|LETTER TO EDITOR
|Year : 2013 | Volume
| Issue : 1 | Page : 56-57
Managing gallbladder ascariasis: To go full throttle or not!
Dilip Gude1, Kiran Biradar2, C Chandrakala3
1 Department of Internal Medicine/Critical Care, Princess Durru-Shehvar Children's and General Hospital, Purani Haveli, Hyderabad, India
2 Department of Radiology, Princess Durru-Shehvar Children's and General Hospital, Purani Haveli, Hyderabad, India
3 Department of Paediatrics, Princess Durru-Shehvar Children's and General Hospital, Purani Haveli, Hyderabad, India
|Date of Web Publication||17-Apr-2013|
Department of Internal Medicine/Critical Care, Princess Durru-Shehvar Children's and General Hospital, Purani Haveli, Hyderabad
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Gude D, Biradar K, Chandrakala C. Managing gallbladder ascariasis: To go full throttle or not!. Int J Health Allied Sci 2013;2:56-7
|How to cite this URL:|
Gude D, Biradar K, Chandrakala C. Managing gallbladder ascariasis: To go full throttle or not!. Int J Health Allied Sci [serial online] 2013 [cited 2019 Oct 21];2:56-7. Available from: http://www.ijhas.in/text.asp?2013/2/1/56/110568
An 18 month-old boy presented with severe colicky abdominal pain, progressive in nature from the last month. There is a history of eating soil and history of passing worms in stool. Physical examination was unremarkable except for pallor. Abdominal exam showed mild tenderness in the epigastric region and other systems were unremarkable. Before the clinical examination was complete, the crying child vomited a live motile worm. Ultrasonography (USG) of the abdomen showed a single, long, motile curvilinear ribbon like echogenic structure with inner hypoechoic band representing the "double tube" sign (corresponding to the digestive apparatus of the worm, Ascaris lumbricoides) in the gallbladder (GB) [Figure 1]. The thickness of GB wall was 2.5 mm with GB capacity of 40 ml and no features of cholecystitis (no evidence of thickened wall, pericholecystic fluid collection and/or fat stranding). Common bile duct (CBD) was normal with a diameter of 4.5 mm. Nasogastric suction was done where one of the worms obstructed the tube (nasogastric tube was then replaced and suction continued). Patient was prescribed albendazole 200 mg (5 ml syrup) stat dose and cefuroxime 250 mg and metronidazole 200 mg twice daily for 5 days. Patient was on close follow-up and stool test on the 3 rd day revealed Ascaris worms and eggs. Over the next week, his abdominal pain subsided and repeat ultrasound did not show any worm in the GB.
|Figure 1: Ultrasound abdomen showing ascaris as a single, long, curvilinear echogenic structure (thin arrow) in the gallbladder (thick arrow)|
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In India, ascariasis is highly endemic in Kashmir (70%) and Central and South-West India (20-49%).  Migration of Ascaris lumbricoides into the bile duct is more common than that of GB (2.1% of biliary ascariasis cases)  owing to the narrow and tortuous cystic duct. Abdominal USG is a valuable modality for the diagnosis of gallbladder ascariasis (GBA) and determining the intestinal parasite burden, especially in endemic countries. Serial USG may confirm the spontaneous expulsion of the worms. Computerized tomography may be of benefit over USG in cases of macerated worms with dense fibrosis and stones within the GB.  Endoscopic retrograde cholangiopancreatography can be of diagnostic and therapeutic help in biliary and pancreatic ascariasis, including ascaris in the duodenum. Acute cholecystitis (by a single worm or Ascaris eggs obstructing the cystic duct and/or nidus formation or by multiple worms distending GB) and rarely cholangitis may occur secondary to GBA. The longer CBD and dilated cystic duct facilitate easier access to the GB for worms. At times, worms in the CBD may retard the escape of worms from the GB leading to longer duration of GBA. Intestinal worm burden, worm size, sex and age of patients may influence the worm migration in GBA.  The absence of cholecystitis in our case was owing to albendazole, prophylactic antibiotics and the inherent motile nature of the worm. A case of liver abscess with fertilized eggs of Ascaris has been reported.  GBA is also known to complicate severe pancreatitis. 
Although, less than 1% of the volume of antiparasitic drugs is excreted in bile,  the motile nature of the worm allows expelling itself spontaneously from the GB. This may rationalize the conservative therapy at least initially. Varying percentages (78%  and 17.8%  in studies) of GBA have reported to expel the worms spontaneously, with the rest requiring surgical treatment. In another study, medical treatment including endoscopic management was successful in 97%.  Cholecystectomy (laparoscopic or open) is recommended in GBA if there is failure of a spontaneous clearance of worms after conservative treatment, a dead worm inside the GB, worm associated with calculi, cholecystitis, with impacted bolus worms inside the GB and an anomalous cystic duct. Worms can pose a nidus for recurrent cholelithiasis, which warrants cholecystectomy. In our case, we opted for conservative medical management with careful follow-up and reserved invasive therapy in case of complications. Another similar case in an adult was successfully managed conservatively. 
GB ascariasis, although uncommon, may pose a significant threat and through our experience we highlight that conservative therapy may suffice in uncomplicated GBA, thus avoiding the unwarranted morbidities of surgery.
| Acknowledgment|| |
We thank our colleagues and staff of Internal Medicine and Critical Care, Princess Durru-Shehvar Children's and General Hospital.
| References|| |
|1.||Khuroo MS. Ascariasis. Gastroenterol Clin North Am 1996;25:553-77. |
|2.||Chakrabarti I, Giri A, De A, Roy AC. Radio-pathological diagnosis of hepatobiliary ascariasis: A rare entity. J Cytol 2011;28:114-6. |
|3.||Maheshwari PR. Gall bladder ascariasis. Clin Radiol Extra 2004;59:8-10. |
|4.||Wani I. Gallbladder ascariasis. Turk J Gastroenterol 2011;22:178-82. |
|5.||Darlong LM, Das R, Hajong R, Topno N. A report of two cases of ascariasis pancreatitis managed conservatively. Ann Trop Med Public Health 2011;4:48-50. |
|6.||Javid G, Wani N, Gulzar GM, Javid O, Khan B, Shah A. Gallbladder ascariasis: Presentation and management. Br J Surg 1999;86:1526-7. |
|7.||Malik AH, Saima BD, Wani MY. Management of hepatobiliary and pancreatic ascariasis in children of an endemic area. Pediatr Surg Int 2006;22:164-8. |
|8.||Cha DY, Song IK, Choi HW, Chung EA, Shin BS, Song YW, et al. Successful elimination of Ascaris lumbricoides from the gallbladder by conservative medical therapy. J Gastroenterol 2002;37:758-60. |