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CASE REPORT Table of Contents   
Year : 2007  |  Volume : 13  |  Issue : 1  |  Page : 25-32
Biliary ascariasis: Report of a complicated case and literature review


1 Division of Hepatology, Dept. of Medicine, Riyadh Military Hospital, Saudi Arabia
2 Division of Gastroenterology, Dept. of Medicine, Riyadh Military Hospital, Saudi Arabia

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Date of Submission11-Oct-2006
Date of Acceptance11-Dec-2006
 

   Abstract 

Invasion of the Ascaris worm into the biliary system leads to a wide variety of clinical syndromes. Most of the descriptions of the disease have originated from the developing world, where due to the environmental factors there is a high level of parasitism. An increased incidence of biliary ascariasis borne out of population migration and increased facilities for diagnosis has led to a renewal of interest in this disease in the developed world. Significant morbidity and mortality is associated with the concomitant complications, and early diagnosis and management is of utmost importance. Common disease presentations include biliary colic, obstructive jaundice, acalculous cholecystitis, choledocholithiasis, pancreatitis, and cholangitis. Although with a potential for serious mortality, pancreatitis, and cholangiocarcinoma constitute relatively less common threats. Recent advances in endoscopy have shifted the attention of this disease from the surgeon to the gastroenterologist and a consensus of opinion is arising for early intervention. We present here a patient with biliary ascariasis managed endoscopically and review the epidemiology, prevalence, clinical presentation, diagnosis, and management of this disease.

Keywords: Ascariasis, bile duct, cholangitis, diagnosis, endoscopic retrograde cholangiopancreatography, endoscopy, Jaundice, parasite, treatment

How to cite this article:
Sanai F M, Al-Karawi M A. Biliary ascariasis: Report of a complicated case and literature review. Saudi J Gastroenterol 2007;13:25-32

How to cite this URL:
Sanai F M, Al-Karawi M A. Biliary ascariasis: Report of a complicated case and literature review. Saudi J Gastroenterol [serial online] 2007 [cited 2017 Mar 30];13:25-32. Available from: http://www.saudijgastro.com/text.asp?2007/13/1/25/30462



   Introduction Top


0Ascaris lumbricoides continues to be one of the commonest human parasitic infestations of our times with over one billion people affected worldwide.[1],[2] The increased detection of this parasite in the developed world is probably related to population migration and world travel.[3],[4] Although the adult ascaride normally resides in the small intestine, it has been known to migrate to various regions of the body such as lungs, urinary bladder, peritoneum, and biliary system. Worm migration to ectopic sites is influenced by conditions such as fever, drug intake, general anesthesia, and bowel manipulation during surgery. The disease may have various manifestations depending upon the organ-system it is affecting.

Biliary ascariasis is commonly reported from highly endemic regions like the Far East, Indian subcontinent, Latin America, and some parts of the Middle East. Symptoms of biliary colic occur when the worm migrates across the papilla, but at times may produce more serious complications like cholangitis and pancreatitis. Lately, there has been a rising interest in biliary ascariasis, as ever-increasing cases of its complications are reported. In Saudi Arabia, this parasite is uncommon and is found mostly in the expatriate population.[5] Included in this article are two reports of complicated biliary ascariasis that were managed endoscopically; and a comprehensive literature review of its various manifestations, diagnosis and management.[6]


   Case report Top


A 42 years old Filipino male presented with a history of abdominal pain and jaundice of 4 days duration. His past history included laparoscopic cholecystectomy 5 years previously for gallstones. He had been evaluated for a similar presentation 2 years ago at which time he had undergone an endoscopic retrograde cholangio-pancreatography (ERCP) with removal of stones from the biliary tree. His investigations on this admission showed an abnormal liver profile: bilirubin, 55 µmol/L (normal 2-22), alanine transaminase 102 U/L (normal 2-40), alkaline phosphatase, 1015 U/L (normal 98-279). Ultrasonography showed a dilated biliary tree with shadowing echogenic foci within it.

The patient subsequently underwent ERCP, which showed a grossly dilated biliary tree and multiple filling defects. Numerous pigmented stones were extracted by basket and balloon through the widened papilla along with a small live Ascaris worm. Subsequently, the patient's clinical and biochemical profile improved. He was given a course of oral mebendazole and has had no further complications since then.


