Hepatobiliary and pancreatic ascariasis

Ascending cholangitis in a child: A rare case of biliary Ascariasis visualized by ultrasound

Biliary ascariasis, resulting from the infestation of the biliary system by the roundworm Ascaris lumbricoides, is a rare but important cause of biliary blockage in children. In this case report, we present the clinical and radiological findings of a child who presented with symptoms and signs of ascending cholangitis, which followed biliary ascariasis. Double tube sign, typical for biliary ascariasis, was visualized on real time abdominal ultrasound examination.

Abdominal complications of ascariasis in childhood

OBJECTIVE

Complications of ascariasis are a significant cause of abdominal pain in pediatric emergencies, especially where it is endemic. A literature review was conducted with the aim of improving diagnostic and therapeutic approaches for these patients.

DATA SOURCES

A PubMed search was conducted using the key terms "ascariasis complications" and "hepatobiliary ascariasis". The search strategy included meta-analyses, randomized controlled trials, clinical trials, observational studies, case reports, and reviews published up to December 2023.

SUMMARY OF FINDINGS

Obstruction of the small bowel is the most common complication. Others that are, rarer and more difficult to properly identify and treat, such as biliary, hepatic, and pancreatic complications, acute appendicitis, Meckel's diverticulitis, or peritoneal granulomas. Hepatic and pancreatic complications are rarer and more serious in children than in adults. While plain radiography is usually the only option in cases of intestinal obstruction, ultrasonography is the examination of choice in cases of hepatobiliary, pancreatic, and appendicular ascariasis complications in childhood. The treatment is clinical and conservative in most patients. Surgical treatment is indicated if conservative therapy fails, or if there are signs of complications. Laparoscopy has been used as an excellent technical alternative in adults with hepatobiliary complications of ascariasis, but further studies on its use in children are still needed.

CONCLUSION

The creation of protocols and greater debate on this subject should be encouraged for a better understanding of the disease and to establish an early diagnosis and adequate treatment for children with complications resulting from massive infestation by Ascaris lumbricoides.

Embryonal Rhabdomyosarcoma of the Bile Ducts Causing Obstructive Jaundice in a Child: A Case Report

Jaundice in older children can occur when any obstruction is found within the bile ducts, either from bile stones, parasites, choledochal cysts and rarely, secondary to tumors. We present a previously well, 10-year-old Filipino boy with three-week history of progressive jaundice and tea-colored urine, and was initially assessed to have biliary ascariasis. Ultrasound showed a heterogeneous focus spanning the gallbladder neck and confirmed on endoscopic retrograde cholangiopancreatography as an exophytic mass at the ampulla of Vater. Tumor biopsy and immunohistochemical staining confirmed the diagnosis of Embryonal Rhabdomyosarcoma of the Bile Ducts. Chemotherapy was initiated to reduce the size of the tumor before any surgical intervention could be attempted. Despite chemotherapy, the tumor progressively grew. He acquired a respiratory infection which led to sepsis and his eventual demise. The disease should be considered in the differential diagnosis of a child with obstructive jaundice after exclusion of other more common causes.

Biliary fibrosis is an important but neglected pathological feature in hepatobiliary disorders: from molecular mechanisms to clinical implications

Fibrosis resulting from pathological repair secondary to recurrent or persistent tissue damage often leads to organ failure and mortality. Biliary fibrosis is a crucial but easily neglected pathological feature in hepatobiliary disorders, which may promote the development and progression of benign and malignant biliary diseases through pathological healing mechanisms secondary to biliary tract injuries. Elucidating the etiology and pathogenesis of biliary fibrosis is beneficial to the prevention and treatment of biliary diseases. In this review, we emphasized the importance of biliary fibrosis in cholangiopathies and summarized the clinical manifestations, epidemiology, and aberrant cellular composition involving the biliary ductules, cholangiocytes, immune system, fibroblasts, and the microbiome. We also focused on pivotal signaling pathways and offered insights into ongoing clinical trials and proposing a strategic approach for managing biliary fibrosis-related cholangiopathies. This review will offer a comprehensive perspective on biliary fibrosis and provide an important reference for future mechanism research and innovative therapy to prevent or reverse fibrosis.

Intestinal parasitic infections in children from marginalised Roma communities: prevalence and risk factors

BACKGROUND

Intestinal parasitic infections remain a significant global health issue, particularly affecting poor and marginalised populations. These infections significantly contribute to children's diseases, malnutrition, poor school performance, cognitive disorders, and future economic losses. This study aimed to explore and compare the occurrence of intestinal parasites in early childhood among the group of infants from the Slovak majority population and from marginalised Roma communities (MRCs). Furthermore, it aimed to explore the health complaints of children with and without intestinal parasitic infection in the past month and assess the effect of various risk factors on the occurrence of intestinal parasitic infection in infants from MRCs.

METHODS

We obtained cross-sectional data from mothers and stool samples of their children aged 13-21 months using the first wave of the longitudinal RomaREACH study. A total of 181 stools from infants were analysed: 105 infants from the Slovak majority population and 76 from MRCs.

RESULTS

Infants from MRCs are significantly more often infected by Ascaris lumbricoides, Trichuris trichiura and Giardia duodenalis than their better-off peers from the majority population. Infection rates are 30% in infants from MRCs vs. 0% in the majority population (p < 0.001). Single and mixed infections were observed in children from MRCs. Infants with intestinal parasitic infections suffer significantly more often from various health complaints, particularly cough, stomach ache, irritability, and diarrhoea. Within MRCs, the risk of parasitic infections in infants is significantly increased by risk factors such as the absence of flushing toilets in households (OR = 4.17, p < 0.05) and contact with un-dewormed animals (OR = 3.61, p < 0.05). Together with the absence of running water in the household, these three factors combined increase the risk more than ten times (p < 0.01).

