Endoscopic management of early postoperative biliary ascariasis in patients with biliary tract surgery

Bile leak and residual stones are well known complications of biliary tract surgery. In endemic areas of ascariasis, invasion of the biliary tract by roundworms during the early postoperative period is an infrequent but serious complication. The present study describes the endoscopic management of postoperative biliary ascariasis in 19 consecutive patients. There were 5 men and 14 women with a mean age of 33.3 +/- 6.3 years. All patients had undergone cholecystectomy, with choledocholithotomy and placement of a T-tube in 13 (68.4%) patients. Eight (42.1%) patients including two with T-tubes were acutely sick at referral. Altogether, 16 (84.2%) patients had widened papillae due to previous endoscopic sphincterotomy (3 patients) or recent dilatation of the sphincter of Oddi by Bake's dilators (13 patients). All patients with a T-tube in situ had undergone unsuccessful attempts to remove the worms by flushing saline through the T-tube. Endoscopic retrograde cholangiopancreatography was performed 4 to 16 days after biliary tract surgery and revealed roundworms in the common bile duct in 10 patients, in the hepatic ducts in 2, or in both ducts in 7. Three patients had coexisting biliary leakage: from the cystic duct stump in two and from a T-tube track in one. Endoscopic treatment consisted of extracting the worms from the biliary tree and placing stents in those with coexisting leakage. Endoscopic success was defined as complete worm extraction and resolution of biliary leakage and was achieved in all patients. Complications occurred in one (5.3%) patient. We concluded that endoscopic management is an effective, safe approach for extracting ascarids from the biliary tree during the early postoperative period. It reduces the hospital stay, avoids T-tube-related complications, and permits a postoperative complication to be treated using a nonsurgical method.

Cdc42 and the actin-related protein/neural Wiskott-Aldrich syndrome protein network mediate cellular invasion by Cryptosporidium parvum

Cryptosporidium parvum invasion of epithelial cells involves host cell membrane alterations which require a remodeling of the host cell actin cytoskeleton. In addition, an actin plaque, possibly associated with the dense-band region, forms within the host cytoplasm at the host-parasite interface. Here we show that Cdc42 and RhoA, but not Rac1, members of the Rho family of GTPases, are recruited to the host-parasite interface in an in vitro model of human biliary cryptosporidiosis. Interestingly, activation of Cdc42, but not RhoA, was detected in the infected cells. Neural Wiskott-Aldrich syndrome protein (N-WASP) and p34-Arc, actin-regulating downstream effectors of Cdc42, were also recruited to the host-parasite interface. Whereas cellular expression of a constitutively active mutant of Cdc42 promoted C. parvum invasion, overexpression of a dominant negative mutant of Cdc42, or depletion of Cdc42 mRNA by short interfering RNA-mediated gene silencing, inhibited C. parvum invasion. Expression of the WA fragment of N-WASP to block associated actin polymerization also inhibited C. parvum invasion. Moreover, inhibition of host cell Cdc42 activation by dominant negative mutation inhibited C. parvum-associated actin remodeling, membrane protrusion, and dense-band formation. In contrast, treatment of cells with a Rho inhibitor, exoenzyme C3, or cellular overexpression of dominant negative mutants of RhoA and Rac1 had no effect on C. parvum invasion. These data suggest that C. parvum invasion of target epithelia results from the organism's ability to activate a host cell Cdc42 GTPase signaling pathway to induce host cell actin remodeling at the attachment site.

Wandering ascaris coming out through the T-tube tract--a rare occurrence

A case of ascariasis of the common bile duct in the postoperative period of cholecystectomy and choledocholithotomy with T-tube drainage is reported. The living adult wandering ascaris came out through the T-tube tract immediately after removal of the T-tube. No such previous report has been found in the available literature.

Pathobiology of opisthorchiasis: an update

Opisthorchis viverrini infection is associated with several hepatobiliary diseases including cholangitis, obstructive jaundice, hepatomegaly, cholecystitis and cholelithiasis. Pathological consequences of O. viverrini infection occur mainly in the liver, extrahepatic bile ducts, gall bladder and kidney. These pathologies have been described in both humans and experimental animals. Moreover, both experimental and epidemiological evidence strongly implicate the liver fluke infection in the etiology of cholangiocarcinoma--the bile duct cancer. This review summarizes the pathology of opisthorchiasis from literature mainly published between 1970 and the present time and, particularly, emphasizes on current concept in pathogenesis of the disease. The theme is to highlight the new era of pathogenetic study of opisthorchiasis especially on host-parasite interaction and host immune/inflammatory responses leading to tissue damage.

