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<meta name="robots" content="INDEX,FOLLOW,NOARCHIVE" /><meta name="citation_inbook_title" content="StatPearls [Internet]" /><meta name="citation_title" content="Clonorchis Sinensis" /><meta name="citation_publisher" content="StatPearls Publishing" /><meta name="citation_date" content="2022/12/19" /><meta name="citation_author" content="Victoria Locke" /><meta name="citation_author" content="Alexander Kusnik" /><meta name="citation_author" content="Melissa S. Richardson" /><meta name="citation_pmid" content="30422487" /><meta name="citation_fulltext_html_url" content="https://www.ncbi.nlm.nih.gov/books/NBK532892/" /><link rel="schema.DC" href="http://purl.org/DC/elements/1.0/" /><meta name="DC.Title" content="Clonorchis Sinensis" /><meta name="DC.Type" content="Text" /><meta name="DC.Publisher" content="StatPearls Publishing" /><meta name="DC.Contributor" content="Victoria Locke" /><meta name="DC.Contributor" content="Alexander Kusnik" /><meta name="DC.Contributor" content="Melissa S. Richardson" /><meta name="DC.Date" content="2022/12/19" /><meta name="DC.Identifier" content="https://www.ncbi.nlm.nih.gov/books/NBK532892/" /><meta name="description" content="Clonorchis sinensis is a trematode known as the Chinese or Oriental liver fluke. This parasitic infection is most commonly found in Eastern Asia, including Korea, China, and Vietnam, but it can be endemic in far eastern regions of Russia. These liver flukes are common parasites of fish-eating mammals. Cats and dogs of endemic areas are the most common hosts, but C sinensis can be transmitted to humans who eat infected fish. When infected, C sinensis can live for years within the biliary system of humans and result in various symptoms, including cholecystitis, cholangitis, and cholangiocarcinoma. This can be extremely burdensome for Asian immigrants who emigrate from an area of endemic infection and develop ongoing symptoms years after the initial infection. In parts of Asia, liver flukes are a public health problem, and more than 200 million people are at risk of infection in these regions.[1][2]" /><meta name="og:title" content="Clonorchis Sinensis" /><meta name="og:type" content="book" /><meta name="og:description" content="Clonorchis sinensis is a trematode known as the Chinese or Oriental liver fluke. This parasitic infection is most commonly found in Eastern Asia, including Korea, China, and Vietnam, but it can be endemic in far eastern regions of Russia. These liver flukes are common parasites of fish-eating mammals. Cats and dogs of endemic areas are the most common hosts, but C sinensis can be transmitted to humans who eat infected fish. When infected, C sinensis can live for years within the biliary system of humans and result in various symptoms, including cholecystitis, cholangitis, and cholangiocarcinoma. This can be extremely burdensome for Asian immigrants who emigrate from an area of endemic infection and develop ongoing symptoms years after the initial infection. In parts of Asia, liver flukes are a public health problem, and more than 200 million people are at risk of infection in these regions.[1][2]" /><meta name="og:url" content="https://www.ncbi.nlm.nih.gov/books/NBK532892/" /><meta name="og:site_name" content="NCBI Bookshelf" /><meta name="og:image" content="https://www.ncbi.nlm.nih.gov/corehtml/pmc/pmcgifs/bookshelf/thumbs/th-statpearls-lrg.png" /><meta name="twitter:card" content="summary" /><meta name="twitter:site" content="@ncbibooks" /><meta name="bk-non-canon-loc" content="/books/n/statpearls/article-19619/" /><link rel="canonical" href="https://www.ncbi.nlm.nih.gov/books/NBK532892/" /><link rel="stylesheet" href="/corehtml/pmc/css/figpopup.css" type="text/css" media="screen" /><link rel="stylesheet" href="/corehtml/pmc/css/bookshelf/2.26/css/books.min.css" type="text/css" /><link rel="stylesheet" href="/corehtml/pmc/css/bookshelf/2.26/css/books_print.min.css" type="text/css" /><style type="text/css">p a.figpopup{display:inline !important} .bk_tt {font-family: monospace} .first-line-outdent .bk_ref {display: inline} </style><script type="text/javascript" src="/corehtml/pmc/js/jquery.hoverIntent.min.js"> </script><script type="text/javascript" src="/corehtml/pmc/js/common.min.js?_=3.18"> </script><script type="text/javascript">window.name="mainwindow";</script><script type="text/javascript" src="/corehtml/pmc/js/bookshelf/2.26/book-toc.min.js"> </script><script type="text/javascript" src="/corehtml/pmc/js/bookshelf/2.26/books.min.js"> </script>
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<div class="pre-content"><div><div class="bk_prnt"><p class="small">NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.</p><p>StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. </p></div></div></div>