   Discussion Top


Biliary ascariasis is characterized by migration of the worm into the biliary tree. This leads to a wide clinical spectrum of disease manifestations; the most common amongst these are biliary colic, acalculous cholecystitis, pancreatitis, cholangitis, biliary strictures, and hepatic abscesses.[6],[8],[9] Recognition of this disease is facilitated by the liberal usage of real-time sonography and ERCP.[10],[11] This diagnosis must be suspected in patients from an endemic area presenting with biliary symptoms. Ascaris is an infrequently found parasite within Saudi Arabia and is usually encountered in the expatriate population.[4],[12]

Previous studies have shown that almost 30% of patients with biliary ascariasis have a prior history of cholecystectomy.[13] Following cholecystectomy, there follows a dilatation of the common bile duct (CBD) as well as a rise in cholecystokinin which in turn leads to relaxation of the  Sphincter of Oddi More Details. These factors likely contributed to worm migration into the biliary tree since our patient had undergone previous cholecystectomy. Moreover, our patient had also undergone prior endoscopic sphincterotomy (EPT) and this has been shown to be a pre-disposing factor to biliary worm migration in endemic areas.[14]

Ultrasonography has been shown to be an extremely useful tool in the diagnosis of biliary ascariasis.[10],[11],[15],[16] It is safe, quick, and non-invasive and should be the first imaging method employed when the disease is suspected. However, this test requires a high index of suspicion. Khuroo et al .[16] have reported a sensitivity of 86% for this test in detecting the Ascaris worm. The ultrasonographic films in our patient were reviewed retrospectively and confirmed the negative result. This suggests that the maximum benefit of the test is derived in real-time performance where the writhing movements of the worm may be appreciated. The transient migration of the worms into the intestine may also account for a negative result, while the presence of shadow-casting stones could obscure the parasites as occurred in our case.

Although most patients respond to conservative treatment, both our patients continued to be symptomatic and furthermore, were found to have complicated disease at ERCP. Stone formation within the biliary tree and stricturing are well-known complications of biliary ascariasis.[6],[7],[15],[17] Most authorities agree that complicated disease is an indication for interventional therapy as opposed to the wait-and-watch approach recommended by Gonzalez and colleagues.[13]


   Prevalence and epidemiology Top


Ascaris lumbricoides infection has been reported from almost all regions of the world, with the bulk of the cases being seen in the tropical and sub-tropical countries where the soil and climatic conditions are favorable to proliferation of the roundworm larvae. Several reports on ascariasis have highlighted substantial differences in its prevalence in areas situated in similar geographical zones, the underlying cause being differences in socio-agricultural factors. Hence, the reports of biliary ascariasis have also followed the same demographical pattern [Table - 1]. Biliary ascariasis accounts for 10-19% of ascaris-related hospital admissions.[18],[19]

In the warm and arid regions of the Arabian Peninsula Ascaris infection is only transmitted seasonally. Apart from some infrequently reported cases from the developed world,[20] biliary disease caused by roundworms is mostly endemic in Africa, the Far East, Latin America, South East Asia, and in some parts of the Middle East.[6],[7],[8],[9],[21] No epidemiological data exist on the actual incidence of biliary ascariasis due to the inherent difficulties posed by lack of diagnostic equipment and the transient stay of the roundworm within the biliary tree. Studies have shown that in endemic areas 11-18% of the patients admitted to the surgical ward for gallbladder or biliary complications presented with biliary ascariasis.[8],[22] In the past, most cases were diagnosed either during surgery or at post-mortem. As such, existing figures are based on estimates prepared by a few clinical studies in even fewer selected centers. Women are more commonly affected than men and children much lesser than adults,[7],[8] even though intestinal ascariasis is more predominant in children. Narrower biliary ducts that prevent the worms from invading across the papilla could be a possible explanation. Recurrent worm invasion of the ducts has also been frequently observed in people living in endemic regions. Pre-disposing factors include previous cholecystectomy or sphincterotomy or even prolonged fasting, as reported by a recent study.[8]

Large-scale population migrations and increasing frequency of travel have contributed to the increased prevalence of ascariasis. Rising poverty, overcrowding, and contamination of water supplies have added to the burden of disease in endemic areas. Also, more cases are being reported as a result of technological innovations in the field of diagnostic radiology and endoscopy. The vastly increased number of gallbladder and biliary procedures being performed has also contributed to greater prevalence of this disease.