Clinical manifestation of opisthorchiasis and treatment

This paper presents an overview of recent progress in the clinical study of opisthorchiasis and treatment. Details of clinical manifestations of opisthorchiasis, hepatobiliary diseases and liver functions, community-based ultrasound study, treatment efficacy, and future study are discussed.

Cryptosporidiosis and the pathogenesis of AIDS-cholangiopathy

Cryptosporidium, an intracellular parasite that infects the gastrointestinal epithelium and other mucosal surfaces, causes self-limited diarrhea in immunocompetent subjects and potentially life-threatening syndromes in immunocompromised individuals, primarily those with acquired immunodeficiency syndrome (AIDS). Cryptosporidium is also the single most common identifiable pathogen in the biliary tract in patients with AIDS-cholangiopathy, an important biliary disorder caused by opportunistic infection of the biliary epithelium and resulting in significant morbidity and mortality in AIDS patients. The organism stimulates periductal inflammation in the biliary tree, induces biliary epithelial cell apoptosis, and thus contributes to the pathogenesis of AIDS-cholangiopathy. Currently, there is no fully effective medical therapy for both of the diseases. A better understanding of the parasitology of Cryptosporidium and the pathophysiology of biliary cryptosporidiosis should aid not only our understanding of the pathogenesis of AIDS-cholangiopathy but also the development of effective therapies and control of this ubiquitous, highly infectious threat.

Biliary fascioliasis: case report and review of the literature

Hepatobiliary parasitic diseases are rare in Lebanon. We recently encountered biliary fascioliasis in a Lebanese native. The clinical and laboratory findings were nonspecific. The biliary parasite (Fasciola hepatica) was identified by sonography and confirmed at ERCP that has retrieved the parasite from the common bile duct.

Biliary ascariasis

Biliary ascariasis is a less frequent, but important complication of ascaris infestation, because it may cause biliary colic, pyogenic cholangitis, and septicemia. Early diagnosis and treatment is important to prevent these complications. We present here a five-year-old girl with biliary ascariasis, whose main complaint was abdominal pain. After giving piperazin salt, multiple ascaris worms were seen in the stool within 10 days. She is at the follow-up without any complication.

Hepatobiliary and pancreatic complications of ascariasis in children: a study of seven cases

OBJECTIVES

This study presents seven cases of severe hepatobiliary and pancreatic complications of ascariasis in children. The authors describe the clinical, laboratory, and imaging findings, as well as the patients' clinical evolution.

METHODS

These cases were studied within a period of approximately 1 year and included children younger than 11 years (mean age, 4.4 years). The authors reviewed their medical history and evaluated the results of their main diagnostic examinations.

RESULTS

All of the patients had vomiting, abdominal pain, pallor, and abdominal distension at presentation. Passage of Ascaris lumbricoides in stool occurred in five cases, emesis with worms in three, fever in three, and hepatomegaly in two. Five patients had pancreatitis, of which two were necrohemorrhagic and one had pseudocyst of the pancreas. In three patients, A. lumbricoides was present in the pancreatic duct. Two patients had hepatic abscess (28.6%), and one of them also had cholangitis. One of the patients with pancreatitis also had signs of cholecystitis at presentation.

CONCLUSIONS

Ultrasonography was the imaging diagnostic method of choice and demonstrated the presence of A. lumbricoides in the biliary and the pancreatic ducts, as well as signs of pancreatitis, cholecystitis, and hepatic abscess. Endoscopic retrograde cholangiopancreatography, used to confirm the diagnosis, was a fundamental procedure in the treatment, allowing the removal of worms from the biliary duct in four of seven patients.

Biliary Ascariasis in children

BACKGROUND

Ascariasis is very common in this part of the world. Biliary Ascariasis is rare but is the commonest extra-intestinal complication.