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<div class="main-content lit-style" itemscope="itemscope" itemtype="http://schema.org/CreativeWork"><div class="meta-content fm-sec"><h1 id="_NBK532892_"><span class="title" itemprop="name">Clonorchis Sinensis</span></h1><p class="contrib-group"><h4>Authors</h4><span itemprop="author">Victoria Locke</span><sup>1</sup>; <span itemprop="author">Alexander Kusnik</span><sup>2</sup>; <span itemprop="author">Melissa S. Richardson</span><sup>3</sup>.</p><h4>Affiliations</h4><div class="affiliation"><sup>1</sup> McLaren Greater Lansing</div><div class="affiliation"><sup>2</sup> Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha, NE, USA</div><div class="affiliation"><sup>3</sup> McLaren Greater Lansing</div><p class="small">Last Update: <span itemprop="dateModified">December 19, 2022</span>.</p></div><div class="body-content whole_rhythm" itemprop="text"><div id="article-19619.s1"><h2 id="_article-19619_s1_">Continuing Education Activity</h2><p>
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<i>Clonorchis sinensis, also known as the Chinese liver fluke, is a fish-borne trematode causing </i>clonorchiasis. Low-income areas of Asian countries such as China, South Korea, and northern Vietnam are especially affected. Therefore, the World Health Organization (WHO) listed <i>C sinensis </i>among the most neglected tropical diseases globally. <i>C sinensis</i> is a common parasite of fish-eating mammals, including cats, dogs, and humans. Humans become infected by eating raw or undercooked freshwater fish in fillets, sashimi, or congee containing <i>C sinensis</i> metacercariae. When infected, <i>C sinensis</i> lives within humans' biliary system. These parasites can cause serious complications if not found and treated early. This activity reviews the evaluation and treatment of liver flukes and addresses the role of the interprofessional team in evaluating and treating this condition</p><p>
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<b>Objectives:</b>
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<ul><li class="half_rhythm"><div>Determine the typical presentation of a patient with <i>Clonorchis sinensis</i> infection.</div></li><li class="half_rhythm"><div>Identify the evaluation of <i>Clonorchis sinensis</i>, identifying risk factors associated with the infection.</div></li><li class="half_rhythm"><div>Determine the treatment options for patients suspected of harboring <i>C. sinensis</i>.</div></li><li class="half_rhythm"><div>Communicate the importance of the interprofessional team in identifying <i>C sinensis</i> and providing the best possible care and education for the patient.</div></li></ul>
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<a href="https://www.statpearls.com/account/trialuserreg/?articleid=19619&utm_source=pubmed&utm_campaign=reviews&utm_content=19619" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Access free multiple choice questions on this topic.</a>
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</p></div><div id="article-19619.s2"><h2 id="_article-19619_s2_">Introduction</h2><p>
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<i>Clonorchis sinensis </i>is a trematode known as the Chinese or Oriental liver fluke. This parasitic infection is most commonly found in Eastern Asia, including Korea, China, and Vietnam, but it can be endemic in far eastern regions of Russia. These liver flukes are common parasites of fish-eating mammals. Cats and dogs of endemic areas are the most common hosts,  but <i>C sinensis</i> can be transmitted to humans who eat infected fish. When infected, <i>C sinensis</i> can live for years within the biliary system of humans and result in various symptoms, including cholecystitis, cholangitis, and cholangiocarcinoma. This can be extremely burdensome for Asian immigrants who emigrate from an area of endemic infection and develop ongoing symptoms years after the initial infection. In parts of Asia, liver flukes are a public health problem, and more than 200 million people are at risk of infection in these regions.<a class="bk_pop" href="#article-19619.r1">[1]</a><a class="bk_pop" href="#article-19619.r2">[2]</a></p></div><div id="article-19619.s3"><h2 id="_article-19619_s3_">Etiology</h2><p>Causes of clonorchiasis are mostly limited to the ingestion of fish encysted with <i>C sinensis</i> in endemic regions of the world, including East Asia. </p><p>
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<b>The Lifecycle of <i>C sinensis</i></b>
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</p><p>Eggs of <i>C sinensis</i> enter the water environment from feces (see <b>Image.</b>
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<i>C Sinensis</i> eggs). The first intermediate host then consumes these eggs, the freshwater snails, in which the eggs release miracidia, which undergo a series of developmental stages, such as sporocyst, rediae, and cercariae. The cercariae are released from the snail and are free-swimming in the water until they penetrate a freshwater fish. These cercariae encyst into the flesh of freshwater fish and mature to metacercariae. The infected fish is then ingested by a higher mammal, such as humans, where the metacercariae encyst as juvenile flukes in the duodenum. Hermaphroditic adult <i>C sinensis</i> ascends through the ampulla of Vater into the bile system and can often be found in the intrahepatic bile ducts. Complete maturation can take up to a month. <a class="bk_pop" href="#article-19619.r3">[3]</a> The life cycle can take up to 3 months before eggs show up in the sputum or feces of an infected adult.</p><p>Snails are important intermediate hosts, including <i>Bithynia fuchsiana</i>, <i>Alocinma longicornis</i>, and <i>Parafossarulus striatulus</i>. These snails are often found in the local waterways, ponds, lakes, and paddy fields. Eating raw or uncooked freshwater fish (mostly of the Cyprinidae family) can lead to parasitic infection. Still, contamination of utensils and food with Metacercariae is also a potential infection route, especially in children and women.</p></div><div id="article-19619.s4"><h2 id="_article-19619_s4_">Epidemiology</h2><p>
