LIVER FLUKES

Family Fasciolidae
• Relatively large distomes with the ventral sucker
(acertabulum) close to the oral sucker
• Terument often spinose
• Testes usually branched
• Vitellaria filling much of the lateral fields and confluent
posterior to the testes
• Uterus short
• Eggs large and undeveloped when laid
• Species that are parasites of man
a. Fasciola hepatica – liver fluke
b. Fasciola gigantica – liver fluke
c. Fasciolopsis buski – intestinal fluke

Fasciola hepatica

Scientific name: Fasciola hepatica

Common name: sheep liver fluke
Disease produced:
Fascioliasis hepatica
Sheep liver rot pharyngeal
fascioliasis or halzoun
Life Cycle of Fasciola hepatica. (a) adult worm in bile duct of sheep
and other mammal. (b) egg (c) miracidium (d) mother sporocyst (e)
mother sporocyst with developing rediae (f) redia with developing
cercariae (g) free-swimming cercaria (h) mecercaria, encysted on
aquatic vegetation (i) host animals eating vegetation (j) flukes
released from cyst

Geographic distribution: Has a Pathology

cosmopolitan distribution and prevalent 1. acute or invasive phase – period during which the
sheep raising countries fluke migrates from the intestine to the liver
and its burrowing through the liver
Morphology parenchyma
• Large size, 20-30 mm by 8-13 mm a. no significant change from the intestine to the liver
• Flat, leaf shaped with characteristic shouldered 1. parasite may wander or be carried by blood after
appearance from its cephalic cone penetrating a blood vessel to ectopic sites such as
• Oral and ventral suckers of equal size on the cephalic lungs, subcutaneous tissues, brain and the orbit 
cone abcesses or fibrotic lesions
• Intestine with numerous diverticula
• Highly dendritic testes in tandem formation b. migration to the liver parenchyma- traumatic and
necrotic lesions
• Diffusely branched vitellatia in lateral and posterior
portions of the boidy 2. chronic or latent phase - period when the parasite has
• Short convolutes uterus already reached the bile ducts
a. obstruction in the vessel
b. inflammation and adenomatous changes
of the biliary epithelium
c. fibrosis of the ducts
d. pressure atrophy of the liver parenchyma
e. intensive periductal fibrosis
f. heavy infections
1.erosion of the epithelium
2.young worms wander back into the
liver
a. to produce abscess pockets
b. to send the vital liver tissues
with their eggs

Symptomatology
• colic and obstruction jaundice
• coughing and vomiting
• general abdominal rigidity
• acute epigastric pain and tenderness
• urticaria
• early leukocytosis and eosinophilia
• irregular fever
• more or less persistent diarrhea
• marked anemia
• hemoglobinuria
• cholethiasis – common complication

Life cycle Pharyngeal fascioliasis or halzoun

1. adult flukes in bile ducts of host animals • due to ingestion of infected raw sheep and goat livers
2. egg in feces • adult worm lodges temporarily in the pharyngeal mucosa
3. eggs develop in water; hatched releasing miracidium causing:
(miracidium penetrates snail)
4. mother sporocyst
a. edematous congestion of the soft palate, pharynx,
5. mother sporocyst with developing rediae larynx, nasal fossae, Eustachian tube  suffocation
6. rediae with developing cercariae b. dyspnea
7. cercariae released in water c. deafness
8. metacercariae encysted on vegetation d. asphyxiation
9. vegetation eaten by host animals
(young flukes released from cyst)
Diagnosis

Clinical – based on

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 • biliary symptoms
• moderate to high eosinophilia
• eating watercress as a green salad
Laboratory
• recovery of the eggs in the patient’s stool or form
duodenal or biliary tract drainage
• serodiagnosis – helpful but not adapted for routine
diagnosis
• boiling of water in areas where the infection is endemic
Control measures
• elimination of the snail intermediate hosts
• killing the parasites in the reservoir hosts by
chemotherapy

