World J. Surg. 16, 976-979, 1992
World Journal of Surgery © 1992 by the Soci6td lntcrnalionale de Chirurgie
Biliary Ascariasis: Surgical Aspects N.A. Wani, M.S., F . R . C . S . (Ed.) and R.K. Chrungoo, M.S. Department of Surgery, Sher-i-Kashmir Institute of Medical Sciences, Srinagar-Kashmir, India Presentation and management of 204 patients with biliary ascariasis seen over a period of 5 years is reported from a highly endemic area of Kashmir. Ultrasonography is the single most useful means of diagnosis. Endoscopic retrograde cholangiopancreatography is extremely helpful. Most patients respond to conservative management and around one-fifth of all patients require surgery.
Ascariasis is one of the most common helmenthic disease in humans [1]. It involves hundreds of millions of people in countries where the standards of public health and personal hygiene are low [2]. Normally inhabitants and miscreants of the gastrointestinal tract, the adult worms are encountered at ectopic sites like the biliary tree, heart chambers, fallopian tubes, eustachian ducts, and lacrimal ducts [3]. The most common site is the hepatobiliary tree, an easily accessible passage. The presence of round worms in the biliary tree was thought to be uncommon [4], but our observations disprove this and stress the need for high suspicion of ascaris as the etiological factor in biliary and pancreatic disease in an endemic area. Varied presentation of biliary ascariasis and its management are presented in this study. Clinical Material
The study included patients with upper abdominal pain and clinically established recurrent attacks of cholecystitis with or without pancreatitis and post cholecystectomy symptoms. The patients were attending surgical departments of the Institute of Medical Sciences, Soura and Shri Maharaja Hari Singh Hospital, Srinagar Kashmir, for a period of 5 years. All patients were investigated in detail by a careful history, detailed physical examination, hepatobiliary ultrasonographic examination, and, in pertinent cases, endoscopic retrograde cholangiopancreatography (ERCP). Patients with obstructive jaundice and pancreatitis with the worm as an etiological factor were also similarly included in this study. Other patients included in the study were those with biliary peritonitis secondary to ascardial biliary perforations and those in whom worms were detected in ducts Reprint requests: Prof. N.A. Wani, Head, Department of Gastrointestinal/General Surgery, Sher-i-Kashmir Institute of Medical Sciences, Soura, Srinagar, Kashmir 90011, India.
on T-tube cholangiograms. In all 204 patients with biliary ascariasis encountered over a period of 5 years were evaluated. Ultrasonic examination of the abdomen was performed by using a B-mode ultrasound scanner having grey scale imaging. A standard 3.5 mHz, 19 mm wide, long-focused transducer was used. The scans were obtained mostly in the suspine position though an inclined position of 45° was used in some patients to facilitate descent of the liver and gallbladder. Ascariasis in the biliary system was diagnosed ultrasonically as a linear echogenic mass with a hypoechogenic core within the lumen, which showed movement and changed position when alive. Results
Patients with biliary ascariasis usually reported with an acute abdomen and needed emergency in-patient care. Of the 204 patients, 166 (81.37%) presented with upper abdominal pain. This included 10 patients with a history of past biliary surgery. Many (86 patients) of those with pain had typical biliary colic suggesting intraluminal biliary obstruction. Sixty-one patients had clinical findings of cholecystitis and 4 patients had symptoms suggesting pancreatitis. There were 22 (10.78%) patients with obstructive jaundice and 5 (2.56%) patients with ascardial biliary peritonitis. In 16 patients in whom a T-tube was placed after exploration of the common bile duct (CBD), worms either presented through or around the T-tube or were demonstrated in ducts after a cholangiogram (Fig. 1). Most of the patients infested were very young (Table 1), with 109 (53.43%) patients being children from 10-20 years of age. Interestingly at least 11 (5.39%) patients were < 10 years of age. The youngest patient was a 3 year old girl. All patients, except those with worms in their biliary ducts on postoperative T-tube cholangiogram and those presenting with biliary peritonitis and needing surgical exploration, were diagnosed on ultrasonography (Figs. 2 and 3). They were serially followed by similar scans every week until the worms moved from the ducts into the gut which usually occurred within 4--5 weeks. When the worms did not move with the patient having persistant symptoms, when the worms were suspected to be dead, or when jaundice developed or deepened, operative intervention was contemplated. Abdominal ultrasound was performed in 183 patients with colic, cholecystitis, pancreatitis, and obstructive jaundice
N.A. Wani and R.K. Chrungoo: Biliary Ascariasis
977
Fig. 2. Hepatobiliary ultrasound showing the worms in common bile duct (CBD) (arrow). PV: Portal vein.
