Biliary colic with dilated common bile duct: simple "sheepish" problem?

A 40-year-old man, resident of a rural area of Rajasthan state of India presented with recurrent biliary colic and fever since last 2 years. Examination was normal and investigations revealed a dilated common bile duct with elevated alkaline phosphatase. Magnetic resonance cholangiopancreatography revealed a dilated biliary system without any evident cause. Patient was subjected to endoscopic retrograde cholangioancreatography and it demonstrated biliary dilatation with a linear filling defect in lower common bile duct, further sphinicterotomy was done and a live Fasciola hepatica was extracted using a biliary basket.

Laparoscopic common bile duct exploration for extraction of a round worm

A 35 years old lady presented with fever, biliary colic, mild jaundice, indigestion and flatulence. The upper abdominal ultrasonography revealed cholecystitis with sludge and a round worm in the common bile duct. Laparoscopic cholecystectomy and exploration of the bile duct for the removal of round worm was performed. The post-operative period was uneventful and the patient was discharged fit on the 4th post-operative day.

An unusual cause of recurrent biliary colics

Hepato-biliary ascariasis is a rare condition in non-endemic areas; however, it should always be taken into account in patients with recurrent biliary colics and/or cholangitis, since these are among the most frequent modes of clinical presentation. We report a case of a young woman suffering from recurrent biliary colics in whom a diagnosis of biliary ascariasis was made. Endoscopic retrograde cholangiopancreatography with sphincterotomy and endoscopic extraction of the worm, using a Dormia basket, proved to be a safe and effective procedure for removing the living Ascaris from the biliary tree and relieving symptoms. In the era of worldwide travels, physicians in Western countries should be more aware of this infection especially in patients with biliary symptoms who have travelled to endemic areas or immigrant from endemic countries.

Biliary ascariasis as a cause of post-cholecystectomy syndrome in an endemic area

BACKGROUND

Post-cholecystectomy syndrome encompasses numerous biliary, pancreatic and other entities. Biliary ascariasis is a common cause of adult biliary disease in an endemic area. Post-cholecystectomy biliary ascariasis, a cause of post- cholecystectomy syndrome although not yet defined is frequently seen in this part of the world.

METHOD

Between Jan. 1990 and Jan. 2001, 104 cases of post-cholecystectomy biliary ascariasis were seen. Ultrasonography was found to be an excellent tool for diagnosing and monitoring of the worms inside the biliary tract. Endoscopic retrograde cholangiopancreatography had both diagnostic and therapeutic value.

RESULTS

The majority (68.2%) of patients responded to conservative treatment. Surgical treatment was advocated in 18.2%, which included 2 patients with liver abscesses. Endoscopic extraction of worms was successful in 48.2%.

CONCLUSION

Post-cholecystectomy biliary ascariasis as a cause of post-cholecystectomy syndrome needs to be included in the list of causes for post-cholecystectomy syndrome. Although the majority of patients respond to conservative treatment but endoscopic extraction or surgical intervention may be needed. Routine deworming of patients undergoing cholecystectomy both preoperatively and postoperatively should be done in all patients in endemic areas of ascariasis. Although this entity is rare in Europe and United States, due to population migration and increased travel, it is necessary for surgeons in these countries to be aware of this condition.

[Cholangiohydatidosis. An evolutive complication of hepatic hydatidosis]

Hydatidosis is and endemic disease in the south of Chile, especially in Region IX where remain rates of high prevalence. Cholangiohydatidosis is an infrequent complication of liver hydatidosis. The objective of this paper is to describe clinical features of a series of patients with cholangiohydatidosis. Series of cases of cholangiohydatidosis treated consecutively and the corresponding follow-up is reported. Clinical, laboratory and images characteristics are described. Descriptive statistic was used its incidence was calculated. In the studied period, 13 patients with cholangiohydatidosis were recruited, 9 men (69.2%) and 4 women (30.7%). Observed laboratory abnormalities were an increment of leukocytes in 8 patients (61.5%) and hepatic cholestasis with hepatocyte signs of cytolysis in 11 patients (84.6%). Choledocus diameter average measured by ultrasonography was 24.7 mm. All the patients had at least one liver cyst whose diameter average was of 12.1 cm. At surgery, evidence of biliary communications was detected in all patients and biliary decompression was carried out through a choledocostomy in 12 patients (92.3%) and by choledocoduodenal anastomoses in one case (7.7%). With a mean follow-up of 38.7 months morbility was 23% and mortality 7.7%. Accumulated incidence of this entity was of 0.07 cases in 5 years. Cholangiohydatidosis is an uncommon complication of liver hydatidosis that presents considerable morbidity and mortality rates.