   Clinical Presentations Top


Biliary

In a region endemic for ascariasis, a patient presenting with symptoms referable to the hepatobiliary system should render few diagnostic difficulties. The incidence of biliary ascariasis has been found to be profoundly increased in those who have previously undergone endoscopic sphincterotomy or cholecystectomy.[7],[8] Ascaris lumbricoides was found to be equal in incidence to gallstones as an etiological factor for adult biliary disease in areas of endemicity.[7] Aside from the non-specific features of nausea, vomiting, abdominal pain, and urticaria, the most common presentation of this entity is a biliary colic with figures ranging from 56 to 98%.[6],[7],[8] Since the worms move in and out of the biliary tract, the actual incidence of Ascaris as the contributing factor may be underestimated. Although the vomiting of roundworms during episodes of biliary colic has been found to be significantly high,[7],[8] the identification of worms in the gallbladder or in the cystic duct has been surprisingly low.[6]

Biliary colic and acalculous cholecystitis combine to form the major portion of the clinical spectrum of disease manifestation. In developed countries acalculous cholecystitis accounts for a little less than 10% of the cases of acute cholecystitis; but in the third world countries with a tropical environment, the ratio may be much higher. This is probably related to the lower incidence of gallstone formation in tropical countries combined with the high incidence of Ascaris infestation because of the afore-mentioned factors.

As a consequence of persistent biliary obstruction, deterioration into the more potentially serious complication of ascending cholangitis may occur. The incidence of pyogenic cholangitis ranges between 16 and 25%.[6],[7],[8],[9] Recurrent pyogenic cholangitis may secondarily progress into a destructive cholangiopathy and roundworm migration into the biliary ducts may serve as the initiating event in these cases.[24]

Very rare but well-documented associations with biliary calculi, strictures, and malignancy complete the spectrum of clinical disease. Convincing proof of an etiological basis for these associations is still being sought. Histological analysis of the biliary stones has led to the recovery of Ascaris remnants within them. Thus, it is postulated that the Ascaris worm or its fragments, constitute the nidus around which the stones form.[6],[7],[15],[17] Roundworm-related stones are usually of the pigment type and are aided in their formation by factors such as bile-stasis and ascending bacterial infection. Studies originating from these areas have claimed that Ascaris ova or an immature worm may be the cause of stone formation in 10-66% of patients.[24] Since, the worms rarely enter the gallbladder, stone formation almost universally occurs within the CBD or the intrahepatic ducts. Reports of cholangiocarcinoma occurring in tandem with biliary ascariasis are fairly infrequent.[25],[26] Nevertheless, biliary clonorchiasis and opisthorchiasis have been established as definite risk factors for cholangiocarcinoma[27] and A. lumbricoides with its affinity for recurrent ductal invasion, may contribute with a similar etio-pathogenesis.

Non-biliary

The other less common manifestations include acute pancreatitis and hepatic abscesses. Acute pancreatitis occurs in 4-36% of patients with pancreato-biliary ascariasis.[6],[8],[9] and Pancreatitis may be caused by actual worm invasion of the pancreatic duct or due to the ephemeral blockage of the sphincter of Oddi.[6],[7],[8],[9],[28],[29] This blockage coupled with the simultaneous obstruction to the bile duct, causes bile, and enteric organisms to regurgitate into the pancreatic duct. This activates the pancreatic enzymes with the subsequent development of acute pancreatitis. Between these two causes, duct invasion is a very rare cause of pancreatitis (1.4% in a large series of 500 patients)[30] compared to the one caused by worm obstruction of the sphincter of Oddi. Ascaris has been implicated in up to 23% of patients presenting with acute pancreatitis in endemic areas[30] and is associated with a high mortality-rate. Indeed, most of the mortality associated with biliary ascariasis has been attributed to acute pancreatitis.[6]

Liver abscess formation occurs in the setting of a high worm load, whereupon the parenchyma is invaded, leading to local inflammation, necrosis, and abscess formation. In bilio-pancreatic ascariasis, liver abscess occurs in less than 1% of patients.[6],[8] However, in endemic areas, Ascaris is a frequent etiology for liver abscess. Javid and colleagues describe 510 patients with liver abscess in whom 74 (14.5%) had ascariasis as the source of infection.[31] Early identification of the roundworm is important since the mortality is high and these patients frequently require surgical therapy, especially in those with intact ascaridae within the abscess.[32]


   Diagnosis Top


In an area endemic for A. lumbricoides , biliary invasion of the roundworm should be suspected in any patient who presents with symptoms of hepatobiliary-pancreatic disease. This serves as the primary step in the recognition of the illness. Emesis of worms during episodes of abdominal pain strongly indicates Ascaris as the underlying etiology and is seen in 25-48% of proven cases.[7],[8] Although the disease is under-diagnosed and under-estimated, the improvement of diagnostic equipment has led to an increased recognition of its occurrence.

