MRCP findings of biliary ascariasis before and after medical treatment

A 53-year-old woman presented with the complaints of abdominal pain on right upper quadrant, nausea, vomiting, diarrhea, and loss of appetite. Her physical exam was unremarkable except for right upper quadrant tenderness. Abdominal ultrasound revealed a tubular, mobile, non-shadowing echogenic structure within the slightly dilated common bile duct. Examination of feces for ova suggested the diagnosis of ascariasis. In this report, ultrasonographic and magnetic resonance cholangiopancreatographic findings of the case are described before and after medical treatment.

[Biliary ascariasis after cholecystectomy and papillotomy in a non-endemic area]

HISTORY AND ADMISSION FINDINGS

A 61-year-old woman was admitted to hospital with nausea and vomiting. Four years earlier she had undergone cholecystectomy and papillotomy.

INVESTIGATIONS

Laboratory examination showed a slight increase of aspartate and alanine aminotransferase, glutamyl transpeptidase, and moderate eosinophilia. Ultrasound revealed an elongated echogenic structure within the common bile duct. At endoscopic cholangiopancreaticography (ERCP) a 23 cm-long Ascaris lumbricoides was found.

TREATMENT AND COURSE

The worm was removed endoscopically with forceps. Antihelmintic therapy with mebendazole was given. After that the patient was well and laboratory findings were normal.

CONCLUSION

Biliary ascariasis should also be considered in a non-endemic area. Previous cholecystectomy and papillotomy are predisposing factors. In our case ERCP was the diagnostic and therapeutic method of choice.

Wandering ascaris coming out through the T-tube tract--a rare occurrence

A case of ascariasis of the common bile duct in the postoperative period of cholecystectomy and choledocholithotomy with T-tube drainage is reported. The living adult wandering ascaris came out through the T-tube tract immediately after removal of the T-tube. No such previous report has been found in the available literature.

Obstructive jaundice caused by primary choledochal hydatid cyst mimicking radiologically choledochal cyst

A 12-year-old girl with obstructive jaundice that was initially misinterpreted radiologically as having choledochal cyst is presented. A primary hydatid cyst in the wall of the common bile duct causing obstruction was found at operation. The authors emphasize that hydatid cyst should be included in the list of differential diagnoses of obstructive jaundice and cystic lesions located around the biliopancreatic junction in children.

A case report of ascariasis of the common bile duct in a patient who had undergone cholecystectomy

This is a case report of ascariasis of the common bile duct in a 65-year-old man from Colombia who had undergone prior cholecystectomy. The patient presented with postprandial epigastric pain and a 20-lb weight loss. The laboratory findings were remarkable for peripheral blood eosinophilia. The ultrasound finding was suggestive of periampullary or pancreatic neoplasm. He underwent endoscopic retrograde cholangiopancreatography with endoscopic extraction of a motile, live worm identified as Ascaris lumbricoides. Roundworm infestation should always be suspected in immigrants from endemic areas who present with hepatobiliary symptoms.

Biliary ascariasis: CT, MR cholangiopancreatography, and navigator endoscopic appearance--report of a case of acute biliary obstruction

A case of acute common bile duct obstruction caused by a roundworm in a 6-year-old girl is reported. Computed tomography (CT) and magnetic resonance imaging (MRI) showed "bull's-eye" and "eye-glass" appearances of the ascaris in the common bile duct. On reformation of the transverse CT and coronal MR images, the tubular Ascaris was better depicted. MRI and navigator endoscopic demonstrations of the common bile duct ascaris have not been described previously in the literature. These CT and MRI findings may be helpful in the diagnosis of Ascaris.