Fasciola hepatica ova

Fasciola gigantica

Fasciola hepatica ova

Scientific name: Fasciola gigantica

Common name: giant liver fluke

• large, oval, yellowish brown Disease produced: Fascioliasis

operculated egg
• measures 130 – 150 u b y
63 – 90 u
• unsegmented at oviposition
gigantica
Geographic distribution: parasite of herbivorous mammals
particularly camels, wild hogs, cattle, and water buffalo in Africa,
Asia and Hawaii

Differential diagnosis
• acute hepatitis of other etiology
• cholecystitis Differs from Fasciola hepatica
• cholelithiasis
• cirrhosis resulting from other causes
• more elongated or lanceolate
False fascioliasis –due to ingestion of infected • cephalic cone is shorter and les prominent
livers • ventral sucker is larger
Passage of eggs in the feces • testes are more anterior in position
• shoulders are practically lacking
*Keep the patient on a liver free diet for 3 days
• eggs are larger
or more

false fascioliasis – eggs no longer seen

true fascioliasis – eggs can still be seen

Epidemiology
• definitive hosts are herbivorous animals like sheep
• man is an accidental final host
• 1st intermediate host – Lymneid snail
a. Lymnaea philippinensis
b. Lymnea swinhoe
• 2nd intermediate host – aquatic vegetation – watercress
• humans contract the disease by ingesting plants sush as Family Opistorchiidae
watercress or possibly water containing the encysted • parasites of the bile ducts and gall bladder
metacercaria • small to medium-sized, usually elongate and relatively
• herbivorous or omnivorous animals acquire the infection delicate with weakly developed suckers
in low, damp pastures, where the vegetation is infested • testes located posteriorly may be branched or lobed
with metacercaria • ovary is near midbody
• coiled uterus fills the area between the ovary and ventral
sucker
• eggs are small and are fully embryonated
*Lymnea swinhoei – 1st intermediate host of
Fasciola hepatic in Taiwan
Clonorchis sinensis

Scientific name: Clonorchis sinensis

Common name: Chinese liver fluke

Treatment
• bithionol (dichlorophenol) – 30-50 mg/kg per body weight
on alternate days to complete 10-15 doses
• dehydroemetine hydrochloride – 1 mg per kg daily
intramuscularly for 10 days
• emetine hydrochloride – 30 mg daily for 17-18 days
intramuscularly or 40 mg daily to a total of 5 mg/ kg body
weight
• hexachloroparaxylene – favorable results as reported
from Russia
• praziquantel – probably effective as in other liver fluke
infections
Prevention and Control
Preventive measures
• thorough washing or cooking of vegetables
Disease produced: Clonorchiasis
Geographic distribution:
• an important parasite of
Humans in the Far East
• a parasite of fish eating
mammals and humans in Japan, China, South Korea,
Formosa and Vietnam
Morphology
• flat, spatulate,aspinous, flabby, transparent gray worm
tapering anteriorly and somewhat rounded psoteriorly
• measures 12-20 mm (10-25 mm) by 3-5 mm
• ventral sucker smaller that 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

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 • 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

Pathology
• distal bile ducts are irritated mechanically and by toxic
secretions
• slight leukocytosis and eosinophilia in early infection
• enlarged tender liver
• bile ducts thicken and become dilated and tortuous
• adenomatous proliferation of the biliary epithelium
• fibrosis and destruction of hepatic parenchyma
• liver function is impaired although SGPT and SGOT are
normal

Life cycle
1. egg containing miracidium
2. miracidium hatches after being eaten by snail
3. sporocyst
4. redia
5. cercaria
6. cercaria leaves snail and penetrates fish
7. metacercarial cysts in fish muscle
8. human (adult in bile duct liver) *Cholangiocarcinoma of the liver. Severe chronic infection may
9. lead to marked pericholangitic fibrosis and finally mulitfocal
cholangiocellular carcinoma of the liver

