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Ascariasis of gallbladder: a rare case report and a review of the literature Sachin Khanduri, Umesh C Parashari, Deepak Agrawal and Samarjit Bhadury Trop Doct 2014 44: 50 originally published online 19 November 2013 DOI: 10.1177/0049475513512637 The online version of this article can be found at: http://tdo.sagepub.com/content/44/1/50
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On behalf of: THET
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Case Report
Ascariasis of gallbladder: a rare case report and a review of the literature
Tropical Doctor 2014, Vol 44(1) 50–52 ! The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0049475513512637 tdo.sagepub.com
Sachin Khanduri1, Umesh C Parashari2, Deepak Agrawal3 and Samarjit Bhadury1
Abstract Ascariasis of the gallbladder is a very rare presentation. We report a case of a 15-year-old boy who presented with complaints of pain in the abdomen, vomiting, pruritus, and fever on-and-off for 10 days. On radiological examination, an ultrasonography of the abdomen showed a dilated gallbladder with multiple linear echogenic, tubular, parallel lines inside the lumen of the gallbladder, common bile duct and intrahepatic biliary radicles. The zigzag and coiling movement of a worm was noted in the lumen of the gallbladder on real time B-mode ultrasonography. The patient was successfully treated with an anthelminthic drug. On follow up no evidence of the worm was noted in the gallbladder or common bile duct lumen.
Keywords Gallbladder ascariasis, zigzag, coiling, anthelminthic drug
Introduction The round worm named as ascaris lumbricoides is the most common helminthic infection (nematode) in humans.1 The adult nematode worm is mainly present in the small intestine.1,2 Sometimes the worm enters into the common bile duct, passing through the papilla of water present in the second part of duodenum and then into the gallbladder lumen through the cystic duct. This is a very rare presentation. We report a rare case of gallbladder ascariasis with intrahepatic biliary radicles ascariasis.
Case report A 15-year-old boy presented to the outpatient clinic with complaints of pain in the abdomen, vomiting, pruritus, and fever on-and-off for 10 days. There was also history of multiple episodes of passing worms in the stool for 20 days. On examination he was thin and toxic in appearance and jaundice was present. His vitals were normal except for a raised temperature. On laboratory investigation, his haemoglobin was 10 gm%, total white blood count (WBC) – 20,000/mm3. A liver function test (LFT) showed serum bilirubin – 5.6 mg/dL, alkaline phosphatase (ALP) – 160 IU/L, angiotensin sensitivity test (AST) – 140 IU/L, and alanine aminotransferase (ALT) – 98 IU/L.
On radiological examination, an ultrasonography of the abdomen showed a dilated gallbladder with multiple linear echogenic, tubular, parallel lines inside the lumen of the gallbladder, common bile duct and intrahepatic biliary radicles (Figures 1 and 2). The common bile duct was dilated with a diameter of approximately 12 mm with dilatation of the biliary radicles. The zigzag and coiling movement of the worm was noted in the lumen of the gallbladder on real time B-mode ultrasonography. Mild hepatomegaly was also noted. There was no evidence of cholecystitis. A diagnosis of ascariasis of the gallbladder and common bile duct was made and the anthelminthic drug albendazole (400 mg/day) was given. The patient improved after 10 days of multiple episodes of the passage of worms in his stools. 1 Professor, Department of Radio Diagnosis, Era’s Lucknow Medical College, Lucknow, India 2 Associate Professor, Department of Radio Diagnosis, Era’s Lucknow Medical College, Lucknow, India 3 Junior Resident, Department of Radio Diagnosis, Era Lucknow’s Medical College, Lucknow, India
Corresponding author: Dr Umesh Chandra Parashari, Department of Radio Diagnosis, Era’s Lucknow Medical College, Lucknow, India. Email: [email protected]
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Figure 1. Ultrasonography of the abdomen showing a dilated gallbladder with linear echogenic, tubular, parallel lines inside the lumen of the gallbladder, common bile duct and intrahepatic biliary radicles (black arrow). The common bile duct is dilated with a diameter of approximately 12 mm with dilatation of the biliary radicles.
Figure 2. Ultrasonography of the abdomen showing dilated intrahepatic biliary radicles with multiple linear echogenic, tubular and parallel lines inside the lumen.