CONCLUSION

Maintaining hygienic standards in conditions of socioeconomic deprivation in MRCs without running water and sewage in the presence of un-dewormed animals is problematic. These living conditions contribute to the higher prevalence of parasitic infections in children from MRCs, causing various health complaints and thus threatening their health and healthy development.

Acute necrotising pancreatitis from ascariasis in a gravid patient

Rarer causes of acute pancreatitis may be considered in certain settings, such as parasitism in endemic regions. This report describes a pregnant female (second trimester) in her 20s who presented with 3-day steady epigastric pain radiating to the back and passage of worm from the mouth. She was diagnosed with mild acute pancreatitis, given a significantly elevated serum lipase and absence of organ failures. Fecalysis showed Ascaris lumbricoides ova; hence, she was treated with mebendazole. Plain MR cholangiopancreatography showed an 842 mL necrotic pancreatic fluid collection and tubular flow void foci within the gallbladder and duodenum consistent with helminthiasis. The patient was managed conservatively in the absence of indications for drainage. The abdominal pain remarkably improved, and she underwent eventual vacuum-assisted delivery to a healthy term baby 4 months after the bout of acute pancreatitis.

Biliary Ascariasis in a Pediatric Patient in Lithuania: Case Report and Literature Review

Hepatobiliary ascariasis is caused by the entry of the nematode A. lumbricoides from the duodenum into the biliary duct. We report a case of an Ascaris-induced extrahepatic biliary tract obstruction in a pediatric patient admitted to the hospital due to a wide spectrum of symptoms of biliary disease, which included abdominal pain in the upper abdominal quadrants, vomiting, and jaundice. Imaging tests-including ultrasound, magnetic resonance cholangiopancreatography (MRCP), and endoscopic retrograde cholangiopancreatography (ERCP)-were performed to confirm the diagnosis of biliary ascariasis. The tests did, in fact, demonstrate signs of this disease. Nevertheless, during the ERCP, only the remains of Ascaris parasites in the form of tissue fragments were extracted. We also aim to discuss the prevalence of ascariasis in children, the causes of migration of Ascaris parasites into the bile ducts, together with its clinical manifestations, as well as the diagnostic and treatment methods of this disease.

An uninvited guest, Ascaris in the bile duct causing cholangitis successfully treated with surgery

Parasitic infections continue to be a burden for developing countries-the lack of hygiene measures and clean water results in dangerous scenarios that can lead to challenging problems. Most Ascaris lumbricoides infections are usually mild; nonetheless, in rare cases in endemic regions, they can migrate to the bile duct and cause severe complications requiring surgery. We present the case of a 43-year-old woman who had severe cholangitis due to A. lumbricoides. The worm migrated from the bowel and obstructed the bile duct; after surgery, the patient fully recovered.

Acalculous Cholecystitis in COVID-19 Patients: A Narrative Review

Acute acalculous cholecystitis (AAC) represents cholecystitis without gallstones, occurring in approximately 5-10% of all cases of acute cholecystitis in adults. Several risk factors have been recognized, while infectious diseases can be a cause of cholecystitis in otherwise healthy people. Coronavirus disease 2019 (COVID-19) is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and has spread worldwide, leading to an unprecedented pandemic. The virus enters cells through the binding of the spike protein to angiotensin-converting enzyme 2 (ACE2) receptors expressed in many human tissues, including the epithelial cells of the gastrointestinal (GI) tract, and this explains the symptoms emanating from the digestive system. Acute cholecystitis has been reported in patients with COVID-19. The purpose of this review is to provide a detailed analysis of the current literature on the pathogenesis, diagnosis, management, and outcomes of AAC in patients with COVID-19.

An update on the current and emerging pharmacotherapy for the treatment of human ascariasis

INTRODUCTION

Globally, Ascaris lumbricoides is the commonest helminthic infection that affects people in underdeveloped countries and returning immigrants in industrialized nations. This article aims to provide latest updates on the epidemiology, clinical manifestations, and pharmacotherapy of ascariasis.

AREAS COVERED

A PubMed search was conducted using Clinical Queries and the key terms 'human ascariasis' OR 'Ascaris lumbricoides.' Ascaris lumbricoides is highly endemic in tropical and subtropic regions and among returning immigrants in industrialized nations. Predisposing factors include poor sanitation and poverty. The prevalence is greatest in young children. Most infected patients are asymptomatic. Patients with A. lumbricoides infection should be treated with anti-helminthic drugs to prevent complications from migration of the worm. Mebendazole and albendazole are indicated for children and nonpregnant women. Pregnant individuals should be treated with pyrantel pamoate.

EXPERT OPINION

Cure rates with anthelmintic treatment are high. No emerging pharmacotherapy can replace these existing drugs of good efficacy, safety profile and low cost for public health. It is opinioned that advances in the management of ascariasis include diagnostic accuracy at affordable costs, Emodepside is highly effective in single doses against ascarids in mammals and in human trials. The drug could be registered for human use in multiple neglected tropical diseases.