Cryptosporidium parvum biliary tract infection in adult immunocompetent and immunosuppressed mice

Biliary tract infection by Cryptosporidium parvum is a frequent complication of intestinal cryptosporidiosis in immunosuppressed patients. Although biliary tract infection can be produced in immunosuppressed models as a late complication of intestinal infection, there is no infection model in immunocompetent animals. A murine model of biliary tract cryptosporidiosis was developed by direct intra-gall bladder injection of C. parvum oocysts. In adult immunocompetent mice, intracellular parasitic stages were detected in the epithelium of the common bile duct in all animals on day 7 post-inoculation (p.i.). These findings were associated with a strong inflammatory reaction. Infection was cleared between days 14 and 21 p.i. All animals developed significant levels of specific serum and bile IgG, IgA and IgM. Dexamethasone treatment resulted in the inability of animals to eradicate the parasite and the establishment of ileal parasitism. This model can be used to study the immunological mechanisms involved in the control of biliary cryptosporidiosis.

[37 patients with hepatic hydatid cyst rupturing into choledochus]

2785 patients with hepatic hydatid cyst were treated operatively since 1965 to 1995, and the hydatid cyst rupturing into choledachus occurred in 37 patients (1.3%). Clinical manifestations, diagnosis and operation were described. In epidemic area the possibility of hepatic hydatic cyst rupturing into choledochus should be considered when the patient suffers from stiffness of abdominal muscles, Jaundice, right epigastric pain, hepatic mass and positive reaction of Casoni test. Ultrasound and CT are major means for the diagnosis of this disease. Early operation is the treatment of choice.

[Endoscopic retrograde cholangiopancreatography and sphincterotomy in parasitic diseases]

We report six patients with billary duct obstruction due to parasites (Fasciola hepatica, ascariasis and hydatid cyst) that were diagnosed and managed with the endoscopic approach. This is the first national paper which highlights the importance of endoscopic retrograde cholangiopancreatography in the management of this parasitosis. Despite choledocholithiasis as the most common cause of extrahepatic jaundice, biliary tree parasitosis must be considered in the differential diagnosis.

Effect of diethyldithiocarbamate on Cryptosporidium parvum infection in immunosuppressed rats

Diethyldithiocarbamate was the only immune modulator of 7 evaluated to show activity against Cryptosporidium parvum in immunosuppressed rats. The model was then used to assess the drug's activity further. When administered prophylactically, oral doses > or = 75 mg/kg/day significantly (P < or = 0.05) reduced the severity of ileal infection and doses > or = 300 mg/kg/day significantly (P < or = 0.05) inhibited infection of the biliary tract. When administered to rats with established infection, the drug significantly (P < or = 0.05) reduced the parasite burden in the ileum but was ineffective against biliary tract infection. The data suggest that diethyldithiocarbamate is effective for treating cryptosporidiosis of the small intestine but is probably ineffective against chronic cryptosporidiosis involving the large intestine or biliary tract.

The activity of halofuginone in immunosuppressed rats infected with Cryptosporidium parvum

Halofuginone was evaluated for its activity against experimentally induced infection due to Cryptosporidium parvum in rats rendered immunosuppressed with dexamethasone. The drug's activity was dose-related and both prophylaxis and therapy reduced the rate and severity of infection in the small intestine and caecum. Prophylactic treatment reduced infection of the common bile duct, but therapeutic administration did not and neither form of treatment reduced the infection rate in the colon. Intestinal infection recurred at a level comparable to that of untreated controls when treatment was discontinued. Treatment with halofuginone may reduce the severity of acute cryptosporidiosis, but is less efficacious for chronic cryptosporidiosis involving the colon and extraintestinal tissues, a manifestation increasingly seen in the immunocompromised host.

Light and scanning electron microscopic studies of the extrahepatic bile duct of sheep with experimentally induced Fasciola hepatica infection