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Tropical Doctor 44(1)
Discussion Ascariasis is caused by Ascaris lumbricoides roundworms which belong to the phylum nematode and is the most common helminthic infection in humans.1 The prevalence is worldwide but occurs most often in tropical and subtropical countries. The adult worm is usually seen in the small intestine, mainly in the jejunum. The infection occurs mainly in developing countries due to poor sanitation, unhygienic conditions, and overcrowding, as the route of transmission is faeco-oral. The adult worm enters the common bile duct and main pancreatic duct from the second part of the duodenum through an ampulla of water and then goes into the gallbladder lumen through the cystic duct which is relatively rare. Only 2.1% of all cases involve the biliary tract.3 The incidence is low because of tortuous and narrow cystic duct.4 Biliary ascariasis presents with complaints of right upper abdominal quadrant pain, low grade fever, vomiting, tenderness of the abdomen, and multiple episodes of passage of worms in the stools. The complications can look like acute cholangitis if the obstruction occurs in the common bile duct and presents with fever, jaundice, and tender hepatomegaly. Sometimes it can cause acute cholecystits due to the obstruction of the cystic duct and as acute pancreatitis due to the obstruction of the main pancreatic duct.5,6 On radiological examination, ultrasonography is the modality of choice for the diagnosis of gallbladder ascariasis because the appearance and movement of live worms can be seen.5 The live worm presents as linear, tubular, parallel, non-shadowing echogenic lines inside the gallbladder lumen and shows coiling, zigzag and non-directional movements which confirm that the worm is alive.7 A computed tomography (CT) scan shows tubular hyperdense foci in the gallbladder and common bile duct lumen with dilatation of the intrahepatic biliary radicles.
Conclusion Treatment includes anthelminthic drugs. Most commonly albendazole is given and in most cases the patient responds well to medical management.
Sometimes surgery is required, usually laparoscopic or endoscopic procedures such as endoscopic retrograde cholangiopancreatographic (ERCP) examination8,9 if the worm is dead and causing obstructive in the biliary system. However, in this case the patient responded well to anthelminthic drugs and no intervention was required. On follow-up, no evidence of the worm was noted in the gallbladder or the common bile duct lumen. Declaration of conflicting interests None declared.
Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
References 1. Puneet Tiwary SK, Singh S, Agarwal S and Khanna AK. Gallbladder ascariasis: a case report. Internet J Parasitic Dis 2006; 1: 1. DOI: 10.5580/2646. 2. Mahmoud Adel AF. Intestinal nematodes (round worms). In: Mandell GL, Douglas RG and Bennett JEB (eds) Principles and Practice of Infectious Diseases. 3rd ed. New York: Churchill Livingstone, 1990, pp.2135–2142. 3. Javid G, Wani N, Gulzar GM, Javid O, Khan B and Shah A. Gallbladder ascariasis: presentation and management. Br J Surg 1999; 86: 1526–1527. 4. Khuroo MS, Zargar SA, Yattoo GN, et al. Sonographic findings in gallbladder ascariasis. J Clin Ultrasound 1992; 20: 587–591. 5. Chakrabarti I, Giri A, De A and Roy AC. Radiopathological diagnosis of hepatobiliary ascariasis: a rare entity. J Cytol 2011; 28: 114–116. 6. Gomez NA, Leon CJ and Ortiz O. Ultrasound in the diagnosis of roundworms in gallbladder and common bile duct. Report of four cases. Surg Endosc 1993; 7: 339–342. 7. Aslam M, Dore SP, Verbanck JJ, De Soete CJ and Ghillebert GG. Ultrasonographic diagnosis of hepatobiliary ascariasis. J Ultrasound Med 1993; 12: 573–576. 8. Shah OJ, Dar MA, Wan NA, Robbani I and Zargar SA. Biliary ascariasis as a cause of post-cholecystectomy syndrome in an endemic area. Dig Surg 2004; 21: 108–113. 9. Shetty B, Shetty PK and Sharma P. Ascariasis cholecystitis: an unusual cause. J Minim Access Surg 2008; 4: 108–110.