Extra-intestinal complications of Ascaris lumbricoides infections in India: A systematic review and meta-analysis

The aberrant migration of Ascaris lumbricoides may cause extra-intestinal ascariasis (EIA) involving hepato-biliary-pancreatic (HBP) or other extra-gastro-intestinal (EGI) organs. We performed a systematic review and meta-analysis to study the risk factors and clinical presentations of EIA, and differences in HBP and EGI ascariasis. Medline, Web of Science and Embase were searched for cases of EIA in the English language from India. From 1204 articles, 86 studies (105 cases) were included. The majority of the cases involved the HBP system (78%). Among HBP ascariasis, the most commonly involved site was the bile duct (53.6%). Females had 11.3 times higher odds (95% CI 2.852 to 44.856; p=0.001) of HBP ascariasis, while the pediatric population had lower odds (OR=0.323). Previous gallbladder disease was significantly associated with HBP ascariasis in adults (p=0.046), while a significantly higher number of cases of EGI ascariasis were observed among pediatric patients (p=0.003). Ocular symptoms occurred exclusively in the pediatric population (p=0.017). Overall, death was reported in 3.8% of patients (n=4). This review emphasizes the importance of the complications of EIA. It encourages future research into issues such as the reasons of higher gall bladder ascariasis in females and the implications of Ascaris-related complications following biliary tract interventions. It also suggests considering Ascaris as a differential diagnosis for airway obstuction in intubated critically ill patients.

My 40-Year Encounter with ERCP: A Saga of Service, Syndromes, and Solutions

Endoscopic retrograde cholangiopancreatography (ERCP) has been a significant development in gastrointestinal endoscopy. I did my first ERCP at SKIMS on December 5, 1982, and over the last 40 years, I have performed 10,100 ERCP procedures, including 600 Sphincter of Oddi manometries (SOM), and 3200 therapeutic ERCPs. We were confronted with many clinical challenges that needed answers by applying ERCP as a primary diagnostic tool. These studies gave birth to and/or recognition of several clinical syndromes. The hepatobiliary and pancreatic ascariasis (HBPA) as a clinical disease was recognized in 1985. The nematode, Ascaris lumbricoides, was the most common cause of hepatobiliary and pancreatic diseases in Kashmir, and its impact on healthcare, clinical profile, management policies, and control measures was identified. Kashmir was recognized as an endemic zone for recurrent pyogenic cholangitis (RPC), which constituted 12.5% of all biliary diseases. RPC in this population was found essentially to be an aftermath of HBPA. A subset of patients with hepatic hydatidosis with rupture into the biliary tract was recognized at ERCP and primarily treated by endotherapy. Cholangiographic abnormalities in children with portal cavernoma evolved into the recognition of portal biliopathy. Extensive studies of the sphincter of Oddi manometry in patients with unexplained biliary and/or pancreatic pain following cholecystectomy identified the entity of the sphincter of Oddi dyskinesia (SOD). In a cross-over trial, Nifedipine, compared with a placebo, showed a significant clinical response in 20 of 28 such patients. ERCP studies done in patients with tropical calcific pancreatitis showed an anomalous union of bile and pancreatic ducts. Forty of the 220 patients with liver transplantation had biliary complications namely biliary leaks, bile duct strictures, SOD, and recurrence of underlying primary biliary cholangitis. Biliary complications caused considerable morbidity and mortality in patients with liver transplantation.

Biliary ascariasis misidentified as a biliary stent in a patient undergoing liver resection

Ascaris lumbricoides causes one of the most common soil-transmitted helminthiases globally. The worms mostly infect the human small intestine and elicit negligible or nonspecific symptoms, but there are reports of extraintestinal ectopic ascariasis. We describe a rare case of biliary ascariasis mistaken for biliary stent in a 72-year-old female patient with a history of liver resection. She visited our outpatient clinic complaining of right upper quadrant pain and fever for the past week. She had previously undergone left lateral sectionectomy for recurrent biliary and intrahepatic duct stones 2 years ago. Besides mildly elevated gamma-glutamyl transferase levels, her liver function tests were normal. Magnetic resonance cholangiopancreatography revealed a linear filling defect closely resembling an internal stent from the common bile duct to the right intrahepatic bile duct. A live female A. lumbricoides adult worm was removed by endoscopic retrograde cholangiopancreatography (ERCP). Despite a significant decrease of the ascariasis prevalence in Korea, cases of biliary ascariasis are still occasionally reported. In this study, a additional case of biliary ascariasis, which was radiologically misdiagnosed as the biliary stent, was described in a hepatic resection patient by the worm recovery with ERCP in Korea.

Successful Management of Biliary Ascariasis in a High-Endemic Zone and Low-Resource Setting in Ethiopia

Ascariasis lumbricoides is a roundworm that causes one of the most common soil-transmitted helminth infections worldwide. Ascariasis is typically found in the jejunum and transmitted through the intake of Ascaris lumbricoides eggs through food and water. Initially, ascariasis can cause pulmonary symptoms during the first 6-8 weeks of ingestion and can progress to serious complications of intestinal obstruction and hepatobiliary manifestations. Biliary ascariasis is a complication of ascariasis migration from the jejunum to the hepatobiliary tree and can present with a variety of symptoms ranging from biliary colic to more serious features such as acute cholangitis. Though the mortality rate is low, limited resources for management can make it challenging to manage.

The role of helminths in the development of non-communicable diseases

Non-communicable diseases (NCDs) like cardiovascular disease, chronic respiratory diseases, cancers, diabetes, and neuropsychiatric diseases cause significant global morbidity and mortality which disproportionately affect those living in low resource regions including low- and middle-income countries (LMICs). In order to reduce NCD morbidity and mortality in LMIC it is imperative to understand risk factors associated with the development of NCDs. Certain infections are known risk factors for many NCDs. Several parasitic helminth infections, which occur most commonly in LMICs, have been identified as potential drivers of NCDs in parasite-endemic regions. Though understudied, the impact of helminth infections on the development of NCDs is likely related to helminth-specific factors, including species, developmental stage and disease burden. Mechanical and chemical damage induced by the helminth in combination with pathologic host immune responses contribute to the long-term inflammation that increases risk for NCD development. Robust studies from animal models and human clinical trials are needed to understand the immunologic mechanisms of helminth-induced NCDs. Understanding the complex connection between helminths and NCDs will aid in targeted public health programs to reduce helminth-induced NCDs and reduce the high rates of morbidity that affects millions of people living in parasite-endemic, LMICs globally.

