Saudi Journal of Gastroenterology

CASE REPORT
Year
: 2001  |  Volume : 7  |  Issue : 2  |  Page : 69--70

Biliary ascariasis: Sonographic diagnosis


Najeeb Saleh Jamsheer1, Neelam Malik1, Jehad Al-Qamish2,  
1 Department of Radiology, Salmania Medical Complex, Ministry of Health, P.O. Box 12 Manama, Bahrain
2 Department of Medicine, Salmania Medical Complex, Ministry of Health, P.O. Box 12 Manama, Bahrain

Correspondence Address:
Najeeb Saleh Jamsheer
Department of Radiology, Salmania Medical Complex, Ministry of Health, P.O. Box 12 Manama
Bahrain




How to cite this article:
Jamsheer NS, Malik N, Al-Qamish J. Biliary ascariasis: Sonographic diagnosis.Saudi J Gastroenterol 2001;7:69-70


How to cite this URL:
Jamsheer NS, Malik N, Al-Qamish J. Biliary ascariasis: Sonographic diagnosis. Saudi J Gastroenterol [serial online] 2001 [cited 2020 Feb 25 ];7:69-70
Available from: http://www.saudijgastro.com/text.asp?2001/7/2/69/33405


Full Text

Introduction: The roundworm ascaris lumbricoides is an extremely common cause of biliary pathology in endemic regions. The adult worm infests the small bowel but it has a propensity to migrate up into the common bile duct from where it may enter the gallbladder or the intra-hepatic bile ducts. Biliary colic is common while jaundice, ascending cholangitis and parasitic liver abscesses occurs occasionally.

Ultrasonography is the procedure of choice for recognizing the presence of worms in the hepatobiliary tract. We describe a case of biliary ascariasis with the correct diagnosis made on the basis of characteristic ultrasound findings.

 Case Report



A 35-year old Philippino lady was admitted Salmania Medical Complex with severe epigastric pain and vomiting of two days duration. There was no radiation of the pain to the back or shoulder and the vomitus was non-bilious. She gave history of similar attacks off and on in the previous few months. The pain was aggravated by fatty food and relieved by antacids. Examinations showed stable vital signs. Epigastric tenderness was present but no mass was felt. Liver function tests and serum amylase levels were normal.

Abdominal ultrasound demonstrated normal liver, gallbladder and pancreas. The common bile duct (CBD) was mildly dilated and a non-shadowing tubular structure with a central lucency was seen in it [Figure 1]. A diagnosis of biliary ascariasis was considered and confirmed by endoscopic retrograde cholangiography [Figure 2], which showed a long cylindrical filling defect within the CBD. Through the endoscope the worm was extracted out of the CBD. The patient was treated with antihelminthics and antispasmodics. A repeat ultrasound of her biliary system showed no evidence of disease after a week.

 Discussion



One quarter of the world population is reported to be infected by ascariasis [1] . High-risk populations are in Asia, Fareast, USSR, Latin America and Africa. The adult ascaris lumbricoides worms are chiefly responsible for the illness. Invasion of the bile ducts is the most frequent cause of severe pathology resulting in suppurative cholangitis, cholecystitis and liver abscesses. In the areas where the disease is endemic, biliary ascariasis is a frequent diagnosis in patients presenting with symptoms of biliary colic. Sonography has been shown to have high diagnostic accuracy as noninvasive procedure in the work up of biliary ascariasis [2] . The worms are seen as one or more, non-shadowing tube like structures that may be either straight or coiled in the bile ducts. Sometimes a central longitudinal anechoic tube is seen in the echogenic stripe, which represents the digestive tract of the worm. In addition, real time sonography may demonstrate sinuous mobility of the worms within the gallbladder and the biliary passages, thus unequivocally establishing the diagnosis. Ultrasonography is also helpful in monitoring the exit of worms from the bile ducts.

The presence of ascaris in the bile ducts may also be detected by T tube, trans-hepatic and endoscopic retrograde cholangiography as smooth cylindrical radiolucent filling defects [3] . In patients with ascending or recurrent cholangitis, alternating strictures and dilatations of the biliary radicals may be seen. CT is helpful in identifying the occasional associated hepatic, subdiaphragmatic or pancreatic abscess and pancreatitis.

The majority of patients respond to treatment with antihelminthics and antispasmodics with spontaneous exit of worms from the biliary system. Dead worms may persist in the biliary tree and then may have to be removed by endoscopic basket technique. Successful extraction of the worm from the CBD through pappillotomy opening utilizing dormia basket has been reported from Saudi Arabia [4],[5] . Patients with severe pyogenic cholangitis also require endoscopic biliary decompression and drainage. Follow up sonography is helpful to monitor the efficacy of the treatment.

Conclusion: The possibility of ascariasis should always be considered in patients from hyperendemic areas and presenting with signs and symptoms of biliary disease. Sonography is a simple, rapid and a noninvasive method for the diagnosis and follow-up of patients with biliary ascariasis.

References

1Gabaldan A, Mofidi C, Morishita K, Moskouskij S, Sankale M, Stander DD. Control of Ascariasis. Report of a WHO expert committee. World Health Organ, Tech Rep Ser. 1967; 379: 6-7.
2Schulman A, Loxlon AJ, Hegdenrych JJ, Abdulrahman KE. Sonographic diagnosis of biliary ascariasis. AJR 1982; 139: 485-9.
3Khuroo MS, Zargar SA. Biliary ascariasis - a common cause of biliary and pancreatic disease in an endemic area. Gastroenterology 1985; 88: 418-22.
4Jessen K, Al Mofleh, Al Moferrah M. Endoscopic treatment of ascariasis causing acute obstructive cholangitis. Hepatogastroenterol 1986; 33:275-7.
5Al Karawi MA, Salem 1, Mohammed AS. Endoscopic diagnosis and extraction of biliary ascariasis Annals of Saudi Med 1989; 9(3): 80-1.