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<i>C sinensis</i> is predominantly endemic to the Eastern hemispheres of the world, mainly East Asia and parts of Russia. Previously, it was also prevalent in Japan, but it virtually disappeared after the Second World War following the modernization of agriculture.<a class="bk_pop" href="#article-19619.r4">[4]</a><a class="bk_pop" href="#article-19619.r5">[5]</a></p><p>Additionally, emigrants or travelers from endemic areas increase the risk of disease transmission to other countries.<a class="bk_pop" href="#article-19619.r6">[6]</a> It is estimated that about 15 to 20 million people are currently infected with <i>C sinensis</i>, and 13 million are alone in China, which indicates a dramatic increase compared to an estimated 7 million infections in the 1990s.<a class="bk_pop" href="#article-19619.r7">[7]</a><a class="bk_pop" href="#article-19619.r8">[8]</a> More than 200 million people are at risk of infection in these regions due to the frequent ingestion of improperly cooked fish; the World Health Organization (WHO) therefore listed <i>C sinensis</i> among the most neglected tropical diseases globally.<a class="bk_pop" href="#article-19619.r9">[9]</a> Large fish are commonly less contaminated with metacercariae, but repetitive exposure through frequent ingestion can result in an overall accumulation of adults in the human bile ducts. Additionally, over 31 types of fish and shrimp are hosts of <i>C sinensis</i>, many of which are common fish consumed by humans and are served in restaurants in endemic regions.<a class="bk_pop" href="#article-19619.r10">[10]</a><a class="bk_pop" href="#article-19619.r11">[11]</a> </p><p>
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<i>Qian et al.</i> indicated in a recent study the presence of <i>C sinensis</i> eggs in almost 20% of the feces of 500 school children aged 10 to 17 years in the highly affected Hunan province of southeastern China.<a class="bk_pop" href="#article-19619.r12">[12]</a> Other affected areas in China include the Guangdong province, which borders Hong Kong and Macau, and the Guangxi province.<a class="bk_pop" href="#article-19619.r2">[2]</a><a class="bk_pop" href="#article-19619.r11">[11]</a> </p><p>Men often have a better understanding of the existence of clonorchiasis, but because of still existing misconceptions (eg, "alcohol can prevent infection") and deeply embedded cultural beliefs that eating raw fish is healthy.<a class="bk_pop" href="#article-19619.r13">[13]</a><a class="bk_pop" href="#article-19619.r6">[6]</a> Infection rates show a preference for males over females, with an infection rate increasing with age, climaxing in the 50s.<a class="bk_pop" href="#article-19619.r14">[14]</a><a class="bk_pop" href="#article-19619.r13">[13]</a> Other potential ways of infection include contamination of utensils and food with metacercariae, as cooked and uncooked food is rarely separated. This method of transmission is commonly responsible for infections in children and women. </p></div><div id="article-19619.s5"><h2 id="_article-19619_s5_">Pathophysiology</h2><p>
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<i>C sinensis </i>is 1 of the most common parasitic infections in the world (see <b>Image.</b> Pathology, Trematode, Parasite, <i>Clonorchis Sinensis</i> eggs, Infection). In 2009, <i>C sinensis</i> was classified as a carcinogen by the International Agency for Cancer Research.<a class="bk_pop" href="#article-19619.r15">[15]</a> Approximately 25 to 35 per 100.000 cholangiocarcinomas are attributable to clonorchiasis in endemic areas.<a class="bk_pop" href="#article-19619.r8">[8]</a> The exact events leading to cholangiocarcinoma are unknown; several mechanisms are believed to play a role. One mechanism includes mechanical injury related to damage to the bile duct mucosa related to the feeding activities of the parasite. Secondly, local accumulation of worms results in bile stasis, favoring bacterial growth, inflammation, and, subsequently, recurrent cholangitis. Thirdly, the toxic effects of excretory-secretory products (ESPs) released by the parasite also result in inflammation.<a class="bk_pop" href="#article-19619.r16">[16]</a> </p></div><div id="article-19619.s6"><h2 id="_article-19619_s6_">History and Physical</h2><p>The clinical consequences of infection are directly related to the intensity and duration of infection. The worm burden can be estimated by the number of eggs in feces, which become detectable in stool after 3 to 4 weeks.<a class="bk_pop" href="#article-19619.r17">[17]</a> The more eggs are present, the more symptoms can be expected.