Hepatobiliary and Pancreatic Duct Ascariasis: An Unusual Cause of Obstructive Jaundice and Severe Acute Cholangitis

Introduction

Acute cholangitis caused by hepatobiliary ascariasis is quite rare. Factors like a prior history of hepatobiliary surgery, pregnancy, and prolonged fasting increase the possibility of developing hepatobiliary ascariasis.

Case Presentation

We present a case of obstructive jaundice and severe acute cholangitis caused by massive hepatobiliary and pancreatic duct ascariasis in a 52-year-old male patient. The diagnosis was made based on clinical presentation, imaging, and other basic investigations. The treatment consisted of conservative medical treatment, without an anti-helminthic drug to avoid the death of the worm inside the bile duct with subsequent complications. Our patient declined surgical treatment and died three days after self-discharge.

Conclusion

Ascaris lumbricoides is a uncommon cause of acute cholangitis. It should be suspected in cases with typical clinical presentation and imaging evidence suggestive of hepatobiliary ascariasis. Endoscopic treatment is the treatment of choice in addition to anti-helminthic drugs and additional medical support. Conservative treatment alone is less likely to be successful.

Hepaticojejunostomy Anastomosis Worm Obstruction and Its Laparoscopic Management: A Case Report and Review of Literature

We report a surprising case of intraoperatively detected worm obstruction of a hepaticojejunostomy anastomosis. The patient presented with acute cholangitis including fever, abdominal pain, obstructive jaundice and sepsis. Six years earlier, she had undergone open cholecystectomy with a right subcostal incision. Ultrasonography that night depicted the absence of the gall bladder and the presence of apparent stones in the common hepatic and common bile ducts. The patient was posted for laparoscopic exploration of common bile duct. Intraoperatively, worm obstruction was found in the hepaticojejunostomy anastomosis created during the previous operation. The obstruction was managed laparoscopically, and the patient recovered without any complications and was monitored for two years. In a search of PubMed and Google Scholar, we found reports of laparoscopy-assisted endoscopic retrograde cholangiopancreatography as an established method of relieving hepaticojejunostomy obstruction; however, we found no case of laparoscopic extraction of obstructing worms. Laparoscopic exploration of a hepaticojejunostomy anastomosis through the afferent Roux loop is a feasible and safe alternative to other advanced methods of endoscopic retrograde cholangiopancreatography, for which special technique, logistics, and training are required but may not be available in many parts of the world.

Gall bladder Ascariasis: A rare entity

Gall bladder ascariasis is a rare entity. The causative organism for gall bladder ascariasis is Ascaris lumbricoides It usually presents as acute acalculous cholecystitis. Conservative management with anti-helminthic drugs is preferred while sometimes the patient may need surgical intervention.

Live ascaris in urinary bladder: a case report

Introduction

Ascaris in urinary bladder is an extremely rare phenomenon. It may occur after fistula formation between urinary and gastrointestinal tract or by retrograde migration of adult worm, and is associated with complications.

Case presentation

A 47-year-old Amhara woman from rural northwest Ethiopia presented with a complaint of difficulty to fully evacuate her bladder of 1 year duration. Ultrasonography showed thickened bladder wall with echo debris. There were also thickened bowel and fluid-filled loops of intestine adjacent to urinary bladder. On cystoscopy examination, there was live ascaris swimming inside the bladder. Enterovesical fistula was entertained and explorative laparotomy performed. Findings confirmed presence of iliovesical fistula. The fistula was divided and the continuity of the intestine restored. The inflammatory mass was subjected to histopathology study and turned out to be benign inflammatory reaction. She was also given antihelminthics. Postoperatively, her course was uneventful, and she was discharged cured.

Conclusion

Though it is extremely rare to have urinary symptoms from ascariasis, it is important to have a high index of suspicion for all possibilities.

Successful Conservative Management of Uncomplicated Gallbladder Ascariasis

Ascariasis is one of the common diseases in human beings worldwide. Most cases are asymptomatic. However, the high parasitic load can present with organ-specific symptoms due to the migration of worms to various regions of the body such as the lungs, nasal cavity, oral cavity, and biliary system, and sometimes with surgical emergencies like intestinal and biliary tree obstruction. Treatment modalities depend on the presentation and the complication associated with it. Uncomplicated cases can be initially managed conservatively and followed up subsequently. However, most cases of biliary ascariasis may require surgical intervention or endoscopic management due to failed management or complications. We report a case of a young male with gallbladder ascariasis diagnosed with ultrasonography and successfully treated with a single dose of albendazole 400 mg. Follow-up ultrasonography was done to evaluate the management.

Acute acalculous cholecystitis due to infectious causes

Acute acalculous cholecystitis (AAC) is an inflammation of the gallbladder not associated with the presence of gallstones. It usually occurs in critically ill patients but it has also been implicated as a cause of cholecystitis in previously healthy individuals. In this subgroup of patients, infectious causes comprise the primary etiology. We, herein, discuss the pathophysiological mechanisms involved in AAC, focusing on the infectious causes. AAC associated with critical medical conditions is caused by bile stasis and gallbladder ischemia. Several mechanisms are reported to be involved in AAC in patients without underlying critical illness including direct invasion of the gallbladder epithelial cells, gallbladder vasculitis, obstruction of the biliary tree, and sequestration. We emphasize that multiple pathogenic mechanisms may concurrently contribute to the development of AAC in varying degrees. Awareness of the implicated pathogens is essential since it will allow a more focused examination of the histopathological specimens. In conclusion, additional research and a high degree of clinical suspicion are needed to clarify the complex spectrum of mechanisms that are involved in the pathogenesis of AAC.