Changes in the common bile duct that contained adult Fasciola hepatica of sheep were evaluated by light (LM) and scanning electron microscopy (SEM). Nine ewes were inoculated with F hepatica metacercariae and necropsied 18 weeks after inoculation. The proximal portion of the common bile duct (CBD) that contained adult flukes was recovered and examined by LM and SEM. The CBD from 2 noninoculated ewes were used for control. On gross examination, CBD were markedly large because of the adult flukes, which were free in the lumen of the ducts. Extensive hemorrhage was not found either in intrahepatic or in extrahepatic bile ducts of any sheep. Histologic examination revealed changes, such as villous hyperplasia and hypertrophy of the epithelium; cell infiltration, predominantly with eosinophils or macrophages; and arterial intimal proliferation. By SEM, the epithelial surface of the CBD appeared intact. Villous hyperplasia and hypertrophy of the epithelium observed by LM was clearly seen by SEM. Epithelial damage, seen as small areas of denuded surface by LM and SEM, was confined to a few areas of the mucosa. Lack of extensive hemorrhage and confined epithelial damage were evaluated relative to the mode of feeding of adult flukes.

Massive infestation by Ascaris lumbricoides of the biliary tract: report of a successfully treated case

This is a report of a 25 years old black woman from the city of São Paulo, Brazil, who developed acute obstructive cholangitis of Ascaris lumbricoides with septicemia and multiple hepatic abscesses. The patient had sickle cell trait and normal delivery 3 months ago. Massive infestation of the biliary tract by Ascaris lumbricoides was diagnosed by abdominal ultrasonography and endoscopic retrograde cholangiography. Sixty worms were removed from the common bile duct and hepatic abscesses were drained by surgery. The infectious process was polymicrobial. The patient's recovery was complete after a long evolution with a wide spectrum antibiotic therapy. New surgeries were needed to remove residual worms in the biliary tract. The diagnostic methods, clinical-biochemical features and also the clinical and surgical management are presented. The biliary ascariasis pathophysiology is commented.

Aberrant migration by Toxocara pteropodis in flying-foxes--two case reports

Adults of the large nematode, Toxocara pteropodis, have not previously been reported from extra-intestinal sites in their hosts, juvenile flying-foxes (fruit-bats of the genus Pteropus). In one captive bat which died unexpectedly, a nematode was found coiled within the gall bladder and common bile duct; in another a nematode was in the esophagus and protruded into the laryngopharynx. Like other ascaridoids, this species is capable of aberrant migration.

Percutaneous cholangiography in the diagnosis of hepatic fascioliasis

A case of hepatic fascioliasis is reported in which the diagnosis was made by direct visualization of the parasite by means of percutaneous transhepatic cholangiography. The peculiar radiological image should be included in the differential diagnosis of biliary tract pathology.

Effect of inoculum on the size and location of Fasciola hepatica subsequently recovered from the livers of rats

Two outbred strains of Sprague-Dawley rats were given, by intraperitoneal injection, 5, 10, 20, 30 or 50 newly excysted juvenile (NEJ) Fasciola hepatica. Ninety days post-infection all rats were killed and their livers teased apart under 10 X magnification for quantitation of the flukes present. There was no significant difference in worm numbers between the rat strains. However, several significant differences (P less than 0.05) between the various infection groups were observed. As the size of the infective dose was increased from 5 to 50 NEJ, the percentage of the infective dose recovered from the livers of the infected rats decreased from 36.7 to 12.1%. With the 5 and 10 NEJ infective doses, the worms recovered were large mature flukes (1.52 and 1.68 cm, respectively) and were found in the common bile ducts. In the rats receiving infections of 30 and 50 NEJ, the flukes were smaller (0.88 and 0.55 cm, respectively), immature, and were primarily located in the liver parenchyma. These findings are important in light of previous studies on the development of resistance in the rat to challenge infections in which immunity was based on both the size and the location of the flukes recovered. The results from our study indicate that in a primary infection of 20 or greater NEJ, many small immature flukes remain in the liver parenchyma, even after several months. When testing for resistance to F. hepatica in rats, these flukes may erroneously be thought to comprise a portion of the challenge infection.

A study of the initiation of biliary hyperplasia in rats infected with Fasciola hepatica

Following infection of rats with Fasciola hepatica, an increase in the number of epithelial cells in the common bile duct, labelled with [3H]thymidine, was detected autoradiographically as early as 5 days post-infection (p.i.). This initial mitogenic effect of the infection was limited to that region of the bile duct lying adjacent to the liver, while the region lying next to the duodenum failed to show any increase in labelling until 41 days p.i. Mechanical contact between the parasite and the biliary epithelium did not occur until 41 days p.i. and the initial hyperplasia was evidently not a result of mechanical irritation. The study serves to emphasize the chemical aetiology of the precocious biliary hyperplasia and to more accurately identify its onset.