<a class="bk_pop" href="#article-19619.r18">[18]</a><a class="bk_pop" href="#article-19619.r19">[19]</a> Symptoms occur 10 to 30 days after ingesting an infected fish and are present for at least 2 to 4 weeks. Chronic symptoms are often observed in patients with a heavy burden of liver flukes. These chronic symptoms are generally a result of chronic mechanical and physical injuries of the bile ducts.</p><p>In the early phase of infection, most infected patients are considered to have an innocuous infection (less than 100 flukes) and rarely have symptoms. Patients with a very heavy parasitic load (>20 000) can present with symptoms compatible with acute cholangitis, including jaundice, right upper quadrant abdominal pain, nausea, vomiting, anorexia, malaise, and fevers. <a class="bk_pop" href="#article-19619.r6">[6]</a>  Chronic clonorchiasis can result in several symptoms involving the liver and biliary system. Cholelithiasis is commonly observed and is likely related to <i>C sinensis,</i> predisposing to the formation of gallstones, especially calcium carbonate stones. <i>C sinensis</i> induces hyperplastic changes in the gallbladder wall, resulting in decreased gallbladder contractions and the subsequent precipitation of bilirubinate and mucin on the parasitic eggs.<a class="bk_pop" href="#article-19619.r20">[20]</a><a class="bk_pop" href="#article-19619.r21">[21]</a></p><p>Furthermore, pancreatitis and liver abscesses appear more frequently in patients with clonorchiasis.<a class="bk_pop" href="#article-19619.r22">[22]</a> Chronic obstruction and strictures of the bile ducts can also result in bile stasis and recurrent ascending cholangitis mediated by <i>Escherichia coli.</i><a class="bk_pop" href="#article-19619.r6">[6]</a> Clonorchis-associated cholangiocarcinoma is another complication of chronic inflammation and induced cellular proliferation and is often adenomatous in histology.<a class="bk_pop" href="#article-19619.r23">[23]</a> Children with a high parasitic load are at risk for potential developmental delays related to ongoing diarrhea, malnutrition, and anemia.<a class="bk_pop" href="#article-19619.r6">[6]</a></p></div><div id="article-19619.s7"><h2 id="_article-19619_s7_">Evaluation</h2><p>The gold standard of diagnosing <i>C sinensis</i> is detecting eggs in the stool, providing insight into the intensity of infection.<a class="bk_pop" href="#article-19619.r24">[24]</a> Another marker of infection intensity includes bile and serum concentration of IgG4.<a class="bk_pop" href="#article-19619.r6">[6]</a> The absence of eggs in feces does not rule out clonorchiasis, as eggs are usually undetectable in stool during biliary obstruction.<a class="bk_pop" href="#article-19619.r25">[25]</a> Therefore, direct evidence of parasites can also be obtained in duodenal aspirates or biliary secretions via endoscopic retrograde cholangiopancreatography (ERCP).<a href="https://www.ncbi.nlm.nih.gov/books/NBK532892/" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">[7]</a><a href="https://www.ncbi.nlm.nih.gov/books/NBK532892/" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">[3]</a></p><p>Standard diagnostic tests include a direct fecal smear via the Kato-Katz method, which is a method of preparing stool samples where stool is pressed through a mesh, and the remaining sample is a piece of cellophane soaked in glycerol which clears the stool from the eggs. The sensitivity of the test correlates with the intensity of infection, and the sensitivity of the test in low-intensity infections can be increased with repetitive assessments of stool samples. As differentiation between <i>Clonorchis sinensis</i> and <i>Opisthorchis viverrine</i> eggs is difficult (they appear morphologically similar), other factors like geographic exposure must be considered.</p><p>Alternatively, the formalin-ether centrifuge sedimentation method concentrates the eggs in the feces and has better sensitivity than the Kato-Katz method, especially in suspected low-intensity cases.<a class="bk_pop" href="#article-19619.r26">[26]</a><a class="bk_pop" href="#article-19619.r14">[14]</a> Serodiagnostic tests like enzyme-linked immunosorbent assay (ELISA) are commonly used and are equally helpful for diagnosing <i>C sinensis</i>. Specific antigens used in ELISA include ESPs and crude extract antigens, with the caveat that these assays can potentially cross-react with infections caused by other trematodes.<a class="bk_pop" href="#article-19619.r1">[1]</a></p><p>Polymerase chain reaction (PCR) is also frequently used and has high sensitivity and specificity for diagnosing <i>C sinensis</i>, but it might not be readily available. Newer diagnostic tools include loop-mediated isothermal amplification (LAMP), which targets <i>C sinensis</i> DNA and is optimal for point-of-care diagnosis.<a class="bk_pop" href="#article-19619.r27">[27]</a><a class="bk_pop" href="#article-19619.r14">[14]</a> Despite these technical achievements within the last few years, the underdiagnosis of <i>C sinensis</i> is still a major issue due to the lack of diagnostic tools and training within the affected areas.