A 68-year-old female patient was referred to our clinic with a one-week history of epigastric pain, increasing with food intake and radiating to her back, nausea and vomiting. She also complained of red-colored urine and jaundice, starting five days previously, at which point the abdominal pain, nausea and vomiting diminished and her faeces become colourless. On physical examination, her temperature was 38.80 C, the skin and the mucosa were icteric and the upper right abdomen tender. Examination of other systems was normal laboratory values were as follows: Leucocyte count 19.600/mm3 (normal value: 4.000-10.000), granulocytes: 86% (normal value: 37.0%-73.0%), hemoglobin: 13.1 g/dl (normal value:12.1-17.2 g/dl), thrombocytes: 360.000/mm3 (normal value: 150.000-400.000/mm3), SGOT: 142, 57 U/L (normal value: 5-35 U/L), SGPT: 270, 127 U/L (normal value: 5-40 U/L), alkaline phosphatase: 1258, 1137 U/I (normal value: 98-290 U/L), total bilirubin: 17.8 mgr/dl (normal value: 0-1.0 mgr/dl), direct bilirubin: 12.8 mgr/dl (normal value: 0-0.3), total protein: 5.78 g/dl (normal value: 6.0-8.5 g/dl), albumin: 3.93g/dl (normal value: 3.5-5.0 g/dl), fasting blood glucose level: 98 mgr/dl (normal value: 60-100 mgr/dl), creatinine: 0.28mg/dl (normal value: 0.6-1.1 mgr/dl), Na: 140 MEQ/L (normal value: 136-145MEQ/L), K: 4.2 MEQ/L (normal value: 3.5-5.0 MEQ/L), serum amylase: 2356 U/L (normal value: <220U/l), urine amylase: 8200U/L (normal value: <1000U/l). Occult fecal blood and repeated stool testing for parasites were negative. In abdominal ultrasonography (USG), the choledochus canal was observed to be 10 mm. wide and in the canal, echogenic formations without acoustic shadows were detected. Other upper abdominal organs and the pancreas were found to be normal. Findings supporting edematic pancreatitis were detected in the computed tomography carried out for acute pancreatitis. At endoscopic retrograde cholangiopancreotography (ERCP) the papilla was seen to be swollen and edematous and a bile containing abscess was found to be projecting from the opening of the papilla. After completion of this procedure and extraction of the endoscope, the intra and extra hepatic biliary ducts were found to be larger than normal and a cylindric filling defect about 4-5 cm. long was detected in the choledochus canal on x-ray. The pancreatic canal was observed to be normal (Figure1). After detection of the cylindric filling defect, endoscopy was repeated and sphincterotomy performed. The parasite was removed from the canal using a Dormia Basket (the cholangiography performed after this procedure is shown in Figure 2). The structure in the choledochus canal was found to be a mature form of ascaris lumbricoides. The patient, who had obstructive jaundice associated with ascariasis cholangitis and edematous pancreatitis, was prescribed Cefepime HCI 1 gr bid for her cholangitis. Although no eggs were found on repeated stool examination, because of the images obtained at ERCP, albendazole 200 mg bid was prescribed for three days in case there was a male or an immature female parasite. Symptoms of abdominal pain, nausea, vomiting and fever disappeared, the leucocyte count, SGOT, SGPT, bilirubin and amylase values returned to normal and the patient made a complete recovery and was discharged.
Figure 1: Ascaris in choledochus canal observed on ERCP.
Figure 2: Cholangiography after removal of parasite