[Echinococcosis of intra- and extrahepatic bile ducts. Report of a case at the Central Military Hospital]

We present a woman 34 years old with echinococcosis of intra and extra hepatic biliary ducts including gallbladder. We found alive cysts, dead cysts and fragments of germinative membranes of a complicated cyst in left lobe (I - II) with clinical findings of obstructive jaundice; pain; cholecystitis and great dilation of biliary ducts. We performed left lobectomy, exploration of biliary ducts, transduodenal sphincteroplasty, cholecystectomy. We haven't had complications. We present ultrasound images of the pathologic pieces.

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.

[Obstructive jaundice caused by hydatid cyst rupture in main bile duct]

Hydatid hepatic cyst rupture into bile duct is a complication of hydatid disease. The rupture is more frequent in right or left epatic duct and occasionally in common bile duct (7-9%). A 50-year old man came to emergency room owing to jaundice, fever and abdominal pain. TC show an hydatid cyst with daughter's cyst of left liver and dilatation of biliary tree. Laboratory data of significance included an increased of liver function tests (Bilirubin, Alkaline ph., SGOT, SGPT), VES and leukocytosis. The patients was surgically treated, by total pericystectomy, colecystectomy and coledocotomy with lavage o common bile duct; finally we placed one Kehr drainage and two abdominal drainage. After 15 days of postoperative hospitalization patient was discharged. The best treatment of hydatid cyst is total pericystectomy (when possible). An alternative surgical treatment is possible for the presence of communication with biliary tree. ERCP is very important for a correct diagnosis and for a complete surgical treatment.

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.

Pancreatic-biliary ascariasis: experience of 300 cases

BACKGROUND

Infestation with Ascaris lumbricoides is seen worldwide. Recently, there has been much interest in the pancreatic-biliary complications of Ascaris infection. In this study, we present our experience of 300 patients seen in a tertiary referral center.

MATERIALS AND METHODS

Case charts of patients seen in the Department of Gastroenterology, University of Damascus, Syria, were analyzed, retrospectively, over a 5-yr period (September of 1988 to August of 1993). During this period, 1666 endoscopic retrograde cholangiopancreatographic studies were performed and pancreatic-biliary ascariasis was diagnosed in 300 patients (18%).

RESULTS

The most common presenting symptom was abdominal pain, seen in 98% of patients (294 patients). Complications observed were ascending cholangitis (48 patients; 16%), acute pancreatitis (13 patients; 4.3%), and obstructive jaundice (4 patients; 1.3%). History of worm emesis was present in 25% of patients (76 patients). Most patients (240 patients; 80%) had previously undergone a cholecystectomy or an endoscopic sphincterotomy (232 patients; 77%). Worms were successfully extracted endoscopically in all except two patients, and there were no procedure-related complications.

CONCLUSIONS

In endemic countries, ascariasis should be suspected in patients with pancreatic-biliary disease, especially if a cholecystectomy or sphincterotomy has been performed in the past. Endoscopic management results in rapid resolution of symptoms and prevents development of complications.

Therapeutic endoscopy of the hepatobiliary and pancreatic system: a Vietnamese experience

INTRODUCTION

Therapeutic endoscopic retrograde cholangiopancreatography (ERCP) was initially utilized at Binh Dan Hospital, Viet Nam, in August 1993. From August 1993 through March 1997, 318 ERCP procedures were performed on 271 patients. It was not possible to obtain cholangiography in 32 cases of the 318 procedures of ERCP, for a success rate of diagnostic ERCP approaching 89%.

MATERIALS AND METHODS

Cases treated by ERCP included: 14 cases of Ascaris lumbricoides in the common bile duct (CBD). 69 cases of bile duct stones. 12 cases managed by nasobiliary catheter drainage. 3 cases treated by bile duct stent. Sphincterotomy was attempted on 108 cases. Complications included: 5 cases of acute pancreatitis. 7 cases of purulent cholangitis, which resulted in 1 death. 2 cases of retroperitoneal duodenal perforation. 9 cases of postsphincterotomy bleeding.

CONCLUSIONS

We conclude that ERCP is a useful therapeutic modality for bile duct stones and parasitic worms in the bile ducts.