Symptomatology
• light infection – produce only mild symptoms or go
unnoticed
• moderate infections: indigestion, epigastric discomfort
unrelated to meals, weakness, loss of weight
• heavy infections – complicated by cholekethiasis and
bouts of pyogenic cholangitis

Epidemiology
• man is the definitive host
• 1st intermediate host – operculate snails of several
genera, including Alocinma and Parafossarulus, Bithynia
(Bulimus), Semisulcospira, Melanoides, tuberculatus
• 2nd intermediate host – fresh water fish of the family
Cyprinidae, Ctenopharyngodon idellus
• humans are usually infected by: eating uncooked fish
containing the infective metacercaria, ingestion of the
cysts in drinking water

*Ctenopharyngodon idellus, a common host for cercariae of

Clonorchis sinensis

Diagnosis

Clinical – suggestive in patients from endemic areas

Life cycle of Clonorchis sinensis (a) Egg containing miracidium is
With
passed in feces. (b) Miracidium hatches after being eaten by snail.
• history of eating uncooked fish
(c) Sporocyst. (d) Redia (e) Cercaria leaves snail and penetrates
fish (f) Metacercarial cysts in fish muscle. (g) Human becomes • symptoms of biliary tract disease
infected by eating raw fish (h) adult fluke in bile duct. 1. intermittent jaundice
2. bouts of fever
3. right upper quadrant pain
Laboratory
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 • finding the characteristic eggs in the feces or biliary
drainage or duodenal aspiration
• eggs to be differentiated from opistorchid and
heterophyic flukes
• 2 testes lobed and situated obliquely to each other in the
posterior fourth of the worm
• ovary small, oval or slightly lobed is median in position
just in front of the anterior end of the bladder
• vitellaria consist of numerous transversely compressed
follicles disposed in the lateral fields in the middle third of
the body
• uterus- an intricately coiled tubule form the ootype that
proceeds anteriad

Clonorchis sinensis ova

• 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
1. adult worms in biliary tract or small intestine
2. eggs excreted on moist soil or water
3. miracidia hatch from eggs of some species. Eggs of other
species eaten by snails (1st intermediate host)
4. after multiplication, cercariae emerge from snail
5. some species encyst on gills, scales or muscles of fish. Other
species encyst on aquatic plants (2nd intermediate host)
5. metacercariae ingested (by man/cat)

Treatment
• Choloroquine diphosphate – 250 mg TID for 6 weeks
(with treatment failure and side effects including optic
neuropathy)
• Praziquantel – 25 mg/lg TID for 2 consecutive days or 75
mg/kg in 3 doses 4 to 6 hours apart (no treatment failure
and only mild side effects: h eadache and dizziness)
• Heavy infections complicated by obstructive jaundice:
1. cholecystectomy with choledocholithotomy
2. exploration of the common duct
3. drainage procedure such as
sphincteroplasty or
choledochoduodenostomy

Preventive measures
• Thorough cooking of all freshwater fish
Control measures
• Education of the public to break the habit of eating raw
fish after seasoning with condiments
• Stopping the seeding of fish culture ponds
• 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

Scientific name: Opistorchis felineus

Common name: cat liver flukes

Disease produced: 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
Morphology
• Lancet in shape 7-12 mm X
2-3 mm
• Rounded posteriorly and
attenuated anteriorly
• Thin and transparent,
reddish bile colored
• Has a smooth integument
• Two suckers equal in
diameter; oral sucker
subterminal
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 – asymptomatic
• moderate infections
1. moderate, painful enlargement of the
liver
2. passive congestion of the spleen
3. icterus
4. local eosinophilia in the wall of the bile
ducts
• heavy infections
1. invade the pancreas with digestive disturbances
2. bile stones mau form around eggs as nuclei and
cause cholecystitis with colic
3. loss of appetite as patient becomes toxic
4. scar tissue around the bile ducts encroaches on liver
cells and portal vessels  collateral venous circulation,
edema of the face and limbs and at times ascitis