METHODS

This study was conducted At Ayub Teaching Hospital, Abbottabad, a tertiary care hospital. Five cases of biliary Ascariasis were studied from December 1999 to January 2001. History of passage of worms in stool or vomiting and abdominal pain was taken. After clinical evaluation, Stool Examination, Serum amylase, LFTs, and complete blood picture (CP) were done. Ultrasound abdomen was done as a basic tool for diagnosis. All cases were given Piperazine. Spasmolytics were also given to relax sphincter of oddi to release the worms. Surgical opinions were also taken for each case.

RESULTS

About 80% Children were above 10 years of age. One case was 1 1/2 years old. Most common symptom was right upper quadrant abdominal pain. Previous history of passage of worms in stool and vomitus was also present. Two children developed complications of Biliary Ascariasis i.e., Cholecystitis and Portal empyema and responded to antibiotics. All children became symptom free in about 48 hours of treatment. Ultrasound was found to be a reliable, non-invasive, and quick tool for diagnosis and follow up.

Hepatobiliary and pancreatic ascariasis

Ascariasis is a helminthic infection of global distribution with more than 1.4 billion persons infected throughout the world. The majority of infections occur in the developing countries of Asia and Latin America. Of 4 million people infected in the United States, a large percentage are immigrants from developing countries. Ascaris-related clinical disease is restricted to subjects with heavy worm load, and an estimated 1.2 to 2 million such cases, with 20,000 deaths, occur in endemic areas per year. More often, recurring moderate infections cause stunting of linear growth, cause reduced cognitive function, and contribute to existing malnutrition in children in endemic areas. HPA is a frequent cause of biliary and pancreatic disease in endemic areas. It occurs in adult women and can cause biliary colic, acute cholecystitis, acute cholangitis, acute pancreatitis, and hepatic abscess. RPC causing hepatic duct calculi is possibly an aftermath of recurrent biliary invasion in such areas. Ultrasonography can detect worms in the biliary tract and pancreas and is a useful noninvasive technique for diagnosis and follow-up of such patients. ERCP can help diagnose biliary and pancreatic ascariasis, including ascaris in the duodenum. Also, ERCP can be used to extract worms from the biliary and pancreatic ducts when indicated. Pyrantel pamoate, mebendazole, albendazole and levamisole are effective drugs and can be used for mass therapy to control ascariasis in endemic areas.

Non-invasive management of Ascaris lumbricoides biliary tact migration: a prospective study in 69 patients from Ecuador

Ascariasis is one of the most common helminthic diseases. Its most feared complication is migration into the biliary tree. Some authors recommend immediate duodenoscopy in all cases of biliary migration, with sphincterotomy for the extraction of the parasites, and surgical extraction in case of intrahepatic ascariasis. We followed prospectively 69 patients with ultrasonographical evidence of migration. Initial treatment consisted of intravenous analgesics and antispasmodics, and albendazole 800 mg by mouth. Only patients with persisting symptoms or with high amylasaemia underwent duodenoscopy, with extraction in case of a visible worm. Surgery was limited to cases with persistent or progressive complications. In 97% of our cases the worms disappeared with noninvasive therapy alone. A duodenoscopy was done in 30 (42%) cases; in 10 (14%) a worm was found in the ampulla of Vater and extracted without sphincterotomy. In none of the 6 cases with A. lumbricoides in the intrahepatic biliary tree did the parasite persist. Only one patient required surgical intervention. Treatment of A. lumbricoides migration to the biliary tract should be principally medical. Duodenoscopy with extraction of a visible worm should be limited to cases with persisting pain and/or hyperamylasaemia. Invasive methods like sphincterotomy and surgery should be restricted to patients who do not respond to conservative treatment.

Three common presentations of ascariasis infection in an urban Emergency Department

In the United States, approximately 4 million people per year are infected with Ascaris lumbricoides. We reviewed the common presentations of complications of Ascariasis infection in the Emergency Department (ED) and the diagnostic tools and treatment available. This was a retrospective case review conducted on all patients diagnosed with Ascariasis (using ICD-9 codes) over a 6-year period at Los Angeles County and University of Southern California Medical Center. Three patients with distinct complications secondary to Ascariasis were chosen, and all ED and inpatient records were reviewed. The patient's age, sex, race, presenting symptoms, data, outcome, and ED course and diagnosis were recorded. The three cases included a periappendiceal abscess, Loeffler's syndrome, and biliary colic/choledocholithiasis. The first patient underwent a computed tomography-guided drainage of the abscess. The second patient received supportive care and antibiotic therapy secondary to a superimposed bacterial pneumonia. The third patient underwent endoscopic retrograde cholangiopancreatography with sphincterotomy. All three patients had a stool ova and parasites positive for A. lumbricoides, and all received a 3-day course of mebendazole. Symptomatic cases of Ascariasis may present to EDs in the United States. Important diagnostic tools for the ED include chest X-ray, X-ray of the kidney-ureter-bladder and ultrasonography. Single-dose medications given in the ED are very effective in eradicating A. lumbricoides infection, thus avoiding hospitalization.

