Clinical features and management of biliaryascariasis in a non-endemic area
S P Misra, Manisha Dwivedi
SummaryBiliary ascariasis is common in certaingeographical areas of the world. In India,it is common in the Kashmir valley andonly stray cases have been reported fromother parts of the country. Between Janu-ary 1995 and May 1997, 14 patients withbiliary ascariasis were seen at our centre,which is more than 1000 km from theKashmir valley. The mean (± SD) age ofthe patients was 31.7 (± 6.1) years and allwere females. None of them had been to aplace known to be endemic for biliaryascariasis. Four patients presented withacute cholangitis, eight with acute ab-dominal pain and vomiting, and theremaining two were diagnosed inciden-tally during surgery for gallstone disease.Barring these two patients, ultrasoundexamination of the abdomen diagnosedthe condition accurately. In 10 patients, apart of the worm was visible outside thepapilla of Vater. The roundworm wascaught in a Dormia basket and could beextracted in nine patients. In one patientthe worm migrated inside the bile ductwhile it was being caught in a Dormiabasket. In this and two other patients, inwhom the worm had migrated completelyinside the bile duct, worms were removedwith the help of a Dormia basket afterendoscopic sphincterotomy. There wereno complications of endoscopic therapy.In the two patients in whom biliaryascariasis was detected during surgery,the worms were removed after choledo-cholithotomy. On a mean follow-up of 13.8months, only one patient had a recurrenceof biliary ascariasis. It is concluded thatbiliary ascariasis is not an uncommondisease and must be considered as a possi-bility in patients presenting with acutecholangitis and biliary pain even in a non-endemic area. Ultrasonography is anexcellent diagnostic tool and endoscopicmanagement is very eVective and safe inthe treatment of these patients.
Keywords: ascariasis; bile duct; cholangitis
Biliary ascariasis is a common problem in cer-tain areas of the world.1–4 Although it is notcommon in developed countries, with increas-ing air travel and immigration, clinicians inthese countries may more often encounterpatients with biliary ascariasis and, therefore,
must be aware of its clinical features and man-agement.
In India, biliary ascariasis has been reportedas being endemic in the Kashmir valley.5–8 Else-where in the country, only stray cases have beenreported.9–11 Of late we have encounteredseveral patients with biliary ascariasis at ourcentre which is more than 1000 km from theKashmir valley.12 In this report we present theclinical and ultrasonic features and manage-ment of such patients seen between January1995 and May 1997.
Materials and methods
The clinical presentation, ultrasonographicfindings, management and follow-up of pa-tients diagnosed to have biliary ascariasisbetween January 1995 and May 1997 wererecorded. In two patients biliary ascariasis wasdetected incidentally during surgery for chole-lithiasis; these patients had undergone ultra-sound examination 1 and 3 weeks beforesurgery, respectively. The other 12 patientsunderwent abdominal ultrasound examinationjust after being seen by the clinicians.
Endoscopic retrograde cholangiopancrea-tography was performed in all patients, exceptthe two patients in whom the disease wasdetected during surgery. It was performedbefore removing the worm(s), in patients inwhom the worm(s) had migrated fully insidethe bile duct, and after removal of the worm(s)to confirm complete clearance of the bile ducts.In the two patients diagnosed during surgery, aT-tube cholangiogram was done to confirmductal clearance.
Patients with acute cholangitis were man-aged with intravenous fluids, antibiotics andmetronidazole. If a part of the roundworm wasvisible outside the papilla of Vater, it wascaught in a Dormia basket and pulled out. Ifthe worm or other worms had migrated in thebile duct, then a biliary endoprosthesis wasplaced in the bile duct and endoscopic sphinc-terotomy was performed after the patient hadimproved and the worms (living or dead) wereremoved.
In patients presenting with biliary pain andvomiting, if a part of the worm was visible out-side, it was caught in a Dormia basket andextracted. If the worm had migrated fullyinside the bile duct, then endoscopic sphincter-otomy was performed and the worm(s) re-moved.
All patients were given 400 mg of albenda-zole po for three consecutive days and thereaf-ter 400 mg of albendazole every month po.
Results
The mean (± SD) age of these patients was31.7 (± 6.1) years. All the patients werefemales. None of the patients had been to anarea known to be endemic for biliary ascariasis.Four patients presented with acute cholangitis,eight with acute abdominal pain and vomiting,and the remaining two patients were diagnosedincidentally during surgery for gallstone dis-ease. One patient gave a history of vomiting outa roundworm. None of the patients hadundergone abdominal surgery or endoscopicsphincterotomy in the past.
