Endoscopic management of biliary ascariasis

Hepatic and biliary ascariasis

Ascariasis mainly contributes to the global helminthic burden by infesting a large number of children in the tropical countries. Hepato-biliary ascariasis (HBA) is becoming a common entity now than in the past owing to the frequent usage of ultrasonograms and endoscopic diagnostic procedures in the clinical practice. There are a variety of manifestations in HBA and diagnosis depends on a high index of suspicion in endemic areas coupled with subsequent confirmation by sonographic or endoscopic demonstration of the worm. Most of them present with acute abdomen and jaundice. Oriental or recurrent pyogenic cholangiopathy is possibly the result of HBA, commonly encountered in South-East Asian countries. Conservative treatment with anthelminthic agents is used in the majority. Failure to respond to medical therapy usually indicates the need for endoscopic or surgical interventions. Overall, mortality is low and prognosis is good, but many epidemiological and immunological aspects of Ascaris infection are unclear, meaning our understanding the disease and infection still remains incomplete. Therefore, it is difficult to definitely put down a fixed modality of treatment for HBA. This underscores the need for further studies as ascariasis has the potential to adversely affect the national socio-economy by compromising the health of children and adults alike with its sheer number.

[Ascaris-induced acute pancreatitis]

AIM OF THE STUDY

To indicate options in a surgical university team in Vietnam for treatment of ascaris-induced acute pancreatitis.

PATIENTS AND METHODS

From January 1998 to April 2001, 33 patients (mean age 46 years) were admitted with a diagnosis of acute pancreatitis based on elevated serum amylase in 29 patients (88%), and elevated urinary amylase in all patients and a compatible clinical picture. The pancreatic ultrasonography was abnormal in 79% of cases. Biliary and pancreatic ultrasonography shown ascaris in 31 patients (94%). In other two patients ascaris was detected with duodenal endoscopy.

RESULTS

In 24 patients, the worms from the duodenum and/or across the ampullary orifice was trapped and withdrawn during duodenoscopy and failed in three patients. Nine patients were operated on, three after failure of endoscopic treatment, five for lithiasis of the common bile duct associated to the ascariasis, and one for necrotic pancreatitis. Seven patients operated on underwent a choledocotomy with a T-tube drainage, two patients underwent a left pancreatectomy to withdraw the ascaris, and one patient a resection of pancreatic necrosis. All patients recovered without complications except the patient with a necrotic pancreatitis who developed a pancreatic fistula for 23 days. Mean discharge times were 5.6 days after endoscopic treatment and 12.2 days after surgery. Effective antihelminthic therapy was administered in all patients.

CONCLUSION

Endoscopic treatment was effective in 24 out of 33 patients. Surgery was indicated for failures of endoscopic treatment, association of ascariasis and common bile duct stones, migration of ascaris in intra pancreatic duct, and pancreatic necrosis.

Biliopancreatic ascariasis: endoscopic approach

From June 1985 to June 1999, 120 patients were diagnosed by means of panendoscopy, choledocoscopy, and endoscopic retrograde cholangiopancreatography as having biliary and pancreatic ascariasis. All duodenoscopic procedures were performed under fluoroscopic control. Endoscopic extraction was successful in 99 of 108 (92%) patients, some of whom had had previous endoscopic sphincterotomy. The endoscopic accessories used were a basket catheter, polypectomy snare, and balloon catheter. Because no significant complications were observed after this endoscopic treatment, we recommend endoscopic extractions for biliary ascariasis.

Biliary ascariasis: MR cholangiography findings in two cases

We describe the imaging features of two cases of biliary ascariasis. Ultrasonography and CT showed no specific abnormal findings, but MR cholangiography clearly demonstrated an intraductal linear filling defect that led to the correct diagnosis. MR cholangiography is thus a useful technique for the diagnosis of biliary ascariasis.

Hepatolithiasis and biliary parasites

Hepatolithiasis, or the presence of intrahepatic stones, is prevalent in East Asia and is characterized by the finding of stones within the intrahepatic bile ducts proximal to the confluence of the right and left hepatic ducts. Bile stasis and bacterial infection have been incriminated as the major aetiopathogenic factors. Clinical features include recurrent pyogenic cholangitis, multiple liver abscesses, secondary biliary cirrhosis and cholangiocarcinoma. The goals of management include accurate localization of pathologies, control of biliary sepsis and the elimination of stones and stasis. Ultrasonography, computed tomography and direct cholangiography complement each other in defining the stones, strictures and degree of liver damage. Non-operative biliary decompression by endoscopy and interventional radiology is effective in controlling the infection, but surgery remains the mainstay for the treatment of stones and strictures. Intra-operative ultrasound and flexible choledochoscopy, combined with percutaneous transhepatic cholangioscopy and intraductal lithotripsy, facilitate stone removal. Balloon dilatation and biliary stenting serve to open the bile duct strictures. The creation of a hepaticocutaneous jejunostomy after conventional surgery allows atraumatic access to the biliary system for the removal of recurrent stones. The management of biliary parasites begins with conservative measures, including analgesics and anti-helminthic therapy. In refractory cases or patients with acute cholangitis, endoscopic biliary drainage and the extraction of worms may be necessary. Improvement in sanitation plays a crucial role in the epidemiological control of these biliary diseases.

Ultrasound in the diagnosis of gallbladder ascariasis

Ascariasis is the most common helminthic infection, but the invasion of worms into the gallbladder is quite rare. This report illustrates the ultrasonographic findings in gallbladder ascariasis of a typical echogenic structure which exhibits nondirectional movements and contains a central anechoic tube, along the long axis of the gallbladder. The role of ultrasound as a diagnostic tool and in the follow-up treatment is stressed.

Endoscopic retrograde cholangiopancreatography (ERCP) in the diagnosis of biliary and pancreatic duct disease: A prospective study on 668 Jordanian patients

Endoscopic retrograde cholangiopancreatography (ERCP) is the method of choice in establishing the nature and the site of common bile and pancreatic duct disease and related complications. It was used in 668 Jordanian patients who presented with biliary or pancreatic disease and unexplained upper abdominal pain. Common bile duct (CBD) stones, postsurgical traumatic CBD strictures, papillary stenosis and malignant strictures were the most common findings in this study. The incidence of malignant strictures was less and the postsurgical CBD injuries, mainly CBD complete ligation, were more than what was reported by others. This procedure was also valuable in the investigation of unexplained upper abdominal pain and pancreatic disease.