Biliary Ascariasis: Percutaneous TranshepaticManagementNevzat Ozcan, MD, Nuri Erdogan, MD, Can Kucuk, MD, and Engin Ok, MD

In a 60-year-old woman who underwent cholecystectomy and T-tube drainage for biliary ascariasis, postoperativebilirubin levels continued to increase. T-tube cholangiography revealed multiple filling defects in the bile ducts,which suggested roundworm reinfestation. Because the patient could not tolerate endoscopy, a percutaneous trans-hepatic approach with balloon dilatation of the ampulla of Vater and subsequent advancement of roundworms intothe duodenum with an embolectomy balloon was used. The procedure was successful, with no major complications.The use of a percutaneous transhepatic treatment to advancement of roundworms into the duodenum is a feasiblealternative to surgery when endoscopic extraction fails.

Index terms: Ascariasis • Bile ducts, diseases

J Vasc Interv Radiol 2003; 14:391–393

ASCARIASIS is the most widespreadof all helminth infestations of the bili-ary tract (1,2). The adult worm Ascarislumbricoides usually lives in the intes-tinal lumen without any significantsymptoms. They occasionally migrateinto the biliary tract, where they maycause biliary colic, acute cholecystitis,acute cholangitis, acute pancreatitis,and hepatic abscess (2,3). Endoscopicretrograde cholangiopancreatographyhas both diagnostic and therapeuticvalue in the treatment of biliary ascar-iasis if the patient fails to respond toconservative treatment (1,2). This re-port presents a case of postoperativeA. lumbricoides reinfestation of the bileducts. In this case, biliary worms weremanaged with a percutaneous trans-hepatic treatment.

CASE REPORT

A 60-year-old woman presented tothe hospital with right upper quadrantpain, vomiting, and progressive jaun-dice. Preoperative sonographic find-ings included dilated intrahepatic bileducts with echogenic nonshadowingmaterial in the common bile duct.During cholecystectomy, chole-dochotomy revealed that the obstruct-ing lesion was an aggregate of roundworms in the distal duct, which wereremoved. After choledochoscopic ex-ploration of the bile ducts, cholecys-tectomy and T-tube drainage was per-formed. Postoperative bilirubin levelscontinued to increase and T-tubecholangiography was requested onpostoperative day 6. Cholangiographyshowed multiple tubular filling de-fects in the common bile duct, com-mon hepatic duct, and right hepaticduct, which suggested reinfestationwith round worms (Fig 1). Endoscopicretrograde cholangiopancreatographywas performed to relieve obstruction,but the patient could not tolerateendoscopy despite proper premedi-cation. Because the tract was imma-ture, T-tube long and tortuous, andpassage blocked by roundworms inthe distal lumen, a percutaneoustranshepatic technique was used forextraction.

After a T-tube cholangiogram was

obtained, a 21-gauge needle was intro-duced through the 10th intercostalspace in midaxillary line into a rightperipheral hepatic duct. After the in-sertion of a 0.018-inch micro guidewire (Cordis) into the peripheral bileduct, the tract was dilated with an 8-Fdilatator (Boston Scientific) and an8-F-long vascular sheath (Cordis) wasadvanced into the common bile duct.Then, a 0.035-inch guide wire (BostonScientific) was passed via a vascularsheath through the sphincter ofOddi into the duodenum. An angio-graphic balloon dilatation catheter (15mm diameter, 60 mm long; Boston Sci-entific) was placed across the sphinc-ter with use of a duodenal guide wire.The balloon diameter was determinedby measuring the maximum diameterof the common bile duct (ie, 15 mm).The balloon was inflated until nowaist could be seen on fluoroscopy(Fig 2). An embolectomy balloon,(SIMS Portex) conducted through thelong vascular sheath, was advancedinto the common bile duct and allroundworms were pushed into theduodenum (Fig 3). This procedurewas repeated five to six times. Clear-ance was confirmed by carefullysearching the round worms or round-worm remnants in the duct after eachpassage. After the procedure, an 8-Fexternal biliary drainage catheter(Boston Scientific) was inserted into

From the Departments of Radiology (N.O., N.E.)and General Surgery (C.K., E.O.), Erciyes UniversityFaculty of Medicine, 38039-Kayseri, Turkey.Presented at the Cardiovascular and InterventionalRadiology Society of Europe Meeting, Gothenburg,2001. Received August 10, 2002; accepted October24. Address correspondence to N.O.; E-mail:nevzatcan@yahoo.com

None of the authors has identified a potential con-flict of interest.