Common bile duct obstruction and cholangiohepatitis in clonorchiasis

This report describes a patient with common bile duct obstruction and cholangiohepatitis. Patients with clonorchiasis are usually asymptomatic and treatment is limited to complications. Treatment consists of cholecystectomy, choledochotomy, and T-tube drainage. A bypass procedure is indicated in cases of heavy infestation and recurrent disease.

[Sonographic patterns of ascariasis and distomiasis in the biliary ducts (author's transl)]

Concerning two cases of ascariasis and one case of distomiasis in the biliary ducts the authors describe the sonographic patterns leading to the ultrasonic diagnosis of those biliary parasites.--The "strip sign" characterizing ascaridiasis.--The "olympic ring gallbladder".

A case of common bile duct ascariasis diagnosed by duodenoscopy

A case of common bile duct ascariasis diagnosed by duodenoscopy is presented. At the admission, the patient, cholecystectomized for gallstones 13 years before, had been complaining of epigastric pain associated with post-prandial and nocturnal vomiting. Physical examination showed only slight tenderness in the epigastrium. Laboratory findings were within normal limits, with the exception of a moderate leukocytosis. Intravenous cholangiography showed the lack of visualization of the terminal common bile duct, but the flow of contrast medium was normal. Duodenoscopy, carried out without a specific clinical suspicion, revealed an ascaris lumbricoides inserted in the common bile duct and partially protruding from the papilla Vateri. The patient was treated by piperazine, intravenous fluids, antibiotics and a choleretic compound. After 24 hours an ascaris 33 cm long was excreted in the faeces and the patient became symptom-free. Some pathophysiological, clinical and epidemiological aspects of biliary ascariasis are discussed.

[A case of ascaridiosis of the common bile duct]

The authors present a case of ascariasis of the common bile duct in a 45 year old Portugese woman. Perfusion cholangiography showed a lacunar ribbon shaped image of the common bile duct and radiolucent gall-stones. The diagnosis of intracholedochal ascariasis was made and the patient operated: there was in fact an ascaris which was extracted by choledochotomy. Cholecystectomy. Straightforward aftermath.

Acalculous clonorchiasis obstructing the common 3ile duct: a case report and review of the literature

Clonorchis sinensis has a minor incidence in Western countries and most commonly manifests as cholangiohepatitis with secondary bacterial infection. This parasite rarely obstructs the common bile duct without associated biliary stricture, stones or tumor. This paper documents the fourth reported case of acalculous C, sinensis biliary tract obstruction and reviews the world literature.

Current status and usefulness of operative cholangiography

This article is a review of the recent literature on operative cholangiography. The objective is to summarize concisely the important contemporary viewpoints as an aid to students of radiology. To the practicing radiologist, it may offer a concise review of the subject and facilitate upgrading operative cholangiography in his hospital. The introduction covers statistical evidence of the growing dependence of biliary tract surgeons on operative cholangiography. The rudiments of diagnoses of the various diseases that can be detected by operative cholangiography are presented. Pertinent clinical facts along with cholangiographic diagrams are presented under arbitrary sections: I. Stones; II. Anomalies; III. Other Diseases; IV. Techniques of Operative Visualization of the Biliary System.

[Infestation of the ductus choledochus with Fasciola hepatica. Study of human Fasciola]

In a 66-year-old woman with suspected cholecystopathy, cholecystectomy led to the chance finding of the common liver fluke Fasciola hepatica (F.h.) in the common bile duct. Subsequent therapy with Dehydroemetin brought about regression of eosinophilia and of the pathologic immunofluorescent antibody test for F.h. The life cycle of F.h. and the clinical features of human infection are described in detail.