Case Report

Biliary ascariasis: an uncommon cause for recurrent biliary colic after biliary sphincterotomy and common bile duct stone removal

Tropical Doctor 2014, Vol. 44(2) 108–109 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0049475513518199 tdo.sagepub.com

Ragesh Babu Thandassery1, Ashish Kumar Jha1 and Mahesh Kumar Goenka2

Abstract Endoscopic retrograde cholangiography is the most commonly used technique for removal of common bile duct stones. Biliary sphincterotomy during the procedure facilitates stone retrieval from the common bile duct. However, sphincterotomy ablates the normal biliary sphincter mechanism. This facilitates duodeno-biliary reflex and can result in inward migration of luminal parasite into the biliary system. In areas where ascariasis is endemic there is an increased risk of biliary ascariasis in postbiliary sphincterotomy patients. We report an unusual case where a patient presented with recurrent biliary colic after cholecystectomy and common bile duct stone extraction and was diagnosed to have biliary ascariasis with the help of endoscopic ultrasound examination of the biliary system.

Keywords Biliary colic, endosonography, endoscopic retrograde cholangiography

Case report A 32-year-old woman, who had undergone laparoscopic cholecystectomy 18 months previously for gall bladder stones presented with biliary colic. An abdominal ultrasound was performed and it revealed an 8-mm calculus in the distal common bile duct (CBD). She underwent endoscopic retrograde cholangiography (ERC) with biliary sphincterotomy and CBD calculus was removed. Post ERC, a balloon occlusion cholangiogram was performed and it confirmed complete clearance of CBD calculus. She was asymptomatic for 1 week but thereafter again presented with recurrence of biliary colic. There was a possibility of small retained CBD calculus and a radial endoscopic ultrasound (EUS) examination of the biliary system was done. To our surprise, radial EUS showed a linear hypoechoic structure with hyperechoic margins, measuring 4 mm in width, inside the CBD and the CBD was mildly dilated (6.9 mm) (Figure 1, panel 1). We repeated the ERC and found a linear filling defect in the cholangiogram (Figure 1, panel 2). Balloon sweep extruded an adult round worm (Ascaris lumbricoides) partly outside the

CBD (Figure 1, panel 3). It was removed with biopsy forceps and it measured 10 cm. Recurrent biliary colic in patients after cholecystectomy and CBD clearance is usually due to small CBD stones that are missed or recurring. In our case, the balloon occlusion cholangiogram was normal and the chance of missing large stones was less. EUS is a reliable investigation in such situations where small calculi or biliary sludge can be identified.1 Round worms sometimes enter the CBD and cause biliary colic.2,3 Round worms inside the CBD can cause obstructive jaundice and can even present with cholangitis. Sphincterotomy facilitates easy access of the worm into the biliary system. These worms can also enter the gall bladder or the pancreatic duct resulting in 1 Consultant in Gastroenterology, Institute of Gastrointestinal Sciences, Apollo Gleneagles Hospital, Kolkata, India 2 Senior Consultant and Director in Gastroenterology, Institute of Gastrointestinal Sciences, Apollo Gleneagles Hospital, Kolkata, India

Corresponding author: Ragesh Babu Thandassery MD DM, Institute of Gastrosciences, Apollo Gleneagles Hospital, Kolkata, India. Email: [email protected]

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Figure 1. EUS, fluoroscopic and endoscopic appearance of round worm. Panel 1: radial EUS view of the CBD showing round worm (arrow). Panel 2: ERC showing linear filling defect in the CBD. Panel 3: ERC showing extraction of round worm from the CBD. PV: portal vein.

cholecystitis or acute pancreatitis.4,5 Our report re-emphasises that while evaluating biliary colic in areas endemic for ascariasis, the possibility of biliary ascariasis should always be considered. With the high incidence of biliary or pancreatic ascariasis post sphincterotomy, we recommend routine administration of prophylactic antihelminthics in endemic areas after biliary or pancreatic sphincterotomy. 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. Aljebreen A, Azzam N and Eloubeidi MA. Prospective study of endoscopic ultrasound performance in suspected choledocholithiasis. J Gastroenterol Hepatol 2008; 23: 741–745. 2. Ibrarullah M, Mishra T, Dash AP and Upadhaya UN. Biliary ascariasis–role of endoscopic intervention. Trop Gastroenterol 2011; 32: 210–213. 3. Khuroo MS. Hepatobiliary and pancreatic ascariasis. Indian J Gastroenterol 2001; 20(Suppl. 1): C28–32. 4. Wani I. Gallbladder ascariasis. Turk J Gastroenterol 2011; 22: 178–182. 5. Sharma M, Somasundaram A and Mohan P. Acute pancreatitis: an uncommon but easily treatable cause. Gastroenterology 2011; 141: e3–4.

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Biliary ascariasis: an uncommon cause for recurrent biliary colic after biliary sphincterotomy and common bile duct stone removal.

Endoscopic retrograde cholangiography is the most commonly used technique for removal of common bile duct stones. Biliary sphincterotomy during the pr...
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