Periampullary carcinoma following biliary ascariasis--a case report

A 42 year old man presented with obstructive jaundice and cholangits. Ultrasonography (USG) revealed dilated intrahepatic biliary radicals and common bile duct (CBD). The bile duct also showed a curvilinear parallel intraluminal structure suggesting biliary ascariasis. The CBD was explored and a dead worm removed but jaundice persisted. Endoscopic retrograde cholangio pancreaticography (ERCP) was done showing a periampullary mass which on biopsy showed a villous adenoma with highly dysplastic changes. A Whipple's pancreaticoduodenectomy was performed and the growth proved to be a well differentiated periampullary adenocarcinoma.

[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.

Endoscopic treatment of biliary ascariasis. Report of a case

Ascaris lumbricoides is the most common intestinal parasite to infect humans. The incidence of ascariasis is increasing in our regions, due to world travel and population migration. In one third of cases, the worm can enter the bile duct and cause cholangitis or biliary colics. Diagnosis and treatment of ascariasis are discussed. Endoscopic retrograde cholangio-pancreaticography (ERCP) with endoscopic extraction of the worm, using a Dormia basket, is a safe and effective procedure for the diagnosis and treatment of biliary ascariasis. This technique serves as an effective alternative for surgery.

Biliary ascariasis and extrahepatic cholangiocarcinoma: a report of two cases

We report two cases of rural Malay women in Perak, Malaysia, with extrahepatic cholangiocarcinoma and coexistent biliary ascariasis. In both cases, the narrowed bile duct may have resulted in inability of the migratory nematode to return to the gastrointestinal tract. It may be reasonable, also, to postulate that chronic biliary tract infestation by Ascaris lumbricoides may have contributed to the development of cholangiocarcinoma; a situation similar to that observed in liver fluke infestation.

Ascarid worms causing recurrent cholangitis in a patient with an obstructing ampullary tumour

This is a report of a 57-year-old Malay lady who presented with recurrent episodes of cholangitis and septicaemia. A dilated biliary tree caused by a stenosing periampullary tumour was found to contain adult round worms. A pancreatico-duodenectomy was performed following biliary decompression. Ascarid worms are a rare cause of cholangitis in malignant biliary obstruction.

Ultrasound in the diagnosis of roundworms in gallbladder and common bile duct. Report of four cases

Four patients who complained of symptoms and signs compatible with biliary tract disease and in whom the diagnosis of gallbladder (three cases) and common bile duct ascariasis (one case) was made sonographically are reported. In two patients with gallbladder ascariasis, cholecystectomy corroborated the presence of the round-worms, and was curative. The third patient was a pregnant woman (32nd gestational week) who took piperazine citrate, and a second sonogram performed 29 days later was completely normal. The fourth patient with common bile duct ascariasis underwent choledochotomy with extraction of one ascaris lumbricoides from the common duct, and a T tube was left in place for 15 days. All patients received antiparasitics and had a favorable outcome. Ultrasonography is an important noninvasive diagnostic procedure in the work-up of these patients, who usually describe a clinical picture suggesting gallstone disease: this is especially true in the presence of pregnancy.

[Ascariasis of the common bile duct. An ultrasonographic case in Yemen]

A case of a biliary ascariasis associated with a cystic bile duct lithiasis observed in the French Medical Mission of the Republic of Yemen is reported. Ascaris biliary migration, method of diagnosis, complications and treatment are reviewed.

Surgical treatment of hepatic hydatid disease

The results of surgery in 38 patients with hepatic hydatid disease are described. Cystectomy was done in four patients with small peripheral cysts. For them the mean postoperative stay was 8.2 days. Partial cystectomy, introflexion and omentoplasty were performed in 28 patients with uncomplicated large cysts. The mean postoperative stay for these patients was 8.6 days. One patient in this group died of massive hemorrhage and disseminated intravascular coagulation. Exploration of the common bile duct and choledochoduodenostomy were required in three patients who had large cysts complicated by rupture into the biliary tree. This complication resulted in a mean postoperative stay of 11.5 days. Three patients who had cysts complicated by pyogenic infection were treated with tube drainage. They were discharged with their tubes in place after a mean hospital stay of 26.5 days. Hydrogen peroxide 10% was used as a scolicidal agent and was successful in preventing dissemination. All patients underwent ultrasonography 3 months after surgery, and 28 (74%) were followed up by annual examination. There was no recurrence after a mean follow-up of 2.7 years. The results suggest that surgical treatment of hepatic hydatid disease should be governed by the size, location and complications of the cyst. The combination of partial cystectomy, introflexion and omentoplasty was safe and effective therapy for patients with large hepatic cysts uncomplicated by pyogenic infection.