Endoscopic management of biliary ascariasis: A case report

BACKGROUND

Biliary ascariasis is rare but remains the most common parasitic infection in remote areas and in people with poor medical conditions. Here, we reported a case of biliary ascariasis in order to raise awareness of possible parasitic infections.

CASE SUMMARY

A 68-year-old female was admitted to the emergency room of the Affiliated Hospital of Guizhou Medical University on 28 September 2017, with chief complaint of pain in the right upper abdomen. Ultrasonography of the abdomen showed that the upper segment of the common bile duct was slightly dilated with parallel tubular structures, indicative of biliary ascariasis. Endoscopic retrograde cholangiopancreatography was performed under general anesthesia on 29 September 2017, and an adult Ascaris lumbricoides worm was observed. After the worm was removed from the bile duct, the patient’s pain immediately subsided. The patient was successfully cured, without any complications.

CONCLUSION

This report emphasizes the need for physicians to consider biliary ascariasis as a possible cause when treating cases of biliary colic.

Parasites of the liver - epidemiology, diagnosis and clinical management in the European context

Parasites in the liver cause significant global morbidity and mortality, as they can lead to recurrent cholangitis, cirrhosis, liver failure and cancer. Due to climate change and globalisation, their incidence is increasing, especially in Europe. The correct diagnosis of a hepatic parasite is often delayed because clinicians are unfamiliar with respective entities. Therefore, in this review, we aim to provide clinicians with a comprehensive clinical picture of hepatic parasites and to bring these neglected parasitic liver diseases to the wider attention of hepatology stakeholders in Europe and around the world.

An inactivated bacterium (paraprobiotic) expressing Bacillus thuringiensis Cry5B as a therapeutic for Ascaris and Parascaris spp. infections in large animals

Ascaris and Parascaris are important parasites in the family Ascarididae, large, ubiquitous intestinal-dwelling nematodes infecting all classes of vertebrates. Parasitic nematode drug resistance in veterinary medicine and drug recalcitrance in human medicine are increasing worldwide, with few if any new therapeutic classes on the horizon. Some of these parasites are zoonotic, e.g., Ascaris is passed from humans to pigs and vice versa. The development of new therapies against this family of parasites would have major implications for both human and livestock health. Here we tested the therapeutic ability of a paraprobiotic or dead probiotic that expresses the Bacillus thuringiensis Cry5B protein with known anthelmintic properties, against zoonotic Ascaris suum and Parascaris spp. This paraprobiotic, known as IBaCC, intoxicated A. suum larvae in vitro and was highly effective in vivo against intestinal A. suum infections in a new mouse model for this parasite. Fermentation was scaled up to 350 l to treat pigs and horses. Single dose Cry5B IBaCC nearly completely cleared A. suum infections in pigs. Furthermore, single dose Cry5B IBaCC drove fecal egg counts in Parascaris-infected foals to zero, showing at least parity with, and potential superiority to, current efficacy of anthelmintics used against this parasite. Cry5B IBaCC therefore represents a new, paraprobiotic One Health approach towards targeting Ascarididae that is safe, effective, massively scalable, stable, and useful in human and veterinary medicine in both the developed and developing regions of the world.

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IBaCC is Bacillus thuringiensis Cry5B protein crystals trapped inside dead bacteria.

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IBaCC intoxicates Ascaris suum intestinal parasitic nematodes in vitro.

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IBaCC is highly effective against A. suum parasites in vivo in mice and pigs.

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IBaCC is highly effective against related Parascaris parasites in foals.

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IBaCC represents a new paradigm for treating ascarid parasites of humans and animals.

Massive biliary ascariasis: an unusual cause of acute cholangitis

Acute cholangitis is a condition of bacterial infection following hepatobiliary tract obstruction, which signifies poor prognosis unless adequately drained. The most common cause of bile duct obstruction is choledocholithiasis, in contrast to parasitic infestation, a rare entity causing acute cholangitis nowadays. Therefore, we reported the case of a 68-year-old Thai man who presented with acute fever, intense right upper quadrant abdominal pain and jaundice for 2 days. His medical history was normal except for the history of intermittent biliary colic for a year. Endoscopic retrograde cholangiography was performed and demonstrated multiple, creamy-coloured roundworms coming out from the ampulla of Vater as well as a tubular filling defect in dilated common bile duct from cholangiography. He was diagnosed with acute cholangitis by biliary ascariasis and underwent endoscopic parasitic removal, which subsequently improved symptoms.

Traditional herbal medicine therapy of gallbladder ascariasis: a case report

Background

Ascariasis is one of the common intestinal infections in developing countries, including China. Migration of Ascaris lumbricoides into the gallbladder is rare, unlike ascariasis of the bile duct and when it does occur, treatment is generally by endoscopic or surgical extraction.

Case presentation

A 4-year-old Uyghur boy with a history of ascariasis developed intermittent upper abdominal pain for 7 days, was being treated by a local practitioner, and when the pain worsened with yellow sclera for 3 days, he was admitted to our hospital. On physical examination, found out the patient with yellowish skin tone, pale yellow fur on tongue, mild yellow staining of the sclera and tenderness in epigastrium. Laboratory data plus liver function test showed damage of liver function. Abdominal Ultrasonography (USG) and Magnetic resonance cholangiopancreatography (MRCP) showed a long, linear, echogenic structure in the gallbladder neck near to the common bile duct. Once the ascariasis diagnosis was established, he was given conservative treatment of magnesium sulfate with herbal medicine. In 4 days, the patient discharged Ascaris through the stool.

