|Year : 2021 | Volume
| Issue : 1 | Page : 13-15
Ascariasis presenting as acute cholangitis due to common bile duct stone
Pandiaraja Jayabal1, Shalini Arumugam<2
1 Department of General Surgery, Dr. Mehta Hospital, Chennai, Tamil Nadu, India
2 Department of Community Medicine, ACS Medical College, Chennai, Tamil Nadu, India
|Date of Submission||26-Oct-2020|
|Date of Decision||22-Nov-2020|
|Date of Acceptance||06-Feb-2021|
|Date of Web Publication||18-May-2021|
Dr. Pandiaraja Jayabal
26/1, Kaveri Street, Rajaji Nagar, Villivakkam, Chennai - 600 049, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Ascaris lumbricoides is an intestinal parasite, more common habitant of the small intestine, particularly in the jejunum. It can produce a variety of presentations starting from anemia, gastrointestinal bleeding, intestinal obstruction, perforations, intussusception, and rarely obstructive jaundice. Obstructive jaundice is mainly due to proximal migration of the parasite into the biliary tree and causing an obstruction. It is the most common following biliary procedure. Here, we report the case of obstructive jaundice and cholangitis due to biliary ascariasis in a patient without any prior biliary procedure. Prompt intervention is needed in those cases of ascariasis with biliary sepsis. The patient has been managed by emergency cholecystectomy with common bile duct exploration and T-tube insertion.
Keywords: Acute cholangitis, ascaris lumbricoides, biliary ascariasis, common bile duct exploration, common bile duct stone
|How to cite this article:|
Jayabal P, Arumugam< S. Ascariasis presenting as acute cholangitis due to common bile duct stone. Amrita J Med 2021;17:13-5
| Introduction|| |
Ascariasis can invade into the biliary tree and present as common bile duct stone, biliary colic, cholangitis, and recurrent pancreatitis. The dead parasite acts as a nidus for the formation of common bile duct stone. Sometimes, stone is also formed with live parasites due to its ova, which act as a nidus for the stone formation. Most of the patients with biliary ascariasis can be managed medically with anti-helminthic treatment, but in some cases need surgical intervention. Surgical intervention now rarely required due to the wide availability of endoscopic retrograde cholangiopancreatography (ERCP) for biliary ascariasis. However, in some cases, surgical intervention is needed due to obstructed biliary tree with difficulty ERCP.
| Case Report|| |
A 28-year-old male admitted with a history of abdominal pain, nausea, and vomiting for 2 days. There was a history of fever with chills and rigors. He also told the history of passing high-colored urine. There was a history of yellowish discoloration of the eyes. He denied a history of recent blood transfusion. There was no history of previous surgery. He was an alcoholic and a smoker for the past 5 years. On examination, the patient was moderately built and nourished. On general examination, the patient was jaundiced. His vitals showed a pulse rate of 110/min and blood pressure of 90/60 mmHg. Abdominal examination showed tenderness in the right hypochondrium. The rest of the abdominal examinations were normal.
The blood investigations showed leukocytosis (white blood cells – 36,200 per mL) with high bilirubin levels (total bilirubin – 8.2 mg/dl, direct bilirubin – 7.2 mg/dl, and indirect bilirubin – 1.0 mg/dl). Ultrasound examination of the abdomen showed dilated intrahepatic radicals with common bile duct stones measuring around 1.5 cm. It also showed the curvilinear echogenic structure suggestive of Ascariasis. Upper gastrointestinal endoscopy showed ascariasis worm in the ampulla of Vater [Figure 1]. He was diagnosed with cholangitis due to common bile duct stone due to biliary ascariasis.
|Figure 1: (a and b) Upper gastrointestinal endoscopy shows ascariasis worm in the ampulla of Vater|
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Our patient had a huge common bile duct stone that could not be removed with ERCP. Hence, we proceeded with open cholecystectomy with open common bile duct exploration and T-tube insertion. The intraoperative picture showed two common bile duct stone more than 1.5 cm with dilated common bile duct and few ascariasis worms [Figure 2]. Postoperative cut open specimen of the gall bladder showed no evidence of gallstone but only inflammatory changes [Figure 3]. The patient has dewormed with Albendazole 400 mg for 3 days.
|Figure 2: Intraoperative picture shows two common bile duct stone more than 1.5 cm with dilated common bile duct and few ascariasis worms|
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|Figure 3: Postoperative cut open specimen of the gall bladder shows no evidence of gallstone but inflammatory changes|
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The patient has been followed up in the postoperative period. He showed a significant improvement following surgery. The T-tube is removed after T-tube cholangiogram showed that there was no evidence of residual or retained stone.