<a class="bk_pop" href="#article-19619.r6">[6]</a> </p><p>Imaging modalities like ultrasound, CT, and MRI are useful to determine the infection's location, progression, and extent. On ultrasound, diffuse dilatation of intrahepatic bile ducts is commonly seen in patients infected with <i>Clonorchis sinensis. Still, the</i> finding is too unspecific for diagnostic purposes and is significantly operator-dependent.<a class="bk_pop" href="#article-19619.r28">[28]</a><a class="bk_pop" href="#article-19619.r29">[29]</a> Choi et al. indicated in a sonographic study with 457 subjects that enhanced periductal echogenicity and floating echogenic foci in the gallbladder are useful for diagnosing clonorchiasis.<a class="bk_pop" href="#article-19619.r30">[30]</a> CT imaging can help delineate the diagnosis of clonorchiasis, as it shows a regular caliber of the unaffected larger bile ducts/extrahepatic ducts compared to the more frequently affected intrahepatic bile ducts.<a class="bk_pop" href="#article-19619.r22">[22]</a> MR cholangiographic imaging is also helpful in the diagnosis of C sinensis. A classic sign of this imaging modality includes "too many intrahepatic ducts"- a sign resulting from parasitic obstruction of the smaller intrahepatic bile ducts in the periphery.<a class="bk_pop" href="#article-19619.r31">[31]</a></p></div><div id="article-19619.s8"><h2 id="_article-19619_s8_">Treatment / Management</h2><p>The most effective treatment for clonorchiasis is praziquantel. The World Health Organization (WHO) recommends 25 mg/kg orally 3 times daily for 2 to 3 days or 40mg/kg in a single administration, resulting in cure rates above 90%.<a class="bk_pop" href="#article-19619.r32">[32]</a><a class="bk_pop" href="#article-19619.r33">[33]</a> Regional policies might vary, including higher dosing with less frequent administration, eg, 75 mg/kg of praziquantel twice daily within 48 hours.<a class="bk_pop" href="#article-19619.r32">[32]</a>  In the case of heavy parasitic infections or the continuous presence of eggs in feces after treatment, re-treatment is necessary.<a class="bk_pop" href="#article-19619.r32">[32]</a> Associated side effects of praziquantel include abdominal discomfort, vomiting, and cephalgias.<a class="bk_pop" href="#article-19619.r34">[34]</a> </p><p>Of note, the recovery period for pathological changes of the bile duct may be prolonged for weeks, and symptoms can persist despite adequate treatment. As symptoms tend to be unspecific and large populations are unknowingly inhabited by the parasite, pilot studies elucidated the effects of mass treatments in endemic areas with praziquantel, indicating positive effects of(semi-)annual treatment with praziquantel reducing the prevalence from 59.5% in 2001 to 7.5% in 2004.<a class="bk_pop" href="#article-19619.r35">[35]</a> </p><p>An alternative regimen includes albendazole (10mg/kg) for 5 to 7 days.<a class="bk_pop" href="#article-19619.r36">[36]</a><a class="bk_pop" href="#article-19619.r6">[6]</a> Patients’ family members and close contacts should also be tested for infection because it is more than likely that they may have eaten the same contaminated food or were exposed to metacercariae by contaminated surfaces.</p><p>According to recent studies, another alternative includes tribendimidine, a relatively new drug with promising cure rates and a favorable side effect profile.<a class="bk_pop" href="#article-19619.r37">[37]</a><a class="bk_pop" href="#article-19619.r32">[32]</a> Researchers have been trying to develop a vaccine, but these have only been tested in animals.</p></div><div id="article-19619.s9"><h2 id="_article-19619_s9_">Differential Diagnosis</h2><p>The differential diagnosis includes acute hepatitis, cholecystitis, choledocholithiasis, cholangiocarcinoma, primary sclerosing cholangitis, primary biliary cholangitis, and other parasitic infections, including schistosomiasis, fascioliasis, and ascariasis.<a class="bk_pop" href="#article-19619.r1">[1]</a></p></div><div id="article-19619.s10"><h2 id="_article-19619_s10_">Prognosis</h2><p>An initial prognosis can be based on the number of eggs found in feces, as more eggs indicate more pronounced disease intensity.<a class="bk_pop" href="#article-19619.r17">[17]</a><a class="bk_pop" href="#article-19619.r18">[18]</a><a class="bk_pop" href="#article-19619.r19">[19]</a> Initial infections are often untreated as most patients remain asymptomatic or have non-specific symptoms. The reversibility of pathological changes induced by <i>C sinensis</i> is largely dependent on the timing of initiation of treatment, meaning that when praziquantel treatment is delayed, the recovery period for pathological changes of the bile duct may be up to 12 weeks, and even longer or irreversible if the infection is severe or prolonged.<a class="bk_pop" href="#article-19619.r38">[38]</a></p><p>Initial symptoms of <i>C sinensis</i> are frequently unspecific so that they can result in a missed diagnosis and the inhabitation of <i>C sinensis</i> adult worms for many years.<a class="bk_pop" href="#article-19619.r19">[19]</a> Chronic complications like cholecystitis, cholangitis, or liver abscesses usually respond to symptomatic treatment. The prognosis of cholangiocarcinoma is sinister, with a median overall survival of fewer than 30 months.