Ultrasound examination did not reveal thepresence of biliary ascariasis in the two patientsin whom it was found incidentally duringsurgery for cholelithiasis. During the operationthe surgeon felt cord-like objects in the dilatedcommon bile duct and on choledocho-lithotomy two ascarides were removed from thecommon bile duct in one and three from thebile duct of the other patient. In the other 12patients ultrasound examination of the abdo-men showed the common bile duct to bedilated with a hyperechoic linear structure witha radiolucent central tube running across thebile duct (figure 1). In four patients the wormwas seen to move inside the common bile duct.
Of the four patients presenting with acutecholangitis, the tail of the roundworm was vis-ible outside the papilla of Vater in two patients.The tail was caught in a Dormia basket and theworms were extracted. In the third patient withacute cholangitis, a part of one worm was seenoutside and was removed with a Dormiabasket. Two other dead worms were presentinside the common bile duct. A 7 Fr straightbiliary endoprosthesis was placed in the bileduct and the patient managed conservatively.In the remaining patient the worm hadmigrated completely inside the bile duct. A 7Fr straight biliary endoprosthesis was placed inthe bile duct and the patient was managedconservatively. After both these patients im-proved, endoscopic sphincterotomy was per-
formed and roundworms removed with thehelp of a Dormia basket.
Eight patients presented with abdominalpain and vomiting. A single worm was noted ineach of these patients and a part of the wormwas seen outside the papilla of Vater (figure 2).In seven patients the worms were caught in aDormia basket and removed. In one patient,while the worm was being enclosed in the Dor-mia basket it migrated into the common bileduct. Endoscopic sphincterotomy was per-formed and the worm extracted with the helpof a Dormia basket. All patients had immediaterelief in symptoms after endoscopic manage-ment.
On a mean (± SD) follow-up of 13.8 (± 8)months, one patient, aged 27 years developedanother episode of biliary pain and vomitingdue to biliary ascariasis, two and a half monthsafter the first episode. She had undergoneendoscopic sphincterotomy for removal of aroundworm during the first episode. A part ofthe worm was seen outside the papilla of Vater.The tail of the worm was caught in a Dormiabasket and the roundworm was extracted.
Discussion
Ascaris lumbricoides is a common parasite andover a billion people are estimated to beinfested with it.13 There are several ways inwhich intestinal ascariasis can manifest.12 14 15
However, the most dramatic and serious pres-entation is that of pancreatobiliaryascariasis.5–8 12 Although it is not a commonproblem in developed countries, with increas-ing air travel and immigration, it is increasinglylikely that clinicians in these countries willencounter a patient with biliary ascariasis.
It is generally believed that, in India, biliaryascariasis is mostly confined to the Kashmirvalley5–8 and only stray cases have beenencountered outside Kashmir.9–11 However, thepresent study demonstrates that even in otherparts of the country, biliary ascariasis may be acommon problem and should be considered as
Figure 1 Abdominal ultrasound examination in apatient with biliary ascariasis. Note the presence of alinear hyperechoic structure with a central echo-freetube in the common bile duct. This ultrasonicappearance is typical of biliary ascariasis
Figure 2 Endoscopic appearance in a patient withbiliary ascariasis. The worm was caught in a Dormiabasket and removed
a diVerential diagnosis in patients having acuteabdominal pain and acute cholangitis. In therecent past we have reported endoscopy-assisted emergency management of five casesof gastroduodenal and pancreatobiliaryascariasis.12 None of the patients in that report,nor those in the present series, had been to anarea known to be endemic for biliary ascariasis.
Apart from the two patients in whom thediagnosis was made at laparotomy, the diagno-sis was evident from the typical findings notedat ultrasonic examination of the abdomen. Theultrasonic appearance of biliary ascariasis hasbeen described in detail. Features include thepresence of long echogenic structures, linear orcurved, single or multiple, with or without acentral anechoic tube, mostly without acousticshadowing.6 If the typical findings are not seen,choledocholithiasis may also be confused withbiliary ascariasis,16 especially since acousticshadowing may not be seen in about 10% ofcommon bile duct stones.17–19
In two patients, ascarides were detected inci-dentally in the bile duct during surgery forgallstones, when the operating surgeon foundthe common bile duct to be dilated and feltcord-like structures within it. This led the sur-geon to perform choledocholithotomy. Ultra-sound examination of the abdomen, performed1 and 3 weeks earlier had not detectedascarides in the bile ducts. While it may bepossible that the ascarides were missed by theultrasonologist, as there were multiple wormsin both patients, it is more likely that theroundworms entered the bile ducts after theultrasound examination was performed. Ultra-sound examination has been noted to diagnosebiliary ascariasis in 86% of patients having asingle worm in the bile duct. However, allpatients with two or more worms in the bileduct could be diagnosed accurately byultrasonography.6
All patients in the present study were youngor middle-aged females. Even in the Kashmirvalley, where the disease is endemic, the diseaseis commoner in middle-aged females.5–8 It ispossible that in these young females, thehormone progesterone, leads to relaxation ofthe smooth muscles of the sphincter of Oddi,allowing the ascarides to gain easy entrance tothe bile duct. Progesterone is a known inhibitorof smooth muscle contraction,20–24 and is alsoknown to significantly increase gallbladder vol-ume and decrease its emptying.25 A similar
delay in the emptying of the gallbladder is seenin the normal menstrual cycle.26 However, theexact reason for the female preponderance isstill not clear.
