Endoscopic ultrasound appearance of dead Ascaris lumbricoides in the biliary tract

A 2-year-old Indian girl was referred withsymptoms of biliary colic and obstruc-tive jaundice of 3 weeks’ duration. Ab-dominal ultrasonography revealed dila-tion of intrahepatic biliary radicles, adistended gallbladder, and a dilatedcommon bile duct (CBD) of 15mm (nor-mal diameter up to 6mm) containingmultiple ill-defined, oval, hyperechoicshadows near the lower end (▶Fig. 1).Magnetic resonance cholangiopancrea-tography (MRCP) showed multiple intra-luminal curvilinear, hypointense areas inthe lower CBD consistent with stones orworm (▶Fig. 2). Linear endoscopic ultra-sound (EUS) was performed for evalua-tion of the CBD filling defects visualizedon abdominal ultrasound and MRCP.Linear EUS from the stomach and duo-denal bulb revealed a dilated CBD withmultiple hyperechoic structures withoutacoustic shadowing. EUS showed cur-vilinear, disc-shaped short-segmentechogenic structures, 2–6mm in size,with a central anechoic core and paralleland equidistant from each other; thiswas suggestive of recently broken downsoft parallel fragments of roundworms(▶Fig. 3, ▶Video1). The central anec-hoic core represented the digestive tractof Ascaris lumbricoides. Cholangiographyrevealed a dilated CBD with tapering atthe lower end showing multiple fillingdefects (▶Fig. 4). After multiple balloonsweeps on endoscopic retrograde chol-angiopancreatography (ERCP), creamywhite structures and yellow-colored ma-terial were removed that were sugges-tive of recently fragmented roundworm(▶Fig. 5, ▶Video1). The patient’s clini-cal condition improved significantlyafter ERCP, and repeat abdominal ultra-sound after 1 week demonstrated de-creased size of the CBD. The patient un-derwent deworming with albendazole,with the passage of multiple round-worms in stools further confirming thediagnosis of obstructive jaundice due toAscaris.

Pancreaticobiliary ascariasis is a commonproblem in tropical countries [1]. DeadAscaris is a rare but an important causeof obstructive jaundice in the developingworld [2]. In conclusion, we describe anunusual appearance of recently deadAscaris lumbricoides on abdominal ultra-

sound, MRCP, and EUS. In endemicregions, biliary ascariasis should be con-sidered in any child presenting with ob-structive jaundice [3].

Endoscopy_UCTN_Code_CCL_1AF_2AF_3AD

E-Videos

Video 1 Appearance at linear endoscopic ultrasonography (EUS) of dead Ascarislumbri-coides causing obstructive jaundice in a 2-year-old girl, and removal of thefragmentedroundworm at endoscopic retrograde cholangiopancreatography (ERCP). CD, cysticduct;CBD, common bile duct; IVC, inferior vena cava.

▶ Fig. 1 In a 2-year-old Indian girl with symptoms of biliary colic and obstructive jaundiceof 3 weeks’ duration, abdominal ultrasonography showed a dilated common bile duct (CBD)with multiple ill-defined, oval, hyperechoic shadows near the lower end.

Somani Piyush et al. Endoscopic ultrasound appearance… Endoscopy 2017; 49: E275–E276 E275

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Competing interests

All authors have no conflict of interest to dis-close.

The Authors

Piyush Somani, Malay Sharma, Saurabh Jindal

Department of Gastroenterology, Jaswant Rai

Speciality Hospital, Saket, Meerut, Uttar

Pradesh, India

Corresponding author

Piyush Somani, MD, DM

Department of Gastroenterology, Jaswant

Rai Speciality Hospital, Saket, Meerut,

PIN-250 001, Uttar Pradesh, India

Fax: +91-121-2657154

dr_piyushsomani@yahoo.co.in

References

[1] Somani P, Sharma M, Pathak A et al. Endo-scopic ultrasound imaging of pancreaticduct ascariasis. Endoscopy 2016; 48: E33–E34

[2] Sharma M, Pathak A, Bansal S. Dead worm incommon bile duct. Trop Gastroenterol2011; 32: 343–345

[3] Sharma M, Mookiah B, Hari RS. Double ductsign in a 3-year-old child. Gastroenterology2014; 146: e6– e7

Bibliography

DOI https://doi.org/10.1055/s-0043-117601

Published online: 10.8.2017

Endoscopy 2017; 49: E275–E276

© Georg Thieme Verlag KG

Stuttgart · New York

ISSN 0013-726X

▶ Fig. 3 Endoscopic ultrasound (EUS) shows multiple disc-shaped echogenic structures with/without a central anechoic core in a dilated CBD. PV, portal vein; PD, pancreatic duct; IVC,inferior vena cava.

▶ Fig. 4 Cholangiography revealed adilated CBD with tapering at the lower endshowing multiple filling defects.

▶ Fig. 5 At endoscopic retrograde chol-angiopancreatography (ERCP) creamywhite structures and yellow-colored ma-terial, suggestive of recently fragmentedroundworm, were removed from the CBD.

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▶ Fig. 2 Magnetic resonance cholangio-pancreatography (MRCP) showed dilationof intrahepatic biliary radicles with a dis-tended gallbladder and dilated CBD andcommon hepatic duct. There are multipleintraluminal curvilinear, hypointenseareas in the lower CBD, consistent withstones or worm.

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