<a class="bk_pop" href="#article-19619.r39">[39]</a></p></div><div id="article-19619.s11"><h2 id="_article-19619_s11_">Complications</h2><p> In 2009, <i>C sinensis</i> was classified as a carcinogen by the International Agency for Cancer Research. The liver flukes reside within the biliary tree and cause obstruction, inflammatory irritation, and fibrosis, resulting in the potential development of cholangiocarcinoma (CCA).<a class="bk_pop" href="#article-19619.r8">[8]</a> One study even reported <i>Clonorchis sinensis</i> as a risk factor for hepatic carcinoma, potentially synergistically occurring in a co-infected patient with HBV infection or alcohol use disorder.<a class="bk_pop" href="#article-19619.r40">[40]</a> As initial symptoms are often non-specific and missed for many years, histological changes like the epithelial proliferation of bile ducts and periductal fibrosis go unnoticed and can result in adenomatous hyperplasia, giving rise to neoplastic changes.<a class="bk_pop" href="#article-19619.r19">[19]</a><a class="bk_pop" href="#article-19619.r41">[41]</a> </p><p>Long-standing infection also increases the risk of strictures of the bile ducts and, together with the mechanical obstruction caused by the parasite, can result in recurrent pyogenic cholangitis, pancreatitis, and liver abscesses.<a class="bk_pop" href="#article-19619.r22">[22]</a> Regarding cholangiocarcinoma, <i>C sinensis</i> infection increases the risk of intrahepatic and extrahepatic CCA.<a class="bk_pop" href="#article-19619.r42">[42]</a><a class="bk_pop" href="#article-19619.r41">[41]</a> Children with a high parasitic load are at risk for potential developmental delays related to ongoing diarrhea, malnutrition, and anemia.<a class="bk_pop" href="#article-19619.r6">[6]</a></p></div><div id="article-19619.s12"><h2 id="_article-19619_s12_">Deterrence and Patient Education</h2><p>Preventing <i>C sinensis</i> infection is heavily based on patient education and proper food preparation. Endemic areas promote education with public awareness programs, health guide booklets, and educating school children. These educational programs enforce proper food preparation and avoidance of undercooked or raw fish. Removing farm animals from nearby fish farms and recognizing symptoms is also essential. These areas must undergo cultural changes to begin the decline of infection rates of <i>C sinensis</i>, including replanting family farms to move farm animals from water sources and decreasing the consumption of raw fish in their diet.<a class="bk_pop" href="#article-19619.r43">[43]</a></p></div><div id="article-19619.s13"><h2 id="_article-19619_s13_">Enhancing Healthcare Team Outcomes </h2><p>While most <i>C sinensis</i> infections are asymptomatic with a parasite load of approximately 100, acute infections require a more detailed and rigorous management strategy with several medical teams on board. Patients with a heavy parasite load of approximately 20,000 are at a higher risk for chronic, long-term issues. Such risks include ascending cholangitis, cholangiocarcinoma, and hepatitis. Once it has become clear that a parasitic liver infection has developed, an interprofessional healthcare team, including gastrointestinal (GI)/surgery, internal medicine, and infectious disease specialists, must have a clear line of communication to begin therapy as soon as possible.</p><p>Specialty-trained infection control and gastroenterology nurses should educate patients and their families, monitor patients, and provide status reports to the interprofessional team. Pharmacists evaluate the appropriateness of medications prescribed, assess drug-drug interactions, and participate in education. It is also important to accurately diagnose which parasite is the culprit of the current disease, as there are several types of different parasitic liver infections. Clear communication between all involved specialties ensures that the patient and any close contacts are treated quickly and appropriately to avoid severe consequences.</p></div><div id="article-19619.s14"><h2 id="_article-19619_s14_">Review Questions</h2><ul><li class="half_rhythm"><div>
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</div></li></ul></div><div class="floats-group" id="article-19619.s15"></div><div class="floats-group" id="article-19619.s16"></div><div id="article-19619.s17"><h2 id="_article-19619_s17_">References</h2><dl class="temp-labeled-list"><dt>1.</dt><dd><div class="bk_ref" id="article-19619.r1">Hong ST, Fang Y. Clonorchis sinensis and clonorchiasis, an update. <span><span class="ref-journal">Parasitol Int. </span>2012 Mar;<span class="ref-vol">61</span>(1):17-24.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/21741496" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 21741496</span></a>]</div></dd><dt>2.</dt><dd><div class="bk_ref" id="article-19619.r2">Qian MB, Chen YD, Yan F. 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Accuracy of the Kato-Katz method and formalin-ether concentration technique for the diagnosis of Clonorchis sinensis, and implication for assessing drug efficacy. <span><span class="ref-journal">Parasit Vectors. </span>2013 Oct 29;<span class="ref-vol">6</span>(1):314.