Biliary Ascariasis: A difficult extraction

Hepatobiliary ascariasis (HBA) is a common complication of Ascaris infestation. It is reported mostly from developing countries. It is a common cause of biliary colic and cholangitis in some parts of India. It is also proposed as an etiology of a subset of patients with recurrent pyogenic cholangitis (RPC). Conservative management, endoscopic removal of the worm wherever needed and deworming is the accepted treatment approach. We herewith present a unique challenge that we encountered during worm removal. The patient was a 35-year-old female with 3 days history of epigastric pain, fever with rigors and vomiting. Her biochemical evaluation showed mild neutrophilic leukocytosis, mild elevation of aminotransferases and alkaline phosphatase. Ultrasound abdomen showed a tubular filling defect in the common bile duct extending in to the left hepatic duct. On endoscopic retrograde cholangiopancreatography (ERCP), the extraction was difficult because of left ductal stricture and a knot at the end of the worm. Such a worm conformation is rarely reported in the literature. In addition to presenting a challenge during removal it may act as a nidus for further infections and damage to the biliary tree particularly if the worm is dead or decaying. RPC is a disease with high morbidity and mortality. HBA is argued as an inciting event in significant number of cases. Recognition of such worm conformations emphasizes the need of meticulous ductal clearance at the time of ERCP, subsequent deworming and improved sanitation to protect such case from subsequent dreaded complications.