Endoscopic Management of Biliary Ascariasis

Ascaris lumbricoides is a common parasite and the most serious and dramatic presentation is hepatobiliary and pancreatic ascariasis (HPA). Therefore, this study was planned prospectively to elucidate the clinical presentation of HPA and evaluate the efficacy and safety of endoscopic intervention. In this study we documented 77 consecutive patients with HPA from January 2000 to November 2005. All the patients had endoscopically proven HPA. A total of 77 patients were included in the study. The age ranged from 6 to 80 years, with the third decade most commonly (28.6%) affected. Females were 6 times more likely to be affected than males. The commonest presentation was biliary colic (97.4%); other presentations were acute cholangitis (15.6%), obstructive jaundice (9.1%), acute pancreatitis (6.5%), choledocholithiasis (6.5%), acute cholecystitis (6.5%) and liver abscess (2.6%). In this report 51 (66.2%) had living, 10 (13%) had dead and 16 (20.8%) had both living and dead worms. Choledocholithiasis was associated only with dead worms. From one to 23 worms were found in the biliary tree. In 94.8% of cases we had to remove the worm by wide papillotomy followed by basket extraction. We did not experience any major complications during or following the procedures. Three patients had recurrent HPA during the course of follow-up (1 to 12 months). The majority of patients with HPA presented with biliary colic. This should be kept in mind in the management of an acute abdomen, especially in tropical countries. Endoscopic extraction is a safe and effective procedure for the treatment of HPA. SOUTHEAST ASIAN J TROP MED PUBLIC HEALTH 632 Vol 38 No. 4 July 2007 ultrasonographic findings and management from January 2000 to November 2005, at the Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh. All were followed for one to twelve months for complications and recurrence. All patients underwent ultrasonographic examination of the hepatobiliary system after being seen by a clinician. Inclusion criteria were patients with acute abdominal pain which was progressive or not relieved by 1 week of conservative management with ultrasonographic evidence of biliary ascariasis and endoscopic evidence HPA at any time during the illness. Exclusion criteria were hemodynamically unstable patients, recent myocardial infarction and coagulopathy. Endoscopic retrograde cholangiopancreatography (ERCP) was performed when the ascaris worm was fully inside the papilla (Fig 1). If a part of the round worm was visible outside the papilla of Vater, it was caught in a Dormia Basket and pulled out. If the worm had fully migrated inside the bile duct, then endoscopic sphincterotomy was performed and the worm(s) removed. To extract large worms which could not be extracted through the working channel, the scope had to be withdrawn completely until all the worms were removed. In the case of living worms, a few re-entered the biliary channel after partial extraction, which required repeated maneuvers for successful extraction. In the case of dead worms, a few torne during extraction which required repeated basket sweeping. All patients were subsequently given albendazole 400 mg once in a week for two consecutive weeks and thereafter, every three months.