendritic ova Vegetation Animals like
Fluke intestinal ceca & testes Sheep

Fasciola Giant Cephalic cone is shorter & Oval Metacercaria Unembryonated Snail Aquatic Camels, Wild Man
gigantica Liver less prominent, ova Vegetation hogs, Cattle,
Fluke (-)Shoulder, Dendritic Water buffalo
intestinal ceca & testes

Dicrocoelium Lancet Uterine coils in posterior Oval, Deep Metacercaria Embryonated Snail Ants Sheep Man
dendriticum Fluke 1/3, Vitelline follicles in golden brown ova
middle 1/3

CN – Common Name 1st IH – First Intermediate Host 2nd IH – Second Intermediate Host AFH – Accidental Final Host

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