Conclusions

Conservative treatment of magnesium sulfate with Uyghur medicine treatment according to syndrome differentiation is proven to have curative effect.

Human Ascariasis: An Updated Review

Background:

Ascaris lumbricoides is the most common helminthic infection. More than 1.2 billion people have ascariasis worldwide.

Objective:

This article aimed to provide an update on the evaluation, diagnosis, and treatment of ascariasis.

Methods:

A PubMed search was conducted in February 2020 in Clinical Queries using the key terms “ascariasis” OR “Ascaris lumbricoides”. The search strategy included meta-analyses, randomized controlled trials, clinical trials, observational studies, and reviews published within the past 10 years. The search was restricted to English literature. The information retrieved from the above search was used in the compilation of the present article. Patents were searched using the key term “ascariasis” OR “Ascaris lumbricoides” in www.freepatentsonline.com.

Results:

Ascaris lumbricoides is transmitted through the ingestion of embryonated eggs from fecal- contaminated material. Ascariasis has high endemicity in tropical and subtropical areas. Predisposing factors include poverty, poor sanitation, inadequate sewage disposal, and poor personal hygiene. The prevalence is greatest in children younger than 5 years of age. The majority of patients with intestinal ascariasis are asymptomatic. For those with symptoms, anorexia, nausea, bloating, abdominal discomfort, recurrent abdominal pain, abdominal distension, and intermittent diarrhea are not uncommon. Other clinical manifestations vary widely, depending on the underlying complications. Complications include Löeffler syndrome, intestinal obstruction, biliary colic, recurrent pyogenic cholangitis, cholecystitis, acalculous cholecystitis, obstructive jaundice, cholelithiasis, pancreatitis, and malnutrition. The diagnosis is best established by microscopic examination of fecal smears or following concentration techniques for the characteristic ova. Patients with A. lumbricoides infection warrant anthelminthic treatment, even if they are asymptomatic, to prevent complications from migration of the parasite. Albendazole and mebendazole are the drugs of choice for children and nonpregnant individuals with ascariasis. Pregnant women with ascariasis should be treated with pyrantel pamoate. Recent patents related to the management of ascariasis are also discussed.

Conclusion:

The average cure rate with anthelminthic treatment is over 95%. Unfortunately, most treated patients in endemic areas become re-infected within months. Health education, personal hygiene, improved sanitary conditions, proper disposal of human excreta, and discontinuing the use of human fecal matter as a fertilizer are effective long-term preventive measures. Targeting deworming treatment and mass anthelminthic treatment should be considered in regions where A. lumbricoides is prevalent.

Ascaris Lumbricoides Infestation as an Unexpected Cause of Acute Pancreatitis

Ascariasis is the most common helminthic infection. It is most common in children of tropical and developing countries where the transmission is by contamination of soil by human feces or use of untreated feces as fertilizer. Transmission in most endemic areas is via person to person contact. We hereby present a case report of acute pancreatitis due to ascariasis. Twenty-five-year-old male patient presented to us with chief complaint of acute epigastric pain radiating to back and associated with vomiting. Initial lab investigations revealed increased serum amylase and lipase. Probable diagnosis of acute pancreatitis was made. CT scan was done and report revealed bulky pancreas, and significant peri-pancreatic fat stranding. He was managed symptomatically with intravenous fluids, analgesics, anti-emetics and enteral nutrition. However, the cause remained undetermined as we ruled out the possible etiologies of acute pancreatitis until one day the patient vomited a 15-cm round worm. Thereafter, his condition improved dramatically. This is one of the first few case reports of ascariasis-induced pancreatitis from Pakistan and the first one from Baluchistan province of Pakistan. Thus it highlights ascariasis as possible etiology of acute pancreatitis in regions where ascariasis is geographically endemic.

Hidden Nematode Causing Recurrent Pancreatitis: A Case Report

Even though hepatobiliary ascariasis has been found to cause pancreatitis, it is rare in Qatar and other countries in the Middle East. In this report, we present a case of biliary duct ascariasis causing recurrent pancreatitis. A 46-year-old woman from the Philippines presented with recurrent clinical and biochemical features of acute pancreatitis and was found to have hepatobiliary ascariasis. She was successfully treated with endoscopic retrograde cholangiopancreatography (ERCP) and antihelminthic medication. Although hepatobiliary ascariasis as a cause of pancreatitis is rare, it should be considered in patients with recurrent pancreatitis without an obvious cause, especially in those from endemic areas or those who have visited endemic areas.

An Unwanted Guest in the Biliary Tract: A Case Report

Ascariasis is a frequent human gastrointestinal tract helminthic disease caused by Ascaris lumbricoide. It usually stays in the intestinal lumen and occasionally migrates into the biliary tract through ampulla of Vater. Biliary ascariasis is a critical complication of intestinal ascariasis with life-threatening manifestations. We report a case of a-38 year-old lady who presented with colicky type epigastric pain radiating to back with diffuse tenderness over abdomen on examination. Ultrasonography abdomen showed linear echogenic structure in common bile duct. Biliary ascariasis was noted on Endoscopic Retrograde Cholangio Pancreaticography following which extraction was done. Our report highlights the varied clinical features of biliary ascariasis.

Modified percutaneous transhepatic papillary balloon dilation for patients with refractory hepatolithiasis

BACKGROUND

Some patients with hepatolithiasis cannot tolerate surgery due to severe cardiac or pulmonary comorbidities, or cannot be endoscopically treated because of altered gastrointestinal anatomies.

AIM

To propose a modified percutaneous transhepatic papillary balloon dilation procedure, and evaluate the clinical efficacy and safety of this modality.

