A 16-year-old, previously healthy boy presented to the emergency unit with a 3-day
history of fever, severe epigastric pain radiating to his back, nausea, and vomiting.
On physical examination he was acutely ill, febrile (38.8°C), with tachycardia and
mild scleral icterus, and had epigastric and right upper-quadrant tenderness with
guarding. Laboratory test results showed leukocytosis of 16 × 109
/L with 79% neutrophils; his erythrocyte sedimentation rate was 82 mm/h. His serum
amylase level was 625 U/L (normal level < 100), total bilirubin level was 79 mmol/L
(normal level < 17), conjugated bilirubin level was 64 mmol/L, alkaline phosphatase
level was 459 (normal level < 85), and his γ-glutamyltranspeptidase level was 695
(normal level < 50). Abdominal ultrasound showed several live worms in the common
bile duct. Computed tomography confirmed worms in the intrahepatic and extrahepatic
bile ducts as well as the duodenum (Figures A and B
) and features of acute pancreatitis with edema of the pancreas and surrounding tissues.
Duodenoscopy found 4 actively motile worms protruding from a grossly distended papilla
), and endoscopic retrograde cholangiography showed that the worms extended into the
hepatic ducts (Figure D
). The worms were extracted through the endoscope channel using a balloon catheter,
a Dormia basket, and a snare. His symptoms improved dramatically within hours of worm
extraction and he was discharged home well 2 days later.