Downloaded from tdo.sagepub.com at WORLD FUTURE SOCIETY on June 10, 2014
Ascariasis of gallbladder: a rare case report and a review of the literature Sachin Khanduri, Umesh C Parashari, Deepak Agrawal and Samarjit Bhadury Trop Doct 2014 44: 50 originally published online 19 November 2013 DOI: 10.1177/0049475513512637 The online version of this article can be found at: http://tdo.sagepub.com/content/44/1/50
Published by: http://www.sagepublications.com
On behalf of: THET
Additional services and information for Tropical Doctor can be found at: Email Alerts: http://tdo.sagepub.com/cgi/alerts Subscriptions: http://tdo.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav
>> Version of Record - Jan 10, 2014 OnlineFirst Version of Record - Nov 19, 2013 What is This?
Downloaded from tdo.sagepub.com at WORLD FUTURE SOCIETY on June 10, 2014
Case Report
Ascariasis of gallbladder: a rare case report and a review of the literature
Tropical Doctor 2014, Vol 44(1) 50–52 ! The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0049475513512637 tdo.sagepub.com
Sachin Khanduri1, Umesh C Parashari2, Deepak Agrawal3 and Samarjit Bhadury1
Abstract Ascariasis of the gallbladder is a very rare presentation. We report a case of a 15-year-old boy who presented with complaints of pain in the abdomen, vomiting, pruritus, and fever on-and-off for 10 days. On radiological examination, an ultrasonography of the abdomen showed a dilated gallbladder with multiple linear echogenic, tubular, parallel lines inside the lumen of the gallbladder, common bile duct and intrahepatic biliary radicles. The zigzag and coiling movement of a worm was noted in the lumen of the gallbladder on real time B-mode ultrasonography. The patient was successfully treated with an anthelminthic drug. On follow up no evidence of the worm was noted in the gallbladder or common bile duct lumen.
Keywords Gallbladder ascariasis, zigzag, coiling, anthelminthic drug
Introduction The round worm named as ascaris lumbricoides is the most common helminthic infection (nematode) in humans.1 The adult nematode worm is mainly present in the small intestine.1,2 Sometimes the worm enters into the common bile duct, passing through the papilla of water present in the second part of duodenum and then into the gallbladder lumen through the cystic duct. This is a very rare presentation. We report a rare case of gallbladder ascariasis with intrahepatic biliary radicles ascariasis.
Case report A 15-year-old boy presented to the outpatient clinic with complaints of pain in the abdomen, vomiting, pruritus, and fever on-and-off for 10 days. There was also history of multiple episodes of passing worms in the stool for 20 days. On examination he was thin and toxic in appearance and jaundice was present. His vitals were normal except for a raised temperature. On laboratory investigation, his haemoglobin was 10 gm%, total white blood count (WBC) – 20,000/mm3. A liver function test (LFT) showed serum bilirubin – 5.6 mg/dL, alkaline phosphatase (ALP) – 160 IU/L, angiotensin sensitivity test (AST) – 140 IU/L, and alanine aminotransferase (ALT) – 98 IU/L.
On radiological examination, an ultrasonography of the abdomen showed a dilated gallbladder with multiple linear echogenic, tubular, parallel lines inside the lumen of the gallbladder, common bile duct and intrahepatic biliary radicles (Figures 1 and 2). The common bile duct was dilated with a diameter of approximately 12 mm with dilatation of the biliary radicles. The zigzag and coiling movement of the worm was noted in the lumen of the gallbladder on real time B-mode ultrasonography. Mild hepatomegaly was also noted. There was no evidence of cholecystitis. A diagnosis of ascariasis of the gallbladder and common bile duct was made and the anthelminthic drug albendazole (400 mg/day) was given. The patient improved after 10 days of multiple episodes of the passage of worms in his stools. 1 Professor, Department of Radio Diagnosis, Era’s Lucknow Medical College, Lucknow, India 2 Associate Professor, Department of Radio Diagnosis, Era’s Lucknow Medical College, Lucknow, India 3 Junior Resident, Department of Radio Diagnosis, Era Lucknow’s Medical College, Lucknow, India
Corresponding author: Dr Umesh Chandra Parashari, Department of Radio Diagnosis, Era’s Lucknow Medical College, Lucknow, India. Email: [email protected]
Downloaded from tdo.sagepub.com at WORLD FUTURE SOCIETY on June 10, 2014
Khanduri et al.
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Figure 1. Ultrasonography of the abdomen showing a dilated gallbladder with linear echogenic, tubular, parallel lines inside the lumen of the gallbladder, common bile duct and intrahepatic biliary radicles (black arrow). The common bile duct is dilated with a diameter of approximately 12 mm with dilatation of the biliary radicles.
