Biliary Ascariasis in a Non-Endemic Area- Case Reports

Karuna Thapar; Gaurav Dhawan; Naresh Jindal

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Karuna Thapar, Gaurav Dhawan, Naresh Jindal.

Department of Pediatrics, Government Medical College, Amritsar.

ADDRESS FOR CORRESPONDENCE
Dr Karuna Thapar, Department of Pediatrics, Government Medical College, Amritsar, India.
Email: kthapar2000@yahoo.com

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Introduction

Biliary ascariasis is common in a few geographical areas of the world. In India, it is common in the Kashmir valley and only few cases have been reported from other parts of the country. We here report two cases of biliary ascariasis seen at our centre, Department of Pediatrics, Govt. Medical College, Amritsar. Both of these cases were from non-endemic regions.

Case Report

Case Report 1
A 6 year old female child presented with pain in abdomen on and off, nausea, vomiting of long duration. Physical examination revealed pale look & tenderness in right hypochondrium. Laboratory investigations revealed that the Hemoglobin was 6 gm%. Total Leukocytes Count, Platelets, Total Bilirubin, SGOT, SGPT, Alkaline Phosphatase were within normal limits. Ultrasound abdomen revealed a well distended gall bladder with no evidence of calculi but whole of gall bladder and common bile duct were filled with worms suggesting biliary ascariasis. Child was dewormed with a single Tab. albendazole 400 mg but was not relieved of abdominal pain and did not pass stools for 2 days. On 3rd day bowel wash was done, a large mass of worms came out and after a second bowel wash, child became asymptomatic. On follow up, USG abdomen was normal & child was discharged in a satisfactory condition.

Case Report 2
A 4 year old female child presented with multiple episodes of acute colicky pain abdomen since last 2 years. Physical Examination and Laboratory Investigations were within normal limits. Ultrasound abdomen done many times before was normal. We decided to investigate the patient with MRI abdomen that revealed dilated common bile duct (1.2 cms) with a thin coiled filling defect in its proximal part suggestive of a single worm in CBD. Child was dewormed with albendazole 400 mg many times but no improvement was seen. After that child was given piperazine citrate, 150 mg/kg per oral initially followed by 6 doses of 65 mg/kg at 12 hrs interval through a nasogastric tube. Child became asymptomatic. Complete recovery was confirmed by a repeat MRI abdomen.

Discussion

The cases reported here are intended to contribute to creating an awareness that biliary ascariasis must be considered as a possibility in patients with acute abdomen in non-endemic areas. One of the most common helminthic diseases in humans is infestation by Ascaris lumbricoides affecting nearly 1/6th of the world population (1). Its incidence is greater in regions of Africa, Asia & South America. It is closely linked to sanitation so more common in third world countries. The incidence of Hepatobiliary Ascariasis (HBA) is probably underestimated (2). Its incidence is very high in endemic areas, particularly when there is heavy infestation of duodenum with worms. According to a recent study, biliary ascariasis was found to be more common in female children, with most common clinical presentation to be biliary colic followed by cholangitis, cholecystitis, liver abscess, and pancreatitis respectively (3).

The clinical features of acute biliary ascariasis are well established (4, 5). Pyrexia with right upper quadrant pain and tender hepatomegaly are suggestive of cholangitis and / or hepatic invasion (2, 6). Ultrasonography is a non-invasive, cheap and accurate modality for diagnosing biliary ascariasis and its complications (7, 8). Khuroo et al have outlined several sonographic appearances of worms in the bile ducts (2, 9, 10). Linear or curvilinear structures, single or multiple, with or without acoustic shadowing are typical for ascariasis. Various signs have been described for ascariasis which includes "spaghetti appearance", "bull's eye sign" and "impacted worm sign" (10, 11). CT scan, endoscopy and endoscopic retrograde cholangiography are other methods that are being employed in the diagnosis of biliary ascariasis.

With management in the acute stage with IV-fluids and antispasmodics, the worms will spontaneously return to the duodenum in 98% of the cases. Anti-helminthics are used after the acute stage has resolved to avoid killing or paralyzing the worm in the biliary tract, as the dead worms may disintegrate and precipitate calculi formation. Complete recovery is usual in uncomplicated biliary ascariasis with a mortality rate of 1% or less (12). piperazine citrate (50 to 75 mg/kg QD up to a maximum of 3.5 g for 2 days) was a frequent treatment regimen, but it is now being withdrawn from the market in many developed countries because the other alternatives are less toxic and more efficacious. However, it may still be recommended when there is suspected intestinal or biliary obstruction since this drug paralyzes worms to aid expulsion. Pyrantel pamoate, mebendazole, albendazole and levamisole are effective (4). Newer drugs like Ivermectine have also shown good results. Early surgical intervention is advisable in patients not responding to conservative treatment, to avoid serious complications.

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Funding None

Conflict of Interest None

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