© SIR, 2003

DOI: 10.1097/01.RVI.0000058417.01661.ac

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the common hepatic duct and salineirrigation was performed. The pa-tient’s abdominal symptoms im-proved and bilirubin levels decreased

by 50% within 3 days. Four days afterthe procedure, a drainage cathetercholangiography revealed no fillingdefects in bile ducts and free flow of

contrast material into the duodenum.The drainage catheter was withdrawn(Fig 4). No major complications, in-cluding the laboratory and clinical ev-

Figures 1,2. (1) T-tube cholangiogram showsmultiple tubular filling defects in the common bile duct, common hepatic duct, and right hepaticduct. (2) An angiographic balloon catheter was inflated until no waist could be seen on fluoroscopy for dilatation of the sphincter.

Figure 3,4. (3) After dilatation, roundworms were pushed into the duodenumwith an embolectomy balloon. (4) Control cholangiogramshows no filling defects in biliary ducts and free flow of contrast material to the duodenum.

392 • Biliary Ascariasis: Percutaneous Transhepatic Management March 2003 JVIR

idence of pancreatitis, were detectedafter the procedure. Minor complica-tions of abdominal pain and nauseawere treated medically. As an anti-helmintic agent, Mebendazole (100mg, twice daily) was administered,starting from immediately after theinitial procedure to 3 days after theinterventional procedure. During thistime, extensive passage of adult roundworms was observed in the stool. Acontrol clinical and sonographic fol-low-up examination at 3 months re-vealed no abnormality related to bileducts.

DISCUSSION

Biliary ascariasis is a common etio-logic factor of biliary tract disease inendemic areas (2). Migration of wormsinto the biliary tract may be triggeredby some drugs, anesthetic agents, an-tihelminthics, fever, or spicy foods (1).Entry into the bile duct is facilitated inpatients with bilioenteric anastomosis,previous sphincter surgery, or sphinc-terotomy (1). Sometimes, the worm as-cends to the pancreaticobiliary systemafter recent or remote surgery, whichresults in persistent postcholecystec-tomy pain, pancreatitis, recurrentcholangitis, and hepatic abscess afterrecent or remote surgery (4).

The management for biliary ascari-

asis is primarily conservative, consist-ing of intravenous fluids, analgesicsand antibiotics, paralysis of the wormsin the intestines by oral administrationof an antihelminthic, and expulsion byeffective peristalsis of the intestines(5). Patients with worms in the distalcommon bile ducts often respond tothis nonsurgical management (6). En-doscopic therapeutic biliary proce-dures for mechanical removal ofworms may be considered if the pa-tient fails to respond to the conserva-tive treatment, or if stones coexist withworms. Endoscopic removal may notbe uniformly successful because of thefriability of live worms and the frag-mentation of dead worms (7). Also, itis well known that worm secretionsmay lead to sphincter spasm, whichmay be an obstacle for cannulationand therapeutic procedures (8).

In this report, the patient’s postop-erative bilirubin levels continued to in-crease and immediate mechanical de-bulking of the worms was required toprevent cholangitis. However, the pa-tient could not tolerate an endoscopicprocedure. Because the T-tube tractwas tortuous and obstructed in thedistal lumen, the authors did not pre-fer this treatment for extraction. An-other important drawback to the useof a T-tube was the fear of peritonitisas a result of live or dead worms, orbile leak. Percutaneous transhepatic

extraction of the worms was an effec-tive method of nonsurgical manage-ment. This case shows that it may beconsidered as an alternative to surgeryin cases where endoscopic removal ofworms fails.

References1. Mabogunje OA, Daar AS. Ascariasis

and other intestinal nematode infec-tions. In: Oxford textbook of surgery.Oxford: Oxford University Press, 1994;2500–2506.

2. Khuroo MS. Ascariasis. GastroenterolClin North Am 1996; 25:553–577.

3. Khuroo MS, Zargar SA. Biliary ascari-asis: a common cause of biliary and pan-creatic disease in an endemic area. Gas-troenterology 1985; 88:418–423.

4. Wani NA, Shah OJ, Naqash SH. Post-operative biliary ascariasis: presentationand management-experience. WorldJ Surg 2000; 24:1143–1145.

5. Zargar SA. Management of biliary as-cariasis. Am J Gastroenterol 1998; 93:2001–2002.

6. Khuroo MS, Zargar SA, Yattoo GN, etal. Worm extraction and biliary drain-age in hepatobiliary and pancreatic as-cariasis. Gastrointest Endosc 1993; 39:680–685.

7. Wani NA, Chrungoo RK. Biliary ascar-iasis: surgical aspects. World J Surg1992; 16:976–979.

8. Wang HC, Tang CH, Liu HH. Biliaryascariasis: an analysis of 141 cases. ClinMed J 1956; 74:445.

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