METHODS

Data from 21 consecutive patients who underwent modified percutaneous transhepatic papillary balloon dilation with hepatolithiasis were retrospectively analyzed. Using auxiliary devices, intrahepatic bile duct stones were pushed into the common bile duct and expelled into the duodenum with an inflated balloon catheter. The outcomes recorded included success rate, procedure time, hospital stay, causes of failure, and procedure-related complications. Patients with possible long-term complications were followed up for 2 years.

RESULTS

Intrahepatic bile duct stones were successfully removed in 20 (95.23%) patients. Mean procedure time was 65.8 ± 5.3 min. Mean hospital stay was 10.7 ± 1.5 d. No pancreatitis, gastrointestinal, or biliary duct perforation was observed. All patients were followed up for 2 years, and there was no evidence of reflux cholangitis or calculi recurrence.

CONCLUSION

Modified percutaneous transhepatic papillary balloon dilation was feasible and safe with a small number of patients with hepatolithiasis, and may be a treatment option in patients with severe comorbidities or in patients in whom endoscopic procedure was not successful.

Endoscopic Yield, Appropriateness, and Complications of Pediatric Upper Gastrointestinal Endoscopy in an Adult Suite: A Retrospective Study of 822 Children

BACKGROUND/AIMS

This study aimed to study the endoscopic yield, appropriateness, and complications of pediatric endoscopy performed by adult gastroenterologists in an adult endoscopic suite.

METHODS

This a retrospective study in which records of all the patients less than 18 years of age who underwent endoscopy in the last 5 years were studied. The indications of endoscopy in children were categorized as appropriate or inappropriate per the latest guidelines by American Society for Gastrointestinal Endoscopy and North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. Positive endoscopic yield was defined as the presence of any abnormality on endoscopy.

RESULTS

Among the total of 822 children (age <18 years), the most common indications were variceal surveillance/eradication in 157 (19.1%), followed by dyspepsia in 143 (17.4%), upper gastrointestinal (UGI) bleeding in 136 (16.5%), recurrent abdominal pain in 94 (11.4%), unexplained anemia in 74 (9%), recurrent vomiting in 50 (6.08%), chronic refractory gastroesophageal reflux disease in 34 (4.1%) and others; 780 out of 822 endoscopic procedures (94.9%) done in children were appropriate as per the guidelines. The endoscopic yield was 45.8%, highest in patients with UGI bleeding (71.3%), followed by variceal surveillance (54.8%), recurrent vomiting (38%), dyspepsia (37.8%), and recurrent abdominal pain (36%). Minor adverse events occurred in 7.3% of children.

CONCLUSION

Pediatric endoscopy performed by an experienced adult gastroenterologist may be acceptable if done in cooperation with a pediatrician.

Whipworm and roundworm infections

Trichuriasis and ascariasis are neglected tropical diseases caused by the gastrointestinal dwelling nematodes Trichuris trichiura (a whipworm) and Ascaris lumbricoides (a roundworm), respectively. Both parasites are staggeringly prevalent, particularly in tropical and subtropical areas, and are associated with substantial morbidity. Infection is initiated by ingestion of infective eggs, which hatch in the intestine. Thereafter, T. trichiura larvae moult within intestinal epithelial cells, with adult worms embedded in a partially intracellular niche in the large intestine, whereas A. lumbricoides larvae penetrate the gut mucosa and migrate through the liver and lungs before returning to the lumen of the small intestine, where adult worms dwell. Both species elicit type 2 anti-parasite immunity. Diagnosis is typically based on clinical presentation (gastrointestinal symptoms and inflammation) and the detection of eggs or parasite DNA in the faeces. Prevention and treatment strategies rely on periodic mass drug administration (generally with albendazole or mebendazole) to at-risk populations and improvements in water, sanitation and hygiene. The effectiveness of drug treatment is very high for A. lumbricoides infections, whereas cure rates for T. trichiura infections are low. Novel anthelminthic drugs are needed, together with vaccine development and tools for diagnosis and assessment of parasite control in the field.

Immune serum-activated human macrophages coordinate with eosinophils to immobilize Ascaris suum larvae

Helminth infection represents a major health problem causing approximately 5 million disability-adjusted life years worldwide. Concerns that repeated anti-helminthic treatment may lead to drug resistance render it important that vaccines are developed but will require increased understanding of the immune-mediated cellular and antibody responses to helminth infection. IL-4 or antibody-activated murine macrophages are known to immobilize parasitic nematode larvae, but few studies have addressed whether this is translatable to human macrophages. In the current study, we investigated the capacity of human macrophages to recognize and attack larval stages of Ascaris suum, a natural porcine parasite that is genetically similar to the human helminth Ascaris lumbricoides. Human macrophages were able to adhere to and trap A suum larvae in the presence of either human or pig serum containing Ascaris-specific antibodies and other factors. Gene expression analysis of serum-activated macrophages revealed that CCL24, a potent eosinophil attractant, was the most upregulated gene following culture with A suum larvae in vitro, and human eosinophils displayed even greater ability to adhere to, and trap, A suum larvae. These data suggest that immune serum-activated macrophages can recruit eosinophils to the site of infection, where they act in concert to immobilize tissue-migrating Ascaris larvae.

Biliary ascariasis and severe bacterial outcomes: Report of three cases from a paediatric hospital in Brazil

INTRODUCTION

Biliary ascariasis, although uncommon, can lead to infectious complications and severe outcomes. This study reported three patients with biliary ascariasis and who were admitted to a paediatric hospital in Salvador, Brazil.