Laboratory tests

Various patterns of alterations in the LFT may be seen. Due to the routine and easy availability of these blood tests, they are amongst the most frequently performed during an emergency presentation. This review will not deal with the different patterns of LFT abnormalities of the various presentations of biliary ascariasis.

Serum alkaline phosphatase rises early and is the most frequently elevated biochemical parameter to be found.[6] Mild to significant elevations of the serum amylase can occur depending on the presence or absence of pancreatitis. Hematological aberrations including a modest neutrophilic leukocytosis may be seen. A rise in the eosinophil count and serum IgE levels, especially in the later part of the migratory phase of ascariasis, can also be expected and in the proper setting may be of some diagnostic value. These counts reduce rapidly during the intestinal stage of the disease. Unlike in pulmonary disease induced by migrating Ascaris, meaningful hematological data is lacking in patients with biliary disease.

Serological tests are not easily available or routinely employed, however, an indirect diagnosis of ascariasis is possible by immunological means. None of these tests indicate biliary disease, but are merely indicators of A. lumbricoides exposure. Enzyme-linked immunosorbent test is one of the most sensitive and specific of these tests. The solid-phase radioimmunoassay technique, agar-gel diffusion test, and immunoelectrophoretic analysis to detect the presence of IgM antibodies to the Ascaris antigen serve as some of these tests. The indirect hemagglutination test is more sensitive than the bentonite-flocculation test but at the cost of being less specific. Historically, these tests were done in combination and both needed to be positive to hold any diagnostic value. Moreover, these serological tests are plagued with the problem of interpretation due to concomitant infections with Toxocara or the possibility of heterologous reactions with blood group antibodies and also the complex antigenic structure of ascaris worm.[32]

The finding of fertile or infertile eggs (or an adult worm) in the feces may serve as only an indicator of this roundworm infestation. However, in the context of a hepatobiliary disease, positive tests help to reinforce the suspicion. The most effective coprological techniques for the diagnosis of ascaris eggs is the Kato and Miura thick smear, which consists of 30-70 mg of fecal material and has a lot more eggs per female worm than the other smear techniques.[32] Analysis of bile obtained through a nasobiliary or percutaneous transhepatic cholangiographic drain has been effectively used to screen for roundworm ova or fragments but this cannot be accomplished without the assistance of interventional radiology or endoscopy. A high diagnostic yield makes this a potentially useful test especially in scenarios where the worm has already moved out of the biliary tree.

Radiological evaluation

Ultrasonography is the most informative diagnostic modality amongst the different radiological tests available. Various studies have outlined the sonographic features of biliary ascariasis and have promoted it as the initial diagnostic modality of choice.[10],[11],[15],[16] The sensitivity of this test in identifying pancreato-biliary ascariasis ranges from 25 to 91%,[6],[8],[9],[15],[16] being lower in those with pancreatic disease.[30] The sensitivity may also be reduced when the test is performed after symptom resolution corresponding to the migration of the worm out of the bile ducts. It is also impeded by being an operator-dependent tool with possibilities of false positivity due to side-lobe artifacts and other patient-related issues like obesity or bowel gas.

Worms in the biliary ducts appear as tubular, echogenic, non-shadowing images and the digestive tracts of the worm can be seen as inner anechoic tubes ('four lines sign').[16] Sonography may also reveal an intraluminal mass with a pseudotumorous effect. The sinuous movement of the worms inside the gallbladder and the bile ducts is pathognomonic of Ascaris. Patients with biliary obstruction resulting from parasitism usually show dilatation of the ducts. Gallbladder pathology including septation and presence of coiled echogenic structures have also been described.[16] Ultrasound may also be used in the follow-up of patients with previous biliary ascariasis and to monitor the effect of therapy.

Intravenous cholangiography has a yield of less than 50% in proven cases owing to insufficient ductal illumination.[33] Oral cholecystography is even less helpful as Ascaris rarely enter the gallbladder. Barium studies, undertaken incidentally, may add corroborative evidence by showing the intestinal worms. However, most of such diagnoses are made on a retrospective basis. The indication for percutaneous transhepatic cholangiography (PTC) is limited by the routine availability of ERCP over which it has no real advantage. Similarly, computed tomographic scanning (CT scan) and magnetic resonance imaging (MRI) are expensive investigations without any proven accuracy and discussed only as case reports.[34],[35] At present, their role remains unclear and needs further evaluation.

