Case Report
Mr RP resident of Mumbai presented with complaints of pain in right hypochondriac region, fever with chills, and jaundice for period of 10 days. There was no history of passing of worms in stools. On examination patient was tachycardiac and vitally stable. There was significant icterus. Abdomen was tender in right hypochondriac region and Murphy’s sign was positive. X-ray chest was normal. USG was suggestive of cholidocholithiasis with dilated common bile duct [CBD] and distended gall bladder[GB] with multiple calculi. Clinical diagnosis was acute cholecystitis. Bilirubin was 13.5[t] and 4[d] with raised AlkPO4 [900].
Patient was managed conservatively with antibiotics and antispasmodics. After patient had clinically settled a CT scan was performed. It showed choledocholithiais with hepaticodocholithiasis and small cholangiatic abscess in right lobe of liver. There was moderate intrahepatic biliary duct dilatation. Round worm infestation of small bowel was seen. ERCP was performed which revealed that CBD was completely filled of calculi. Stone extraction failed and 7 Fr stent was passed into right hepatic duct. Patient was taken for CBD exploration. On CBD exploration a live round worm approxiately 12 cms was removed from CBD, with its head stuck in right hepatic duct. CBD and both hepatic ducts were cleared of multiple soft pigment caluli using a Fogarthys catheter and clearance was confirmed on an intraoperative cholangiogram. T tube placement was done after sphincterotomy.
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| Fig. 1 :Intraoperative Picture of CBD worm |
Postoperatively the bilirubin levels did not come back to normal. Repeat t tube gram was suggestive of a density in left hepatic duct. LHD was stented and t tube was removed. ERCP was suggestive of ? dead worm in LHD. Patient still has stent in situ. Bilirubin levels have come back to normal.
Discussion
Ascaris lumbricoides is a large helminth which has infected more than a billion people in developing countries mostly in tropics and subtropics.1 Biliary ascariasis is endemic in kashmir valley of India.2 However cases have been reported from non endemic areas.3 In view of world travel and population migration biliary ascariasis may well be seen in non endemic parts of world.
Hepaticodocholithiasis is more prevalent in Taiwan, Southkorea and China. Ours was a case of biliary ascariasis with hepaticodocholithiasis.4 The worm was missed preoperatively on USG as well as CT scan. USG can miss 10% of CBD calculi specially if they are of pigment type as they don’t give acoustic shaddowing.5-7 Biliary ascariasis can present as biliary colic (56%), acute cholangitis (25%), acute cholecystitis (13%), acute pancreatitis (6%) and rarely hepatic abscesses (less than 1%).2 Our patient presented with acute cholecystitis due to obstruction to cystic duct.
Adult forms of Ascaris lumbricoides are usually passed into the intestine, however worms in the duodenum and invading the ampulla of Vater usually present as biliary colic or acute pancreatitis due to blocked CBD or pancreatic duct. These worms migrate through CBD, cystic duct and intrahepatic duct leading to biliary colic and cholangitis. Presence of dead worms form nidus for the CBD or hepatic stone formation. Further migration of worms into the intrahepatic duct causes secondary biliary cirrhosis, stricture formation, bile duct stenosis, hepatolithiasis and abscess formation. These worms also have high glucuronidase activity that deconjugates bilirubin and form pigment stones.
Plain X-ray of abdomen, ultrasound and if required CT scan are good modalities to diagnose biliary ascariasis.
The treatment of choice for biliary ascariasis is ERCP with sos stenting and sphincterotomy.2 However recurrences are known to occur in biliary ascriasis especially if a sphincterotomy has been performed prior.2,3 CBD as well as hepatic duct calculi require a surgical exploration if ERCP fails to extract the calculi. Recurrence of hepatic duct calculi requires surgical management. Anti helmenthics especially Albendazole 400 mg once a month is given following definitive antihelmenthic treatment. But recurrences are known even after that.2,3
Biliary ascriasis should always be considered as a differential for hepaticodocholithiasis in endemic areas.
References
- Editorial. Ascariasis. Lancet 1989; I : 165–9.
- Khuroo MS, Zargar SA, Mahajan R. Hepatobiliary and pancreatic ascariasis in India. Lancet 1990; 335 : 1503-6.
- Mishra SP, Dwivedi M. Clinical features and management of biliary ascariasis in non-endemic area. Postgraduate Med J 2000; 76 : 29–32.
- Pausawasdi A, Watanapa P. Hepatolithiasis: epidemiology and classification. Hepatogastroenterology 1997; 44 : 314–6.
- Dewbury KC, et al. The misdiagnosis of common bile duct stones with ultrasound. J Radiol 1983; 56 : 625–30.
- Einstein EM, et al. The insensitivity of sonography in detection of choledocholithiasis. Am J Radiol 1984; 142 : 725-8.
- Khuroo MS, Zargar SA, Mahajan R, et al. Sonographic appearances in biliary ascariasis. Gastroenterology 1987; 93 : 267–72.
SAFETY AND EFFICACY OF A RECOMBINANT HEPATITIS E VACCINE
Background: Hepatitis E Virus (HEV) is an important cause of viral hepatitis. We evaluated the safety and efficacy of an HEV recombinant protein (rHEV) vaccine in a phase 2, randomized, double-blind, placebo-controlled trial.
Conclusions: In a high-risk population, the rHEV vaccine was effective in the prevention of hepatitis E.
N Engl J Med 2007; 356(9) : 895.
*Resident, **Lecturer, Deparment of General Surgery, Nair Hospital.
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