A rare etiology of idiopathic acute pancreatitis

Sir, We thank Yagnik[1] for his interest in our article.”[2] Ultrasonography (USG) has low sensitivity in the diagnosis of pancreatic duct ascariasis. This is based on our experience of 17 cases of pancreatic duct ascariasis in the last 11 years, which constitutes the largest single‐centre experience in the world. Out of 17 cases, only 2 were diagnosed with USG. Although USG is quite sensitive for diagnosing pancreatobiliary ascariasis, its sensitivity significantly reduces when the worm is thin, in the pancreatic duct, or if the common bile duct is non‐dilated. Endoscopic ultrasound (EUS) is more sensitive for diagnosis of pancreatic duct ascariasis than other radiologic investigations. The probable reasons are excellent imaging of pancreas by EUS, use of high‐frequency probes, and in and out movement of ascaris which might be missed by other investigations. There are no studies comparing magnetic resonance cholangiopancreatography (MRCP) with EUS for pancreatic ascariasis in view of its rarity. In the study by Sandouk et al.[3] there were only 8 cases of pancreatic ascariasis out of 300 cases of pancreatobiliary ascariasis which were all diagnosed by ERCP. EUS and MRCP were not performed in that study. In the largest study till date of 500 patients with hepatobiliary and pancreatic disease caused by A. lumbricoides infection, only seven had pancreatic ascariasis.[4] EUS and MRCP were also not performed in that study. Considering all previous available data on pancreatic ascariasis and our own experience, we conclude that EUS is the investigation of choice for pancreatic ascariasis and should be considered after the first episode of idiopathic pancreatitis.