</span> [<a href="/pmc/articles/PMC3816101/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC3816101</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/24499644" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 24499644</span></a>]</div></dd><dt>27.</dt><dd><div class="bk_ref" id="article-19619.r27">Kim EM, Verweij JJ, Jalili A, van Lieshout L, Choi MH, Bae YM, Lim MK, Hong ST. Detection of Clonorchis sinensis in stool samples using real-time PCR. <span><span class="ref-journal">Ann Trop Med Parasitol. </span>2009 Sep;<span class="ref-vol">103</span>(6):513-8.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/19695156" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 19695156</span></a>]</div></dd><dt>28.</dt><dd><div class="bk_ref" id="article-19619.r28">Hong ST, Yoon K, Lee M, Seo M, Choi MH, Sim JS, Choi BI, Yun CK, Lee SH. Control of clonorchiasis by repeated praziquantel treatment and low diagnostic efficacy of sonography. <span><span class="ref-journal">Korean J Parasitol. </span>1998 Dec;<span class="ref-vol">36</span>(4):249-54.</span> [<a href="/pmc/articles/PMC2732964/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC2732964</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/9868890" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 9868890</span></a>]</div></dd><dt>29.</dt><dd><div class="bk_ref" id="article-19619.r29">Choi D, Hong ST. Imaging diagnosis of clonorchiasis. <span><span class="ref-journal">Korean J Parasitol. </span>2007 Jun;<span class="ref-vol">45</span>(2):77-85.</span> [<a href="/pmc/articles/PMC2526300/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC2526300</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/17570969" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 17570969</span></a>]</div></dd><dt>30.</dt><dd><div class="bk_ref" id="article-19619.r30">Choi D, Hong ST, Lim JH, Cho SY, Rim HJ, Ji Z, Yuan R, Wang S. Sonographic findings of active Clonorchis sinensis infection. <span><span class="ref-journal">J Clin Ultrasound. </span>2004 Jan;<span class="ref-vol">32</span>(1):17-23.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/14705173" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 14705173</span></a>]</div></dd><dt>31.</dt><dd><div class="bk_ref" id="article-19619.r31">Jeong YY, Kang HK, Kim JW, Yoon W, Chung TW, Ko SW. MR imaging findings of clonorchiasis. <span><span class="ref-journal">Korean J Radiol. </span>2004 Jan-Mar;<span class="ref-vol">5</span>(1):25-30.</span> [<a href="/pmc/articles/PMC2698110/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC2698110</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/15064556" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 15064556</span></a>]</div></dd><dt>32.</dt><dd><div class="bk_ref" id="article-19619.r32">Xu LL, Jiang B, Duan JH, Zhuang SF, Liu YC, Zhu SQ, Zhang LP, Zhang HB, Xiao SH, Zhou XN. Efficacy and safety of praziquantel, tribendimidine and mebendazole in patients with co-infection of Clonorchis sinensis and other helminths. <span><span class="ref-journal">PLoS Negl Trop Dis. </span>2014 Aug;<span class="ref-vol">8</span>(8):e3046.</span> [<a href="/pmc/articles/PMC4133228/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC4133228</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/25122121" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 25122121</span></a>]</div></dd><dt>33.</dt><dd><div class="bk_ref" id="article-19619.r33">Keiser J, Utzinger J. The drugs we have and the drugs we need against major helminth infections. <span><span class="ref-journal">Adv Parasitol. </span>2010;<span class="ref-vol">73</span>:197-230.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/20627144" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 20627144</span></a>]</div></dd><dt>34.</dt><dd><div class="bk_ref" id="article-19619.r34">Lee SH. Large scale treatment of Clonorchis sinensis infections with praziquantel under field conditions. <span><span class="ref-journal">Arzneimittelforschung. </span>1984;<span class="ref-vol">34</span>(9B):1227-30.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/6542401" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 6542401</span></a>]</div></dd><dt>35.</dt><dd><div class="bk_ref" id="article-19619.r35">Choi MH, Park SK, Li Z, Ji Z, Yu G, Feng Z, Xu L, Cho SY, Rim HJ, Lee SH, Hong ST. Effect of control strategies on prevalence, incidence and re-infection of clonorchiasis in endemic areas of China. <span><span class="ref-journal">PLoS Negl Trop Dis. </span>2010 Feb 16;<span class="ref-vol">4</span>(2):e601.</span> [<a href="/pmc/articles/PMC2821909/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC2821909</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/20169061" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 20169061</span></a>]</div></dd><dt>36.</dt><dd><div class="bk_ref" id="article-19619.r36">Liu YH, Wang XG, Gao P, Qian MX. Experimental and clinical trial of albendazole in the treatment of Clonorchiasis sinensis. <span><span class="ref-journal">Chin Med J (Engl). </span>1991 Jan;<span class="ref-vol">104</span>(1):27-31.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/1879192" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 1879192</span></a>]</div></dd><dt>37.