GALL BLADDER WORMS

Gursharn Singh Narang; Suneeta Arora; Jivtesh Pahwa; Jaskaran Kaur

doi:https://10.7199/ped.oncall.2012.35

Gursharn Singh Narang, Suneeta Arora, Jivtesh Pahwa, Jaskaran Kaur.

Department of Pediatrics, S.G.R.D.M.I.S.A.R, Amritsar.

ADDRESS FOR CORRESPONDENCE
Dr Gursharn Singh Narang, Associate Professor, Department of Pediatrics, SGRDMISAR, Vallah, Amritsar.
Email: jivteshpahwa@rediffmail.com

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A 5 years old male child admitted with pain abdomen in upper abdomen associated with hepatosplenomegaly. Prior history of passage of worms in the stool was present, which on microscopic stool examination showed eggs of round worms. On investigations, liver function tests were normal. Ultrasound (USG) abdomen revealed dilated gallbladder without any evidence of cholecystitis with tubular echogenic non-shadowing image in the gallbladder lumen and common bile duct (CBD). After treating with albendazole there was improvement in symptoms as well as disappearance of tubular image in the gall bladder on repeat USG.

Ascaris lumbricoides normally live in the lumen of small intestine (1, 2). From the intestine, the worm can invade the bile duct or pancreatic duct but invasion into the gallbladder is quite rare because of the anatomical features of the cystic duct which is narrow and tortuous (3). Biliary ascariasis is more common in females. Pregnant women may be more susceptible due to relaxant effect of hormones on the smooth muscle of the bile ducts (4, 5). The presentation of biliary ascariasis is similar to the cholelithiasis, acute cholecystitis, choledocholithiasis, acute pancreatitis and ascending cholangitis (6, 7). The round worm may be present both in the CBD and gallbladder in the same patient at a time as in our case. The ultrasound is diagnostic in biliary ascariasis. They present like linear echogenic image without acoustic shadow in the lumen of gallbladder and CBD (8,9). The findings of erratic, non directional, zigzag movements are characteristic of live worm (8). Biliary ascariasis has a good response to conservative treatment like bowel rest, antispasmodic and antihelminthic drugs. Worms within the biliary tract are not killed by the antihelminthic drugs. Successful treatment is possible if the worm returns to the small intestine where they are exposed to adequate concentration of drug. The conservative treatment fails usually in the presence of dead worm, concomitant stones or stricture which prevents the returning of worm in the duodenum (10). Endoscopic removal of worm treatment has become the treatment of choice for the CBD ascariasis in which the medical management has failed. Sphinterotomy should be avoided as it appears to predispose to recurrent infestation by the worms (10, 11). All patients who do not respond to conservative or endoscopic treatment should be treated with surgery. Our patient responded to the medical management and showed no evidence of cholecystitis or worm on follow up.

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References

Mahmoud Adel AF. Intestinal Nematodes (round worms). In: Mandell GL, Douglas RG, Bennett JEB, eds. Principles and practice of infectious diseases, 3rd ed. New York: Churchill living stone. 1990; 2135-2142.
Pawlowski ZS. Ascariasis: host-pathogen biology. Rev Infect Dis. 1982; 4: 806-814. [CrossRef]
Khuroo MS, Zargar SA, Yattoo GN, Dar MY, Javid G, Khan BA, et al. Sonographic findings in gallbladder ascariasis. J Clin Ultrasound. 1992; 20: 587-591. [CrossRef]
Javid G, Wani N, Gulzar GM, Javid O, Khan B, Shah A. Gallbladder ascariasis: presentation and management. Br J Surg. 1999; 86: 1526-1527. [CrossRef]
Gerdes MM, Boyden EA. The rate of emptying of the human gallbladder in pregnancy. Surg Gynaecol Obst. 1938; 66; 145-156.
Ochoa B. Surgical complications of ascariasis. World J Surg. 1991; 15: 222-227. [CrossRef]
Gomez NA, Leon CJ, Ortiz O. Ultrasound in the diagnosis of roundworms in gallbladder and common bile duct. Surg. Endosc 1993; 7; 339-342. [CrossRef]
Aslam M, Dore SP, Verbanck JJ, De Soete CJ, Ghillebert GG. Ultrasonographic diagnosis of hepatobiliary ascariasis. J Ultrasound Med 1993; 12; 573-576. [CrossRef]
Filice C, Marchi L. Maloni C, Patruno SFA, Capellini R, Bruno R. Ultrasound in the diagnosis of gallbladder ascariasis. Abdom Imaging. 1995; 20; 320-322. [CrossRef]
Beckingham IJ, Cullis SN, Krige JE, Bornman PC, Terblanche J. Management of hepatobiliary and pancreatic Ascaris infestation in adults after failed medical treatment. Br J Surg. 1998; 85; 907-910. [CrossRef]
Saul C, Pias VM, Jannke HA, Braga NH. Endoscopic removal of Ascaris lumbricoides from the common bile duct. Am J Gastroenterol 1984; 79; 725-727. [PubMed]