Figure 2. Ultrasonography of the abdomen showing dilated intrahepatic biliary radicles with multiple linear echogenic, tubular and parallel lines inside the lumen.
Downloaded from tdo.sagepub.com at WORLD FUTURE SOCIETY on June 10, 2014
52
Tropical Doctor 44(1)
Discussion Ascariasis is caused by Ascaris lumbricoides roundworms which belong to the phylum nematode and is the most common helminthic infection in humans.1 The prevalence is worldwide but occurs most often in tropical and subtropical countries. The adult worm is usually seen in the small intestine, mainly in the jejunum. The infection occurs mainly in developing countries due to poor sanitation, unhygienic conditions, and overcrowding, as the route of transmission is faeco-oral. The adult worm enters the common bile duct and main pancreatic duct from the second part of the duodenum through an ampulla of water and then goes into the gallbladder lumen through the cystic duct which is relatively rare. Only 2.1% of all cases involve the biliary tract.3 The incidence is low because of tortuous and narrow cystic duct.4 Biliary ascariasis presents with complaints of right upper abdominal quadrant pain, low grade fever, vomiting, tenderness of the abdomen, and multiple episodes of passage of worms in the stools. The complications can look like acute cholangitis if the obstruction occurs in the common bile duct and presents with fever, jaundice, and tender hepatomegaly. Sometimes it can cause acute cholecystits due to the obstruction of the cystic duct and as acute pancreatitis due to the obstruction of the main pancreatic duct.5,6 On radiological examination, ultrasonography is the modality of choice for the diagnosis of gallbladder ascariasis because the appearance and movement of live worms can be seen.5 The live worm presents as linear, tubular, parallel, non-shadowing echogenic lines inside the gallbladder lumen and shows coiling, zigzag and non-directional movements which confirm that the worm is alive.7 A computed tomography (CT) scan shows tubular hyperdense foci in the gallbladder and common bile duct lumen with dilatation of the intrahepatic biliary radicles.
Conclusion Treatment includes anthelminthic drugs. Most commonly albendazole is given and in most cases the patient responds well to medical management.
Sometimes surgery is required, usually laparoscopic or endoscopic procedures such as endoscopic retrograde cholangiopancreatographic (ERCP) examination8,9 if the worm is dead and causing obstructive in the biliary system. However, in this case the patient responded well to anthelminthic drugs and no intervention was required. On follow-up, no evidence of the worm was noted in the gallbladder or the common bile duct lumen. Declaration of conflicting interests None declared.
Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
References 1. Puneet Tiwary SK, Singh S, Agarwal S and Khanna AK. Gallbladder ascariasis: a case report. Internet J Parasitic Dis 2006; 1: 1. DOI: 10.5580/2646. 2. Mahmoud Adel AF. Intestinal nematodes (round worms). In: Mandell GL, Douglas RG and Bennett JEB (eds) Principles and Practice of Infectious Diseases. 3rd ed. New York: Churchill Livingstone, 1990, pp.2135–2142. 3. Javid G, Wani N, Gulzar GM, Javid O, Khan B and Shah A. Gallbladder ascariasis: presentation and management. Br J Surg 1999; 86: 1526–1527. 4. Khuroo MS, Zargar SA, Yattoo GN, et al. Sonographic findings in gallbladder ascariasis. J Clin Ultrasound 1992; 20: 587–591. 5. Chakrabarti I, Giri A, De A and Roy AC. Radiopathological diagnosis of hepatobiliary ascariasis: a rare entity. J Cytol 2011; 28: 114–116. 6. Gomez NA, Leon CJ and Ortiz O. Ultrasound in the diagnosis of roundworms in gallbladder and common bile duct. Report of four cases. Surg Endosc 1993; 7: 339–342. 7. Aslam M, Dore SP, Verbanck JJ, De Soete CJ and Ghillebert GG. Ultrasonographic diagnosis of hepatobiliary ascariasis. J Ultrasound Med 1993; 12: 573–576. 8. Shah OJ, Dar MA, Wan NA, Robbani I and Zargar SA. Biliary ascariasis as a cause of post-cholecystectomy syndrome in an endemic area. Dig Surg 2004; 21: 108–113. 9. Shetty B, Shetty PK and Sharma P. Ascariasis cholecystitis: an unusual cause. J Minim Access Surg 2008; 4: 108–110.
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