Management of choledochoascariasis

What is the Definition of choledochoascariasis?

Choledochoascariasis is defined as the presence of  Ascaris /Round Worm in the lumen of common bile duct. 

It is also called as biliary ascariasis. 

Zoological name of round worm is Ascaris lumbricoides. Round worms are the common inhabitant of intestine. When worm load increases in the intestine it is called as ascariasis.  Then ascaris migrate to the common bile duct then gall bladder through the ampula of Vater. 

Prevalence of choledochoascariasis or biliary ascariasis:

Prevalence of choledochoascariasis is high in tropical and Indian subcontinent. 

The prevalence more in Kashmir valley. 

Children are more commonly affected because their lower hygienic level.

The biliary ascariasis is more common in female . 

Pregnant women are more susceptible due to relaxant effect of hormones on the smooth muscle of the biliary tracts.

Common bile duct is a small tube which connect the common hepatic duct and cystic duct to the pancreatic duct at ampulla of Vater, which in turn opens up in middle part of the duodenum. Common bile duct carriage the bile juice formed in liver to intestine..
The diameter of common bile duct should be less than 6 mm, it is found to be dilated in case of cholecystectomy..

Sometimes the worm can also be seen in gall bladder lumen. I have seen one case in my ten year of experience of ultrasonography.

What are the Common Symptoms of choledochoascariasis?

The presentation of  choledochoascariasis is similar to the cholelithiasis, choledocholithiasis, acte cholecystitis, acute pancreatitis and acute cholangitis. 

Pain- Biliary colic is the most common complain in which is pain felt in epigastric region specially just after eating fatty meal. 

Fever-  low grade fever may be present.

Nausea and vomiting-

Obstructive Jaundice- if blockage occurs in common bile duct.

What are the Complications of choledochoascariasis or biliary ascariasis?

Stricture formation of common bile duct

Acute Cholangitis - inflammation if biliary tract.

Liver abscess may develop.

Acute Cholecystitis - inflammation of gallbladder

Acute Pancreatitis - inflammation of pancreas.

How to Diagnose choledochoascariasis or biliary ascariasis?

What are the Investigations:

Haematological examinations -

Haemoglobin percentage in blood - decreased 

Total leukocyte count - raised

 

Differential leukocyte count -

                            Absolute eosinophilia is seen in which eosinophils count is raised.

Biochemical examinations -

Liver function test -

                             Serum bilirubin - Direct serum bilirubin is raised.

Stool examination - 

Round worm ova are examined in microscope.

Radiology - 

1. Ultrasonography -

Ultrasonography is the investigation of choice.

 Ascaris is seen in gall bladder lumen and common bile duct.

Appearances of round worm in the biliary tract are -

1. Inner tube sign - The round worm may be seen as a thick echogenic stripe with a central anechoic tube ( gastrointestinal tract of worms ) in the gall bladder or common bile duct.

2. Stripe sign - Thin non-shadowing stripe without an inner tube within gall bladder or common bile duct.

3.Spaghetti sign - Overlapping longitudinal interfaces in the main bile duct due to coiling of a single worm or several worms in the common bile duct.

                   

2. Endoscopic retrograde cholangiopancreatography ( ERCP ).

3. CT scan abdomen

4. MRCP

5. Fluoroscopy

What are the Management of choledochoascariasis or biliary ascariasis?

1. Conservative- 

Nil by mouth - to give bowel rest.

Start IV fluid for maintenance of energy til pain subsides. 

Antispasmodic drugs for the relaxation of sphincter of Oddi. So that worm will return to the small intestine.

Analgesics - given to relief pain.

Broad spectrum antibiotics - given to prevent the complications.

2. Interventional- 

Endoscopic retrograde cholangiopancreatography ( ERCP ).

Endoscopic removal of round worm.

What are the Prevention and Prophylaxis of choledochoascariasis?

Three monthly deworming of whole family members.

Proper hand wash after toilet and before taking meal.

Proper washing of green vegetables, fruits and salads.

Also Read: Cholelithiasis - causes, signs and symptoms, complications, diagnosis and treatment