ONLINE MANUSCRIPT SUBMISSION
Editorial Board | Instructions for Authors | Main Page | Table of Contents | Archive | Search
The Turkish Journal of Gastroenterology
2001, Volume 12, No 2, Page(s) 154-157
[ Summary ] [ Similar Articles ] [ Mail to Editor ]
Obstructive jaundice and acute pancreatitis due to biliary ascariasis
Ersöz Galip1, Üstün Şebnem1, Dağcı Hande2
Ege University School of Medicine, Departments of Gastroenterology1, and Parasitology2, İzmir
Keywords: Ascariasis, obstructive jaundice, acute pancreatitis, tıkanma sarılığı, akut pankreatit.
Summary
In spite of the fact that intestinal ascariasis is the most common parasitic disease in our country, very few studies on extraintestinal ascariasis have been reported. Complications such as obstructive jaundice, cholangitis and acute pancreatitis as a result of the ascaris lumbricoides passing into the biliary system and pancreatic canal seem to be rare. In this report, a patient with obstructive jaundice, acute cholangitis and an acute pancreatitis attack due to ascaris settling in the extrahepatic biliary canal is presented. The clinical characteristics, diagnosis and treatment are also discussed.
  • Top
  • Summary
  • Introduction
  • Case Presentation
  • Discussion
  • References
  • Introduction
    Ascariasis is a widespread helminthic infection affecting more than 1.4 billion people in the world, with the majority of infections occurring in the developing countries of Asia and Latin America. It is acquired by oral consumption of eggs with embryos. Every year 20.000 people in endemic areas die from disease caused by ascariasis (1). Adult ascariasis infection gives rise to two kinds of disease: the first is intestinal ascariasis (ascariasis intestinalis), which is frequently encountered and the second is a condition called ascariasis aberrance, which appears with the migration of the ascaris to organs outside the intestines. Despite the fact that the adult ascaris is generally not very active in the intestines, in some cases it may enter orifices linked to the intestines such as the stomach, large intestines, pancreatic canal and ductus choledochus, thereby reaching the thinner biliary canals in the liver. Whereas intestinal ascariasis generally does not cause any serious problems, the settling of the ascaria outside the intestines is likely to cause serious disease (2). Hepato-pancreatic ascariasis is an important cause of biliary and pancreatic disease in endemic areas. It affects adult women and may give rise to serious conditions such as biliary colic, acute cholecystitis, acute cholangitis, acute pancreatitis and hepatic abscess (1).

    In this report, a patient with obstructive jaundice, acute cholangitis and acute pancreatitis caused by ascaris in the extrahepatic biliary ducts is described.

  • Top
  • Summary
  • Introduction
  • Case Presentation
  • Discussion
  • References
  • Case Presentation
    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

  • Top
  • Summary
  • Introduction
  • Case Presentation
  • Discussion
  • References
  • Discussion
    In this study, a case of obstructive jaundice, acute cholangitis and acute pancreatitis due to ascaris in the choledoch is presented. In Turkey, especially in the Aegean Area, hepato-pancreatic biliary disease caused by ascaris is uncommon. Of the 1,854 patients on whom ERCP was performed in our clinic in the last two years, no case of hepato-pancreatic ascariasis was found. However, it is a frequent cause of hepatic and pancreatic disease in endemic areas. Sandouk et al. observed hepato-pancreatic ascariasis in 18% of ERCP cases and abdominal pain in 98% of the cases, ascending cholangitis in 16%, acute pancreatitis in 4.3% and obstructive jaundice in 1.3%. In addition, they discovered that 80% of the hepato-pancreatic ascariasis cases had previously undergone cholecystectomy and/or sphincterectomy and they claimed that sphincterotomy especially leads to the development of hepato-pancreatic ascariasis (3). It is an interesting fact that there is no history of sphincterotomy or cholecystectomy in our case, but there is still obstructive jaundice, cholangitis and pancreatitis.

    In a study carried out in India, where ascariasis is widespread, hepato-pancreatic ascariasis was held responsible for 23% of acute pancreatitis cases. It was reported that acute pancreatitis was slight in 78% of cases and severe in 22% and that it was accompanied by pyogenic cholangitis in 13.6% of cases. Treatment by endoscopic methods was successful in 95% of the cases (4). A few cases of pancreatitis and obstructive jaundice due to hepato-pancreatic ascariasis have been reported from aeras where it is uncommon and it was stated that treatment by endoscopic methods was successful in all of them (5-8). Görgül et al reported a biliary ascariasis case where it was removed by balloon extraction after endoscopic sphincteretomy. They stated that this procedure was feasible and harmless in the treatment of biliary ascariasis (9).In a study where the diagnostic value of ultrasonograpy (USG) in ascariasis was investigated, USG was considered as an effective and reliable method in the diagnosis of hepatobiliary, enteric and pancreatic ascariasis (10). In our case, diagnosis could not be established by USG. It was thought to be related to inexperience in evaluating the USG image of hepato-pancreatic ascariasis and the fact that echogenic structures due to debris caused by cholangitis had made the image unclear. Stool testing is the most important method in the diagnosis of ascariasis (2). In our case, no ascaris eggs were found on stool examination and it was therefore thought that hepato-pancreatic ascariasis was caused by a male or immature female parasite.

    In conclusion, ascariasis may occasionally cause hepato-pancreatic disease and such patients can be quickly and easily treated by endoscopy.

  • Top
  • Summary
  • Introduction
  • Case Presentation
  • Discussion
  • References
  • References

    1) Khuroo MS. Ascariasis. Gastroenterol Clin North Am 1996; 25: 553-77.

    2) Unat EK, Altaş K. Tıp Helmintolojisi. Unat EK, Yücel A, Altaş K, Samastı M, ed. Unat'ın Tıp Parazitolojisi. Beşinci baskı. İstanbul: Doyuran matbaası, 1995: 229-479.

    3) Sandouk F, Haffar S, Zada MM et al. Pancreatic-biliary ascariasis: experience of 300 cases. Am J Gastroenterol 1997; 92: 2264-7.

    4) Khuroo MS, Zargar SA, Yattoo GN, et al. Ascaris-induced acute pancreatitis. Br J Surg 1992;79: 1335-8.

    5) Saowaros V. Endoscopic retrograde cholangio-pancreatographic diagnosis and extraction of massive biliary ascariasis presented with acute pancreatitis: a case report. J Med Assoc Thai 1999; 82: 515-9.

    6) Guelrud M, Herrera I. Acute pancreatitis due to pancreatic duct Ascaris migration after pancreatic sphincterotomy and pancreatic stent placement. Endoscopy 1997; 29: 53.

    7) Asrat T, Rogers N. Acute pancreatitis caused by biliary ascaris in pregnancy. J Perinatol 1995; 15: 330-2.

    8) Morovic-Vergles J, Sabljar-Matovinovic M, Scrbec B et al. Acute pancreatitis caused by Ascaris lumbricoides in acute renal failure: case report. Lijec Viesn 1995: 117 Suppl 2: 87-8.

    9) Görgül A, Kayhan B, Ünal S. A case of biliary ascariasis treated medically. Gazi Medical Journal 1995; 6:187-9.

    10) Ferreyra NP, Cerri GG. Ascariasis of the alimentary tract, liver, pancreas and biliary system: its diagnosis by ultrasonography. Hepatogastroenterology 1998; 45: 932-7.

  • Top
  • Summary
  • Introduction
  • Case Presentation
  • Discussion
  • References
  • [ Summary ] [ Similar Articles ] [ Mail to Editor ]
    Editorial Board | Instructions for Authors | Main Page | Table of Contents | Archive | Search