Biliary ascariasis in fifteen patients

Ascarids in the biliary tract may cause cholecystitis, pancreatitis and obstruction of the common bile ducts. We retrospectively evaluated clinical features, radiographic findings and surgical treatment of 15 patients. Obstructive jaundice in eight patients (53.3%), acute cholecystitis in five patients (33.3%), and chronic calculous cholecystitis in two patients (13.3%) had been shown in our series. In four of the patients with obstructive jaundice signs of acute cholangitis were observed. Of 15 patients, two had hepatic abscess besides biliary ascariasis and one had hydatid cyst. In our series, all of the patients were operated on. Choledochotomy and primary closure were performed on six patients (40%), choledochoduodenostomy on six patients (40%), T-tube drainage on two patients (13.3%) and only cholecystectomy on one patient (6.6%). No mortality was determined in our patients.

Ascaris in the common bile duct: diagnosis by ultrasound and endoscopic retrograde cholangiopancreatography (ERCP) and extraction by balloon catheter

This is a case report of ascaris worm in the common bile duct in a 61 year old lady. Ultrasound diagnosis was initially made based on the presence of linear hyperreflective foci within the common bile duct. ERCP confirmed a single worm within the duct. Balloon extraction was then successfully carried out following papillotomy. This case illustrates the value of ultrasound in the definitive diagnosis of biliary ascariasis and the therapeutic role of ERCP.

[Fasciola hepatica in the common bile duct. Presentation of a case]

A case of hepatic fascioliasis in the common bile duct is reported in a 54 years female. Upon surgical exploration of the biliary tract, one adult form of hepatic Fasciola was found, without evidence of cholelithiasis. Retrospectively we reviewed the oral cholecystography and the image originally believed to be gallstone, in fact was a hepatic Fasciola. Reviewing past literature, we have not encountered any previous case in which hepatic Fasciola was diagnosed by oral cholecystography.

Biliary tract disease due to Fasciola hepatica: report of a case

We report a case of a 23 year old woman who presented with symptoms of biliary tract disease to our University Hospital in Bayamón, Puerto Rico. A diagnosis of chronic cholelithiasis was made and the patient was taken to surgery. An adult Fasciola hepatica was recovered from the common bile duct. We review the pathobiology of this uncommon zoonosis.

Biliary ascariasis combined with a villous tumor of the papilla. Diagnostic and therapeutic value of endoscopy

A 64-year-old man admitted for cholangitis presented with an ascaris lumbricoides in the biliary duct and a villous tumor of the ampulla of Vater. ERCP revealed the parasite as a "rail-like" linear defect in the main bile duct, and permitted its extraction. The ampullary tumor was repeatedly ablated with a snare and finally surgically removed because of suspicion of malignancy. This is the first report on such an association.

Sonographic diagnosis of biliary ascariasis

Real-time sonographic imaging can clearly represent the biliary ascarid as a longitudinal double linear echo. We call this representation an intraductal tubular image. Such imaging allows easy differentiation of the biliary parasite from calcification and other foreign bodies in the biliary tracts.

[Obstruction of the principal bile duct caused by Fasciola hepatica. First case in Sicily]

The first case of human liver infestation due to liver fluke in Sicily is reported. After a clinical review of parasitosis, the autochthonous nature of the case is mentioned to highlight its epidemiological and prophylactic importance, especially in those regions where climatic conditions and living and working habits favour infestation. Finally, attention is called to diagnostic difficulties, treatment and appropriate hygiene and dietetic measures.

[Choledochal obstruction due to Fasciola hepatica (author's transl)]

A 45-year-old woman was admitted in July, 1976 with an acute cholecystitis without jaundice. She had suffered from hepatic colic without fever, jaundice, diarrhea or allergic episodes for the past 8 years. The physical examination only revealed an elective pain on the cystic point. Laboratory data were unremarkable, except for a 12 percent eosinophils. The cholecystogram showed a cholelithiasis. The lithiasis was confirmed during the surgical operation and a fasciolasis was diagnosed after one and 10-12 parasites had been found into the cystic and common bile duct, respectively. A cholecistectomy and choledochoduodenostomy were performed. The patient was treated with 60 mg dehydroemetine during 10 days and 500 mg chloroquine during the other next 10 days. Eggs of Fasciola hepatica were found in the stool culture. The follow-up examinations 3 months and a year after surgery were completely normal. The national literature on this topic is reviewed and the clinical manifestations and therapy of this disease are commented on.