| Discussion|| |
Ascariasis is an inhabitant of the small intestine, particularly in the jejunum. It migrates to the duodenum because of the excessive worm load or distal obstruction by the worms. The symptoms of biliary ascariasis are pain abdomen, fever, jaundice, nausea, and vomiting. Intestinal ascariasis produces biliary complications when ascariasis migrates through the ampulla of Vater. It produces a variety of presentation such as obstructive jaundice, cholangitis, cholelithiasis, choledocholithiasis, cholecystitis, pancreatitis, liver abscess, and bile duct perforation. Biliary ascariasis acts as a nidus for common bile duct stone formation. The most common stone associated with biliary ascariasis is pigmented stones.
In most of the cases, biliary ascariasis is asymptomatic. The live ascariasis worms pass spontaneously into the duodenum and the symptoms will resolve automatically. Charcot's triad (fever, pain abdomen, and jaundice) may be seen in the patient with biliary ascariasis with cholangitis. Biliary ascariasis is more common in females, and it is due to progesterone-induced sphincter of Oddi relaxation. Most of the reports of biliary ascariasis show the previous biliary procedure. The reported procedure associated with biliary ascariasis includes cholecystectomy, endoscopic sphincterotomy, and choledochoduodenostomy. Our case did not have any prior biliary procedure. A biliary procedure such as choledochoduodenostomy, sphincterotomy, and biliary stenting allows ascariasis to enter into the biliary tract easily.
An ultrasound abdomen is a useful tool for the diagnosis of biliary ascariasis. It is also an important tool for the primary screening of biliary ascariasis. Ultrasound may show classical signs of biliary ascariasis such as stripe sign, inner tube sign, and Spaghetti sign. Upper gastrointestinal endoscopy will confirm the diagnosis by the presence of ascariasis worms in the ampulla of Vater. ERCP may show a linear filling defect in the common bile duct. Apart from the diagnosis, ERCP is also used as an intervention by the endoscopic extraction of worms.
In biliary ascariasis, anti-helminthic treatment should be started only after complete removal of worms from the bile duct. If anti-helminths started before its removal, it leads to the death of worms and further biliary complications. In uncomplicated biliary ascariasis, medical management with anti-helminthic is sufficient. However, in complicated biliary ascariases such as cholangitis, common bile duct stone, dead worms, and a liver abscess may need an intervention. Endoscopy with ERCP is the most preferable intervention if it is available. If endoscopy is not possible, then proceed with either open or laparoscopic surgery.
| Conclusion|| |
In conclusion, biliary ascariasis is considered one of the differential diagnosis for the patient with symptoms of cholangitis with obstructive jaundice even without the prior biliary procedure. Prompt surgical intervention will avoid further complications by biliary ascariasis in case of cholangitis. Endoscopy and ERCP are the confirmatory investigations for biliary ascariasis. Surgical intervention may be required inpatient with biliary ascariasis with large common bile duct stone.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Lamberton PH, Jourdan PM. Human Ascariasis: Diagnostics Update. Curr Trop Med Rep 2015;2:189-200.
Mukhopadhyay M. Biliary ascariasis in the Indian subcontinent: A study of 42 cases. Saudi J Gastroenterol 2009;15:121-4.
] [Full text]
Krige J, Shaw J. Cholangitis and pancreatitis caused by biliary ascariasis. Clin Gastroenterol Hepatol 2009;7:A30.
Wani MY, Chechak BA, Reshi F, Pandita S, Rather MH, Sheikh TA, et al
. Our experience of biliary ascariasis in children. J Indian Assoc Pediatr Surg 2006;11:129. [Full text]
Sundriyal D, Bansal S, Kumar N, Sharma N. Biliary ascariasis: Radiological clue to diagnosis. Oxf Med Case Reports 2015;2015:246-7.
Lynser D, Handique A, Daniala C, Phukan P, Marbaniang E. Sonographic images of hepato-pancreatico-biliary and intestinal ascariasis: A pictorial review. Insights Imaging 2015;6:641-6.
Hashmi MA, De JK. Biliary ascariasis on magnetic resonance cholangiopancreatography. J Glob Infect Dis 2009;1:144-5.
Das AK. Hepatic and biliary ascariasis. J Glob Infect Dis 2014;6:65-72.
Alam S, Mustafa G, Rahman S, Kabir SA, Rashid HO, Khan M. Comparative study on presentation of biliary ascariasis with dead and living worms. Saudi J Gastroenterol 2010;16:203-6.
] [Full text]
[Figure 1], [Figure 2], [Figure 3]