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GALL BLADDER ASCARIASIS – AN UNWELCOME GUEST IN THE BILIARY TRACT
Krishna Kalyan Reddy Janumpalli
*1, Raghavendra Rao R.V.
1, Divya Kiran S
1, Venu B. Mulpuri
21Surgical Gastroenterology, Renova-National Institute of Gastroenterology and Liver Diseases, Hyderabad, Telangana, India; 2ESIC Medical College & Hospital, Hyderabad, Telangana, India
Introduction:
Ascariasis is the most common parasitic infection in the world and is an endemic disease in India where it poses a major healthcare problem. Whilst adult round worms are primarily seen in intestine, their presence in Hepato Biliary system has been reported. We herein report a case of Gall Bladder(GB) Ascariasis.
Case Details:
A 60-year-old female patient presented with intermittent abdominal pain in the right upper quadrant(RUQ) for 4 months. Physical examination was unremarkable. Labs were within normal range. Ultrasonography of abdomen showed a linear hyperechoic tubular structure within the gall bladder with a hypoechoic centre without any intrinsic movements s/o dead GB Ascariasis worm. MRCP done further corroborated these findings. Patient was managed with single dose of Albendazole and was planned for Elective Laparoscopic Cholecystectomy.
Discussion: Ascaris lumbricoides commonly known as human roundworm is a frequently found intestinal parasite in endemic countries where sanitation facilities are suboptimal and hygiene practices are deficient. Transmission of infection is via ingestion of fertilized eggs through faeco-oral route. Adult worms are mainly inhabitants of small bowel but they have great propensity for migration through ducts and orifices when worm load in the intestine is high. Migration of worms from the duodenum through Ampulla of Vater is well documented but its advancement into gall bladder is rare. Worms make repeated traverses in to and out of the ductal lumen as long as they are alive and get trapped inside the bile ducts, die and become the nidus and source of biliary sludge and brown pigment biliary calculi.
Worms in the biliary tract can cause non specific symptoms like abdominal pain or discomfort, vomiting and fever or present with cholangitis due to biliary obstruction by the migrating worm. Retained worm fragments can serve as a nidus for biliary stones and cause recurrent pyogenic cholangitis. Diagnosis of GB Ascariasis is often accidental during workup for suspected gallstone disease. Ultrasonography usually is diagnostic with characteristic findings of Echogenic linear or curved tubular structure with hypoechoic or anechoic centre without any acoustic shadowing. Live worms may show writhing movement during real time sonography. MRCP show the worms as linear hypo-intense filling defects or bands with linear signals along the gallbladder wall. Initial management is conservative treatment with antihelminthic agents once the worm is out of the biliary tract with either Albendazole 400mg as a single dose or Mebendazole 500 mg as a single dose. Surgical management is considered for cases with dead worm inside the gallbladder and gallbladder with both stones and worms.
Conclusion: GB ascariasis is a surprise differential in patients with RUQ pain from endemic regions and management is usually not complicated.
Ultrasonography images showing the worm as a echogenic, linear tubular structure with a hypoechoic center.
MRCP image showing a linear filling defect in the gall bladder.
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