Epidemiology
• definitive hosts – cats, dogs, fox, wolves, seals
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 • accidental final host – man
It can be distinguished form Opistorhis felineus
• 1st intermediate host –amnicolid snail Bithynia (Bulimus) • Greater proximity of its ovary and testes both of which
leachi are deeply lobulated
• 2nd intermeciate host – fresh water fish (cyprinoid fish) • Aggregation of its vitellaria into a few clusters of
Tinca tinca, Idus melanotus, Barbus barbus, Cyprinus glandular material
carpio, Abramis brama, A. sapa, ALburnus Iucidus, • Esophagus is elongated
Aspius aspius, Blicca bjorkna, Leuciscus rutilis and
Scardiinius erythopthalamus
• the infection is acquired by eating raw or insufficiently
cooked fish harboring the metacercaria
• intermediate snail hosts are infected by feces deposited
on sandy shores and washed into streams
Life Cycle

* Bithynia funiculate – 1st intermediate host of Opistorchis felineus

* Cyprinus carpio, 2nd intermediate host of Opistorchis felineus in

Taiwan

Laboratory diagnosis
• recovery of the typical eggs in the stool or by duodenal
intubation
1. elongate, ovoid in shape with an operculum that fits
into a thickened rim of the shell proper
2. light yellowish brown and are about three times as
long as broad
3. a minute tubercular thickening at the posterior end
4. has a miracidium when laid
5. resembles Clonorchis sinensis but: Pathologic changes
a. are narrower and have more
tapering ends
b. a pointed terminal knob
c. a less conspicuous opercular
Treatment
• Praziquantel – 40 mg/kg body weight in a single dose
after meal
Side effects – abdominal pain, vomiting, diarrhea, Symptomatology
lassitude, myalgia, headache and rashes
Prevention
• Cooking of fish or abstain form eating raw or
inadequately cooked fish
• Sanitary excreta disposal not effective – reservoir hosts
and man pollute the waters containing the intermediate Epidemiology
hosts
Opistorchis viverrini
Scientific name: Opistorhis viverrini
Common name:
Disease produced: Opistorchiasis viverrini
Geographic distribution: an important
human parasite in northeastern Thailand
and in the northernmost province of
Udorn
• Dilatation and thickening of bile duct walls
• Presence of stones and sludge in the gallbladder
• Hyperplastic biliary epithelium form 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
• Mild to moderate infections – few symptoms
• Heavy infections
1. abdominal distress
2. epigastric pain
3. generalized malaise
• Definitive hosts – civet cat, cat, dog and other fish eating
mammals
• Accidental final host – man
• 1st intermediate host – snails
1. Bithynia goniomphalus
2. Bithynia funiculate
3. Bithynia laevis
• 2nd intermediate host – fresh water fish
1. Punteus orphoides
2. Hampala dispar
3. Cyclocheilichthys siaja
• infection is acquired by eating uncooked fish containing
the infective metacercaria

Laboratory diagnosis
• finding eggs in feces or in duodenal aspirates (eggs are
Morphology relatively short and broad with a length of 36.7 um and
breadth of 15 um)

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 9. ant accidentally eaten by sheep

• ultrasonography – to screen fot he presence of

cholangiocarcinoma

Treatment
• Praziquantel -25 mg/kg body weight TID for 2 days

Prevention and Control

• Same as Opistochis felineus and Clonorchis sinensis

Family Dicrocoellidae

• Small to medium-sized flukes that live in the bile or

pancreatic ducts of birds and mammals
• Elongate with well developed suckers
• Notable feature – position of the testes anterior to the
ovary
• Eggs are small with a thick brown shell and
embryonated when laid

Dicrocoelium dendrticulum

Scientific name: Dicrocoelium

dendriticum

Common name: lancet fluke

Disease produced: Dicrocoeliasis

Geographic distribution: has a

cosmopolitan distribution in sheep and
other herbivore in Asia, Africa, Europe
and North and South America

