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Cholangitis and Pancreatitis Caused by Biliary Ascariasis

Published:September 29, 2008DOI:https://doi.org/10.1016/j.cgh.2008.09.008
      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 (Figure C), 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.
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