CASE REPORTS

Case 1: A 1-year-old boy, with HIV, hospitalised with diarrhoea, fever, pain, and abdominal distension. He underwent an exploratory laparotomy, which showed peritonitis secondary to a perforation of the hepatic duct by ascaris. Case 2: A 3-year-old boy admitted with fever, abdominal pain and jaundice. Imaging examination was suggestive of ascaris in the intrahepatic biliary tract and a hepatic abscess. Case 3: A 7-year-old boy who was hospitalised with a history of abdominal colic, jaundice and fever, with a suggestive image of ascaris in the biliary tract and evolution to sepsis.

DISCUSSION

Three cases of biliary ascariasis were reported with severe infectious complications involving peritonitis, hepatic abscess and sepsis.

CONCLUSION

In endemic regions, biliary ascariasis should be considered in cases with jaundice, abdominal pain and fever, due to its morbidity and risk of complications.

Not everything in the gallbladder is gallstones: an unusual case of biliary ascariasis

A 25-year-old female presented with a sore throat, fever and epigastric pain after coming from India. She had an obstructive pattern of liver function tests and an ultrasound scan abdomen showed features suggestive of acute cholecystitis and pancreatitis, with no obvious gallstones. She made no improvement with intravenous antibiotics. Subsequently, a contrast CT demonstrated a curvilinear structure within a thickened gallbladder and common bile duct. After input from multiple specialities, she had a MR cholangiopancreatography (MRCP) which further confirmed the curvilinear filling defect impacted in the gallbladder neck and proximal common bile duct. Biliary ascariasis with mild pancreatitis was diagnosed and was successfully treated with mebendazole. At one-month outpatient follow-up, her liver function tests and ultrasound scan had returned to normal. This case report discusses the radiological findings seen with biliary ascariasis using a range of imaging modalities. It also highlights the importance of the multidisciplinary team in managing a patient who presents a diagnostic challenge, in order to achieve the best patient outcome.

[Surgical approach to benign bile duct alterations]

BACKGROUND

Benign biliary diseases comprise entities, which present with very similar pathognomonic symptoms despite fundamental etiological differences. Obstructions of intrahepatic and extrahepatic bile ducts due to stones, tumors or parasites as well as stenoses and cystic alterations belong to the group of benign biliary diseases.

OBJECTIVE

This article provides a systematic overview of the indications and differential treatment of benign biliary diseases with special emphasis on the surgical treatment.

MATERIAL AND METHODS

The presented recommendations are in accordance with national and international guidelines, current scientific papers and expert opinions.

RESULTS

Essentially the surgical options for benign biliary diseases consist of revision, reconstruction through bilioenteric anastomosis, resection and complete organ replacement in the sense of liver transplantation. The location of the affected segment of the biliary tree, the symptoms, the progress of the disease and suspected malignancy essentially determine the level of escalation in the described treatment level scheme.

CONCLUSION

The treatment of benign biliary diseases is complex and requires achievement of unimpaired, unobstructed bile drainage. It serves the purpose of resolving cholestasis and thereby avoiding recurrent cholangitis and long-term complications, such as biliary cirrhosis and malignant transformation; however, in some cases of premalignant lesions of the bile ducts the strategy resembles cancer surgery, including resection of the affected tissue.

Anti-Ascaris suum immunoglobulin Y as a novel biotechnological tool for the diagnosis of human ascariasis

Human ascariasis is a neglected tropical disease of great relevance to public health and is considered the most frequent helminthiasis in poor regions. Accurately diagnosing this parasite has been challenging due to limitations of current diagnostic methods. Immunoglobulin Y (IgY) technology is a very effective alternative for the production of highly specific and profitable antibodies. This study aimed to produce and apply anti-Ascaris suum IgY antibodies in the immunodiagnosis of human ascariasis. Five immunizations comprising total saline extract from A. suum adult life forms were given at 14-day intervals to Gallus gallus domesticus hens of the Isa Brown line. Eggs and blood samples were collected weekly and fortnightly, respectively, to monitor the production of antibodies. The specificity of antibodies was confirmed by dot-blot, kinetic enzyme-linked immunosorbent assay (ELISA), avidity ELISA, immunoblotting and indirect immunofluorescence antibody tests. The application for disease diagnosis was performed through the detection of immune complexes in human serum samples by sandwich ELISA. Peaks of IgY anti-A. suum production occurred at weeks 6 and 8. IgY showed high avidity levels after the second dose of immunization, ranging from 64% to 93%, with a mean avidity index of 78.30%. Purified IgY recognized 12 bands of proteins from A. suum saline extract. Eggs, the uterine portion and cuticles of A. suum female adult are reactive in immunofluorescence. The detection of immune complexes showed diagnostic values of 80% sensitivity and 90% specificity. In conclusion, specific IgY have been shown to be a potential immunodiagnostic tool with promising future applications in human ascariasis.

A comparison of ancient parasites as seen from archeological contexts and early medical texts in China

This paper integrates our knowledge from traditional Chinese medical texts and archeological findings to discuss parasitic loads in early China. Many studies have documented that several different species of eukaryotic endoparasites were present in early human populations throughout China. Nevertheless, comprehensive paleoparasitological records from China are patchy, largely due to taphonomic and environmental factors. An examination of early Chinese medical texts allows us to fill in some of the gaps and counteract apparent biases in the current archeoparasitological records. By integrating the findings of paleoparasitology with historic textual sources, we show that parasites have been affecting the lives of humans in China since ancient times. We discuss the presence and prevalence of three groups of parasites in ancient China: roundworm (Ascaris lumbricoides), Asian schistosoma (Schistosoma japonicum), and tapeworm (Taenia sp.). We also examine possible factors that favored the spread of these endoparasites among early humans. Therefore, this paper not only aims to reveal how humans have been affected by endoparasites, but also addresses how early medical knowledge developed to cope with the parasitic diseases.