The management of biliary ascariasis is easyif a part of the worm is visible outside thepapilla of Vater. The worm can then simply becaught and removed. However, if the worm hasmigrated fully inside the bile duct, thenendoscopic sphincterotomy is required to passretrieval devices inside the bile duct. Occasion-ally, however, the worm may migrate inside thebile duct in the process of being trapped in aretrieval device, as was noted in one of ourpatients.
In this study recurrence of biliary ascariasiswas seen in only one patient. This was despitethe patient receiving 400 mg albendazole everymonth. The patient had undergone endoscopicsphincterotomy 10 weeks earlier to remove aroundworm from the bile duct. It is well knownthat re-infection commonly occurs in patientswho have undergone endoscopic sphincter-otomy in the past.6 In order to prevent suchrecurrences we have advocated endoscopicballoon dilation of the biliary sphincter insteadof endoscopic sphincterotomy for removal ofroundworms from the bile duct.27
Prior to the study period, we had notencountered any patient with biliary ascariasisat our centre. We were surprised to see the fivecases of gastroduodenal and pancreatobiliaryascariasis12 and conjecture that the incidence ofascariasis is increasing. This is borne out by thefact that within such a short period of time wehave encountered 14 patients with biliaryascariasis. It is known that poor sanitation,unplanned development with increasing ur-banization and the use of human excreta as afertilizer predispose to ascariasis.13
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7 Khuroo MS, Mahajan R, Zargar SA, Javid G, Sapru S.Prevalence of biliary tract disease in India: a sonographicstudy in adult population in India. Gut 1989;30:201–5.
8 Khuroo MS, Zargar SA, Mahajan R. Hepatobiliary andpancreatic ascariasis in India. Lancet 1990;335:1503–6.
9 Aggarwal KK, Aggarwal SP, Aggarwal DC. Demonstrationof a roundworm in the common bile duct. AJR 1964;91:869–70.
x biliary ascariasis is common, not only in theKashmir valley of India, but also in other parts ofthe country and should be considered as adiVerential diagnosis in patients with biliary painor acute cholangitis, even at centres where biliaryascariasis is not endemic
x ultrasound examination of the abdomen is anexcellent tool in diagnosing the condition andendoscopic management yields excellent results
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20 Cohen S. The sluggish gallbladder of pregnancy. N Engl JMed 1980;302:397–8.
21 Abe A. The hormonal control and eVects of drugs and ionson the electrical and mechanical activity of the uterus. In:Bulbring E, Brading A, Jones A, Tomito T, eds. Smooth mus-cle. Baltimore: Williams and Wilkins, 1970; pp 396–417.
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23 Schulze K, Christensen J. Lower sphincter of the oppusumesophagus in pseudopregnancy. Gastroenterology 1977;73:1082–5.
24 Fisher RS, Roberts GS, Grabowski CJ, Cohen S. Inhibitionof lower esophageal sphincter circular muscle by female sexhormones. Am J Physiol 1978;234:E 243–7.
25 Everson GT, McKinley C, Lawson M, Johnson M, Kern FJr. Gallbladder function in the human female: eVect of theovulatory cycle, pregnancy and contraceptive steroids. Gas-troenterology 1982;82:711–9.
26 Nilsson S, Stattin S. Gallbladder emptying during thenormal menstrual cycle. Acta Chir Scand 1967;133:648–52.
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Images in medicine
Needles should not be re-sheathed
Re-sheathing needles is commonly practiseddespite universal condemnation.1 2 Even if thiscan be done without pricking oneself, anotherhidden danger is that of re-sheathing a largeneedle with a smaller sheath. It can be seen thatthe needle has penetrated the sheath and istherefore dangerous. Needles should not bere-sheathed under any circumstances.
A HUANGDepartment of General Surgery
D DUTTADepartment of Anaesthetics
Milton Keynes General Hospital, Standing Way,Eaglestone, Milton Keynes MK6 5LD, UK
Correspondence to Mr A Huang, 40 York Terrace East,London NW1 4PT, UK
Submitted 12 August 1999Accepted 19 August 1999
1 The impact of HIV on surgical practice. London: Royal Collegeof Surgeons of England, 1992.
2 Guidance for clinical health care workers: protection againstinfection with HIV and hepatitis viruses. London: HMSO, 1990.