Endoscopy

The trend of utilizing ERCP as a primary diagnostic tool for biliary ascariasis has evolved whereby it is now utilized mainly for therapeutic purposes. However, earlier studies have recommended early usage of ERCP, since worm extraction through the papillary orifice can also be accomplished in the same setting.[8],[9],[28],[36] Demonstration of roundworms within the biliary tree is diagnostic; and in those in whom the ascaris cannot be demonstrated, visualization of the worms within the duodenum, extends supportive evidence of ascaris as the possible etiology behind the biliary-pancreatic disease.

Used alone, ERCP can diagnose 53-58% of cases but the sensitivity approaches almost 100% when used in conjunction with real-time sonography.[6],[8] However, there is no existing control for the diagnosis of biliary ascariasis and studies have relied heavily on circumstantial evidence. Cholangiograms reveal various abnormalities like dilatation of the CBD or intrahepatic ducts, motile tubular structures within the biliary tree [Figure - 1] or irregularity and stricturing of the ductal walls. Cholangiographic features of the worms include long, smooth, linear defects; smooth, parallel filling defects; and curves and loops crossing the hepatic ducts transversely. Quite frequently the worm is seen lying across the papillary opening and at other times circumstantial evidence of its recent invasion into the biliary tree can be seen in the form of an ulcerated or inflamed papilla.[8] Movement of the ascaride out of the biliary tracts coincides with the resolution of symptoms.[7],[37] Therefore, the highest diagnostic yield is achieved when endoscopy is performed soon after the onset of symptoms.


   Management Top


Conservative measures

From an age when surgery was the only available treatment, the management of biliary ascariasis has seen a major metamorphosis. While most cases respond sufficiently to endoscopic worm extraction, this may not be indicated in the majority as the Ascaris may move out of the biliary tree spontaneously. Conservative measures include prohibition of oral feeding, intravenous fluid, analgesics, antibiotics, and antispasmodics. Conservative treatment is continued usually for 3 days and success is gauged by alleviation of symptoms. During this period migration of the worm should be monitored by serial ultrasonography. Previous studies have shown that 42-90% of patients could be treated by non-invasive means.[6],[7],[13],[38] Targeted vermifuge against A. lumbricoides should be delayed until the worms move out of the biliary tree. Aside from a few isolated reports of Chinese acupuncture and traditional herbal medicine,[39] management has been more or less streamlined towards conventional therapy.

Endoscopy

Most authors recommend early intervention with endoscopy since this has brought about a major reduction in the morbidity and mortality of this disease.[9],[30],[36],[40] However, Khuroo et al.[38] showed that ERCP/endoscopic intervention was required in only 29% of patients after failing conservative management. Much depends on the technical skill of the endoscopist. Maximum utility is derived when the procedure is undertaken in a symptomatic patient.[7],[30] Grasping of the worm by a Dormia basket [Figure - 2] and extracting it through the papilla leads to a rapid relief of symptoms and a reduction in complication rate.[9],[31],[36],[40] Early endoscopic intervention is also an option in the presence of pyogenic cholangitis and acute pancreatitis. In instances where the worm has migrated completely into the bile ducts, an ERCP may be indicated. Although largely successful, it is not without complications. Fragmentation or incomplete extraction of the worm may cause sclerosing strictures of the ducts and subsequent failure of endoscopic treatment. Sphincterotomy should be avoided if possible and worm extraction attempted by balloon to avoid possible future worm re-invasions. Most authors have reported successful worm-extraction rates in excess of 90%.[41] In the scenario where the worm cannot be removed, nasobiliary drainage, and supportive treatment with analgesics, antispasmodics and antibiotics can still accomplish biliary decompression. Difficulty is encountered when the parasite lies within the intrahepatic ducts[36],[38] while dead and calcified worms, which get impacted, are also difficult to extract. Lastly, worms within the pancreatic duct are also not amenable to easy endoscopic extraction and therefore, these patients carry a poor prognosis.[30] Sandouk et al . recently described the 'whirlpool jet technique', which proscribes injecting a jet of contrast material into the pancreatic duct to flush the roundworm out following which it can be grasped by a basket and then extracted.[42]

Although ERCP has been widely recommended as the preferred modality of therapy, it must be balanced against potential complications of the procedure. Moreover, sphincterotomy performed during ERCP for worm extraction predisposes to recurrent worm infestation.[6] Since this disease is more rampant in the poorer tropical countries of the world, the expense of an ERCP adds significantly to the overall cost of treatment. Therefore, ERCP as a therapeutic intervention should be considered if a patient fails to respond to conservative treatment; or the worm persists (as demonstrated by serial sonograms) or has died within the pancreato-biliary tree. Presence of coexistent strictures or stones within the ducts is also indications for ERCP. Against the backdrop of these considerations, there is a pressing need for randomized controlled trials comparing the outcomes of ERCP with conservative therapy.