</dt><dd><div class="bk_ref" id="article-19619.r37">Qian MB, Yap P, Yang YC, Liang H, Jiang ZH, Li W, Tan YG, Zhou H, Utzinger J, Zhou XN, Keiser J. Efficacy and safety of tribendimidine against Clonorchis sinensis. <span><span class="ref-journal">Clin Infect Dis. </span>2013 Apr;<span class="ref-vol">56</span>(7):e76-82.</span> [<a href="/pmc/articles/PMC3588115/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC3588115</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/23223597" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 23223597</span></a>]</div></dd><dt>38.</dt><dd><div class="bk_ref" id="article-19619.r38">Lee SH, Hong ST, Kim CS, Sohn WM, Chai JY, Lee YS. Histopathological changes of the liver after praziquantel treatment in Clonorchis sinensis infected rabbits. <span><span class="ref-journal">Kisaengchunghak Chapchi. </span>1987 Dec;<span class="ref-vol">25</span>(2):110-122.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/12886061" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 12886061</span></a>]</div></dd><dt>39.</dt><dd><div class="bk_ref" id="article-19619.r39">Zhang GW, Lin JH, Qian JP, Zhou J. Identification of risk and prognostic factors for patients with clonorchiasis-associated intrahepatic cholangiocarcinoma. <span><span class="ref-journal">Ann Surg Oncol. </span>2014 Oct;<span class="ref-vol">21</span>(11):3628-37.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/24781504" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 24781504</span></a>]</div></dd><dt>40.</dt><dd><div class="bk_ref" id="article-19619.r40">Tan SK, Qiu XQ, Yu HP, Zeng XY, Zhao YN, Hu L. [Evaluation of the risk of clonorchiasis inducing primary hepatocellular carcinoma]. <span><span class="ref-journal">Zhonghua Gan Zang Bing Za Zhi. </span>2008 Feb;<span class="ref-vol">16</span>(2):114-6.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/18304427" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 18304427</span></a>]</div></dd><dt>41.</dt><dd><div class="bk_ref" id="article-19619.r41">Choi BI, Han JK, Hong ST, Lee KH. Clonorchiasis and cholangiocarcinoma: etiologic relationship and imaging diagnosis. <span><span class="ref-journal">Clin Microbiol Rev. </span>2004 Jul;<span class="ref-vol">17</span>(3):540-52, table of contents.</span> [<a href="/pmc/articles/PMC452546/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC452546</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/15258092" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 15258092</span></a>]</div></dd><dt>42.</dt><dd><div class="bk_ref" id="article-19619.r42">Choi D, Lim JH, Lee KT, Lee JK, Choi SH, Heo JS, Jang KT, Lee NY, Kim S, Hong ST. Cholangiocarcinoma and Clonorchis sinensis infection: a case-control study in Korea. <span><span class="ref-journal">J Hepatol. </span>2006 Jun;<span class="ref-vol">44</span>(6):1066-73.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/16480786" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 16480786</span></a>]</div></dd><dt>43.</dt><dd><div class="bk_ref" id="article-19619.r43">Tang ZL, Huang Y, Yu XB. Current status and perspectives of Clonorchis sinensis and clonorchiasis: epidemiology, pathogenesis, omics, prevention and control. <span><span class="ref-journal">Infect Dis Poverty. </span>2016 Jul 06;<span class="ref-vol">5</span>(1):71.</span> [<a href="/pmc/articles/PMC4933995/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC4933995</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/27384714" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 27384714</span></a>]</div></dd></dl></div><div><dl class="temp-labeled-list small"><dt></dt><dd><div><p class="no_top_margin">
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<b>Disclosure: </b>Victoria Locke declares no relevant financial relationships with ineligible companies.</p></div></dd><dt></dt><dd><div><p class="no_top_margin">
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<b>Disclosure: </b>Alexander Kusnik declares no relevant financial relationships with ineligible companies.</p></div></dd><dt></dt><dd><div><p class="no_top_margin">
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<b>Disclosure: </b>Melissa Richardson declares no relevant financial relationships with ineligible companies.</p></div></dd></dl></div><div class="bk_prnt_sctn"><h2>Figures</h2><div class="whole_rhythm bk_prnt_obj bk_first_prnt_obj"><div id="article-19619.image.f1" class="figure bk_fig"><div class="graphic"><img src="/books/NBK532892/bin/896_lores.jpg" alt="Image 896_lores" /></div><div class="caption"><p>Pathology, Trematode, Parasite, <i>Clonorchis Sinensis</i> eggs, Infection M Melvin, MD, Public Domain, via the Centers for Disease Control and Prevention's Division of Parasitic Diseases and Malaria</p></div></div></div><div class="whole_rhythm bk_prnt_obj"><div id="article-19619.image.f2" class="figure bk_fig"><div class="graphic"><img src="/books/NBK532892/bin/C__Sinesis.jpg" alt="Image C__Sinesis" /></div><div class="caption"><p>
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<i>C Sinensis</i>, Ova Centers for Disease Control and Prevention's Division of Parasitic Diseases and Malaria</p></div></div></div></div></div></div>
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