Morphology
• Slender, lancet shaped, flat transparent, aspinous body
5-15 mm by 1.5-2.5 mm
• Acetabulum lies at the beginning of the second fifth of
the body
• 2 large, slightly lobed testes situated obliquely to each
other anterior to the small subglobose ovary just behind
the ventral sucker
• voluminous uterine coils in the posterior thirds of the
worm
• subglobose ovary lies to the right of themidline and
somewhat anterior to the equator of the worm
• discrete vitelline follicles occupy lateral fields in the
midline of the body
Life cycle of Dicrocoelium dendriticum. (a) Adult, in bile duct of
sheep or other plant-eating mammal. (b) Egg released in feces. (c)
Miracidium hatching from egg after being eaten by snail (d) Mother
sporocyst (e) Daughter sporocyts (f) Cercariae escaping from snail
in slimeball (g) Slimeballs containing cercariae by ant (h)
Metacercaria encysting in ant. (i) Ant accidentally eaten by sheep
Pathology –same as Fasciola hepatica
In animals
• enlargement of the bile ducts
• hyperplasia of the biliary epithelium
• formation of the periductal fibrous connective tissue
• arophy of the liver cells
• portal cirrhosis in heavy infections
In humans
• hepatic changes are less pronounced

Symptomatology
In humans
• digestive disturbances
• flatulence
• vomiting
• biliary colic
• chronic constipation or diarrhea
• enlarged liver
• systemic toxemia less pronounced than in fascioliasis

Life cycle
1. adult worm develops in bile duct of sheep or other plant-eating
mammal
2. eggs released in feces (miracidium in egg)
3. miracidium hatches from egg after being eaten by snail
4. mother sporocyst
5. daughter sporocyst
6. cercariae escaping from snail in slimeball
7. slimeball containing cercariae eaten by ant
8. metacercaria encysts in ant
Epidemiology
• principal definitive host – sheep and other herbivorous
mammals
• accidental final host – man
• 1st intermediate hosts – land snails of the genera Abida,
Cochlicopa, Helicella and Zebrina
• 2nd intermediate hsots – ants, (Formica fusca)
• infection of the mammalian definitive host and man is by
the ingestion of ants harboring the metacercaria
Laboratory diagnosis
• finding the eggs consistently in the feces and duodenal
drainage

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 • eliminate spurious infections form eating livers *eggs are deep golden-brown thick shelled, distinctly operculated,
containing the eggs measuring 38-45 u by 22-30 u containing a fully developed
miracidium

Treatment – same as Clonorchis sinensis

• praziquantel – 25 mg/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 ants

Scientific name Common nameInfective Diagnostic

stage stage
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Fasciola hepatica sheep liver fluke metacercaria unembryonated ova
___________________________________________________________________________
Fasciola gigantica giant liver fluke metacercaria unembryonated ova
___________________________________________________________________________
Clonorchis sinensis Chinese liver fluke metacercaria embryonated ova
___________________________________________________________________________
Opistorchis felineus cat liver fluke metacercaria embryonated ova
___________________________________________________________________________
Opistorchis metacercaria embryonated ova
viverrini
___________________________________________________________________________
Dicrocoelium lancet fluke metacercaria embryonated ova
dendriticum
____________________________________________________________________________

Scientific name 1ST IH 2ND IH FH AFH

___________________________________________________________________________
Fasciola hepatica snail aquatic vegetation herbivorous animals man
like sheep
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Fasciola gigantica snail aquatic vegetation camels, wild hogs, man
cattle and water
buffalo
___________________________________________________________________________
Clonorchis sinensis snail fresh water fish man
___________________________________________________________________________
Opistorchis felineus snail fresh water fish cats, dogs,fox,wolves
seals man
___________________________________________________________________________
Opistorchis snail fresh water fish civet cat, cat,dog man
viverrini and other fish eating
mammals
___________________________________________________________________________
Dicrocoelium snail ants sheep man
dendriticum
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