Drug therapy

Important advances have been made in the vermifuge of human parasitic diseases. Effective drugs against A. lumbricoides are easily available. Although there is reasonable efficacy of these drugs against the intestinal form of ascariasis but, due to a lack of enterohepatic circulation of these drugs,[43] there is no evident activity against the worms when they invade the biliary tree. Direct instillation of the antihelminthic into the biliary tree is not recommended. The resultant flaccid paralysis of a worm within the biliary tree eventually leads to its death within the ducts. The macerated worm then elicits a severe inflammatory reaction eventually leading to fibrotic strictures. Nevertheless, these drugs are of considerable benefit when the roundworms move out of the biliary tree into the small intestine. At this point, worm eradication can be achieved with a confidence-factor of around 90% by using oral mebendazole or pyrantel pamoate.[44] However, this has not been shown to be effective in preventing the recurrence of biliary ascariasis, as there is a high rate of re-infection in these endemic areas. While once-monthly courses of these medications have been studied, these have been ineffective in preventing relapses.[6] Moreover, the potential complications of long-term drug therapy argue against this course of action.

The drugs used for treatment of ascariasis include mebendazole, pyrantel pamoate, piperazine citrate, and levamisole. Amongst these mebendazole and pyrantel are the most recommended, claiming the least side effects. Efficacy of treatment can be determined by stool examination 1-2 weeks after initiating treatment. However, negative stool samples do not necessarily indicate eradication of the roundworm.

Surgical aspects

The need for surgical intervention has been gradually eroded by the introduction of ERCP in the management of biliary tract diseases. Worms may not always be found in the bile ducts at the time of surgery, even in proven cases of biliary ascariasis, thereby arguing in favor of a less invasive procedure. However, rare cases that are not amenable to endoscopic extraction may need to undergo surgery, but these constitute less than 1% of the treatment spectrum.[8],[36],[38] It is important to note that the skill of the individual endoscopist greatly influences this ratio. Other indications include presence of hepatic-ductal or gallbladder ascarides and acute pancreatitis. Choledochotomy, choledochoduodenostomy and intra-operative biliary duct syringing to increase the hydrostatic pressure and facilitate worm expulsion, are some of the surgical methods employed in the management of intractable biliary ascariasis. An intractable stricturing disease of the biliary ducts can be overcome by hepato-jejunostomy, while that localized to one lobe of the liver may necessitate lobectomy. Flush therapy with normal saline injected through a T-tube has been effectively used to manage post-operative biliary ascariasis.[45]

Ascaris lumbricoides continues to be one of the commonest human parasitic infestations in the developing world with an increasing prevalence in the industrialized nations as a consequence of population migration. Biliary migration of the worm is infrequent, but can cause serious morbidity and mortality necessitating early recognition of the disease. While laboratory tests are non-specific, ultrasonography demonstrates features highly suggestive of biliary ascariasis. The vast majority of patients respond to conservative measures. Endoscopic therapy has replaced surgery with a high rate of success. Early endoscopic intervention may be sought in those presenting with complicated disease. Worms visible at the ampulla may be extracted endoscopically prior to attempting more intrusive forms of therapy. ERCP remains the therapeutic modality of choice when intervention is required. Recurrence of the disease is frequent due to re-infestations. Sphincterotomy should be avoided for worm extraction since an open biliary sphincter facilitates future disease recurrences should worm re-infestation occur. Worm eradication with anti-helminthic therapy is essential after biliary disease resolution, although reinfections are common in the endemic areas. We suggest herein an algorithm [Figure - 3] designed to manage patients with pancreato-biliary ascariasis.[46]

 
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Correspondence Address:
F M Sanai
Hepatology division (A41), Department of Medicine, Riyadh Military Hospital, P. O. Box 7897, Riyadh 11159
Saudi Arabia
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DOI: 10.4103/1319-3767.30462

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