Biliary ascariasis as etiology of recurrent abdominal pain

A 37-year-old woman had a history of cholelithiasis and choledocholithiasis in 2007, and cholecystectomy and endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy had been performed.

She was admitted to our unit with a 10-day history of upper abdominal pain that radiated into the back. She reported no weight loss, no fever, and no change in bowel habit. On questioning, the patient reported that she had travelled to Peru 6 months previously, and had probably ingested contaminated water. Laboratory tests showed minimal elevation of serum amylase, and normal findings for lipase, hepatic function, complete blood count, electrolyte levels, and blood chemistry. Abdominal ultrasound revealed hepatic steatosis.

Mild pain persisted despite treatment with antispasmodics. After 5 days, upper gastrointestinal endoscopy was performed and showed antral chronic gastritis. Endosonography showed normal large blood vessels. The uncinate process, head, isthmus, body, and tail of the pancreas showed normal appearances, as did the size and shape of the papilla and pancreatic duct. The common bile duct was dilated to 9 mm, and a tubular entity about 4 mm in diameter was extending through it, from the duodenal lumen to the intrahepatic bile duct. Tubular structures that moved independently were observed ([Fig. 1]). Because the endoscopic appearance was suspicious for parasitic infestation, we exchanged the echoendoscope for a duodenoscope, confirmed the diagnosis ([Fig. 2]), and extracted the specimen completely using a Talon grasping device (US Endoscopy, Mentor, Ohio, USA), observing a parasite of 20 cm in length ([Video 1]).

Fig. 1 Endosonographic view of Ascaris lumbricoides parasite inside the common bile duct (CBD).

Fig. 2 Endoscopic view of Ascaris lumbricoides exiting from the major duodenal papilla.

Diagnosis and removal of Ascaris lumbricoides parasite from the common bile duct.

Microbiological study confirmed Ascaris lumbricoides. After extraction of the parasite, the patient reported no abdominal pain. A single dose of albendazole (400 mg) was administered [1] and the patient was discharged.

Ascaris lumbricoides is an intestinal nematode (roundworm), producing a globally distributed helminthic infection. The majority of infections occur in the developing countries of Asia and Latin America [2]. The symptoms and complications of infection can be pulmonary and hypersensitivity manifestations [3], intestinal symptoms and obstruction [4], and hepatobiliary and pancreatic [5].

Endoscopy_UCTN_Code_CCL_1AF_2AF_3AZ

• References

• 1 Norhayati M, Oothuman P, Azizi O et al. Efficacy of single dose albendazole on the prevalence and intensity of infection of soil-transmitted helminths in Orang Asli children in Malaysia. Southeast Asian J Trop Med Public Health 1997; 28: 563-569
• 2 Khuroo MS. Ascariasis. Gastroenterol Clin North Am 1996; 25: 553-577
• 3 Miller LA, Colby K, Manning SE et al. Ascariasis in humans and pigs on small-scale farms, Maine, USA, 2010 – 2013. Emerg Infect Dis 2015; 21: 332-334
• 4 Teneza-Mora NC, Lavery EA, Chun HM. Partial small bowel obstruction in a traveler. Clin Infect Dis 2006; 43: 214 , 256–258
• 5 Sandouk F, Haffar S, Zada MM et al. Pancreatic-biliary ascariasis: experience of 300 cases. Am J Gastroenterol 1997; 92: 2264-2267