Fig. 1. T-tube cholangiogram showing worms as linear filling defects in the ducts (arrow). Table 1. Age of patients with biliary ascariasis. Age (yrs)
No. of pts. (%)
World Journal of Surgery © 1992 by the Soci6td lntcrnalionale de Chirurgie
Biliary Ascariasis: Surgical Aspects N.A. Wani, M.S., F . R . C . S . (Ed.) and R.K. Chrungoo, M.S. Department of Surgery, Sher-i-Kashmir Institute of Medical Sciences, Srinagar-Kashmir, India Presentation and management of 204 patients with biliary ascariasis seen over a period of 5 years is reported from a highly endemic area of Kashmir. Ultrasonography is the single most useful means of diagnosis. Endoscopic retrograde cholangiopancreatography is extremely helpful. Most patients respond to conservative management and around one-fifth of all patients require surgery.
Ascariasis is one of the most common helmenthic disease in humans [1]. It involves hundreds of millions of people in countries where the standards of public health and personal hygiene are low [2]. Normally inhabitants and miscreants of the gastrointestinal tract, the adult worms are encountered at ectopic sites like the biliary tree, heart chambers, fallopian tubes, eustachian ducts, and lacrimal ducts [3]. The most common site is the hepatobiliary tree, an easily accessible passage. The presence of round worms in the biliary tree was thought to be uncommon [4], but our observations disprove this and stress the need for high suspicion of ascaris as the etiological factor in biliary and pancreatic disease in an endemic area. Varied presentation of biliary ascariasis and its management are presented in this study. Clinical Material
The study included patients with upper abdominal pain and clinically established recurrent attacks of cholecystitis with or without pancreatitis and post cholecystectomy symptoms. The patients were attending surgical departments of the Institute of Medical Sciences, Soura and Shri Maharaja Hari Singh Hospital, Srinagar Kashmir, for a period of 5 years. All patients were investigated in detail by a careful history, detailed physical examination, hepatobiliary ultrasonographic examination, and, in pertinent cases, endoscopic retrograde cholangiopancreatography (ERCP). Patients with obstructive jaundice and pancreatitis with the worm as an etiological factor were also similarly included in this study. Other patients included in the study were those with biliary peritonitis secondary to ascardial biliary perforations and those in whom worms were detected in ducts Reprint requests: Prof. N.A. Wani, Head, Department of Gastrointestinal/General Surgery, Sher-i-Kashmir Institute of Medical Sciences, Soura, Srinagar, Kashmir 90011, India.
on T-tube cholangiograms. In all 204 patients with biliary ascariasis encountered over a period of 5 years were evaluated. Ultrasonic examination of the abdomen was performed by using a B-mode ultrasound scanner having grey scale imaging. A standard 3.5 mHz, 19 mm wide, long-focused transducer was used. The scans were obtained mostly in the suspine position though an inclined position of 45° was used in some patients to facilitate descent of the liver and gallbladder. Ascariasis in the biliary system was diagnosed ultrasonically as a linear echogenic mass with a hypoechogenic core within the lumen, which showed movement and changed position when alive. Results
Patients with biliary ascariasis usually reported with an acute abdomen and needed emergency in-patient care. Of the 204 patients, 166 (81.37%) presented with upper abdominal pain. This included 10 patients with a history of past biliary surgery. Many (86 patients) of those with pain had typical biliary colic suggesting intraluminal biliary obstruction. Sixty-one patients had clinical findings of cholecystitis and 4 patients had symptoms suggesting pancreatitis. There were 22 (10.78%) patients with obstructive jaundice and 5 (2.56%) patients with ascardial biliary peritonitis. In 16 patients in whom a T-tube was placed after exploration of the common bile duct (CBD), worms either presented through or around the T-tube or were demonstrated in ducts after a cholangiogram (Fig. 1). Most of the patients infested were very young (Table 1), with 109 (53.43%) patients being children from 10-20 years of age. Interestingly at least 11 (5.39%) patients were < 10 years of age. The youngest patient was a 3 year old girl. All patients, except those with worms in their biliary ducts on postoperative T-tube cholangiogram and those presenting with biliary peritonitis and needing surgical exploration, were diagnosed on ultrasonography (Figs. 2 and 3). They were serially followed by similar scans every week until the worms moved from the ducts into the gut which usually occurred within 4--5 weeks. When the worms did not move with the patient having persistant symptoms, when the worms were suspected to be dead, or when jaundice developed or deepened, operative intervention was contemplated. Abdominal ultrasound was performed in 183 patients with colic, cholecystitis, pancreatitis, and obstructive jaundice
N.A. Wani and R.K. Chrungoo: Biliary Ascariasis
977
Fig. 2. Hepatobiliary ultrasound showing the worms in common bile duct (CBD) (arrow). PV: Portal vein.
Fig. 1. T-tube cholangiogram showing worms as linear filling defects in the ducts (arrow). Table 1. Age of patients with biliary ascariasis. Age (yrs)
No. of pts. (%)