[Opisthorchiasis simulating a malignancy]

We report on 2 patients from Siberia suffering from an infection with the parasite Opisthorchis felineus. The unusual course of their disease pretended in case 1 an eosinophilic leukemia and in case 2 a malignoma of the gallbladder. The Opisthorchiasis is endemic in large areas of Asia and Russia. Humans acquire the infection by eating raw fresh-water fish. Symptoms are nonspecific, but detection of eosinophilia in travellers or residents of endemic areas should induce analysis for specific antibodies against Opisthorchis species. Opisthorchiasis is known to be a precursor of cholangiocarcinoma. Malignoma which was initially suspected could be excluded in both cases and the patients were cured by oral administration of Praziquantel, 40-75 mg/kg body weight for 1 day in 3 divided doses.

Biliary ascariasis: MR cholangiography findings in two cases

We describe the imaging features of two cases of biliary ascariasis. Ultrasonography and CT showed no specific abnormal findings, but MR cholangiography clearly demonstrated an intraductal linear filling defect that led to the correct diagnosis. MR cholangiography is thus a useful technique for the diagnosis of biliary ascariasis.

Bilo-pancreatic Ascaris Lumbricoides infestation. Endoscopic discovery and removal

Ascaris Lumbricoides infestation is relatively rare in industrialized countries, and it occurs mainly in conditions in which hygiene is lacking. We describe here a case of a 39-year-old female from ex-Jugoslavia affected by recurrent hepatic colic. At entry ultrasonography revealed microlithiasis in the gallbladder and widening of the pancreatic head. The subsequent ERCP showed slight filling defects in the choledochus and an inflammation-like stricture of the papilla of Vater, and after endoscopic sphincterotomy we saw an outflow of dense bile and microlitholits. Thus, a standard surgical cholecystectomy was carried out and the patient was dismissed on the 3rd postoperative day without any symptoms. However, the patient was admitted again after four days for a new coliky pain attack. An upper endoscopy showed a 23 cm long mobile parasite in the duodenum: it was caught with the polypectomy loap, extracted and identified as A. Lumbricoides. The patient's symptoms disappeared after the endoscopic removal of the worm and she was dismissed the day after the worm's removal. No recurrence of symptoms was noted during a 1-year follow-up. This case showed that A. Lumbricoides infestation of the biliary tree should be considered when biliary and/or pancreatic symptoms recur, especially in patients coming from undeveloped countries. At the same time we showed that endoscopic removal is a safe and effective treatment for this infestation.

Postoperative biliary ascariasis: presentation and management--experience

Subsequent to preoperative and perioperative indications the common bile duct was explored in 705 patients over a 12-year period, from January 1983 to December 1994. Consequent postoperative T-tube cholangiography revealed the presence of worms in 22 patients. Expulsion of the worms followed T-tube irrigation with 0.9% normal saline in 18 patients. Only one patient had to be reexplored to remove the ascaris. In two patients the worm was removed along with the T-tube, and in one patient the worm came out through the T-tube tract.

Biliary parasites

Parasitic diseases of the biliary tract occur frequently in tropical and subtropical areas and cause high morbidity and mortality. In general, neither the clinical presentation nor the general laboratory findings are sufficiently unique to raise the possibility of a parasitic biliary infestation in the mind of the surgeon. Once considered, however, the presence of a parasitic biliary infestation is easily confirmed. Most commonly this is accomplished by the identification of the parasite in stools or duodenal contents. Ultrasonography, CT and MRI are not only important in the diagnosis of parasitic biliary diseases but also in the follow-up and surveillance. ERCP is an excellent diagnostic tool for demonstrating the presence of parasites in the biliary tree. Furthermore, ERCP is also used in the therapy of biliary parasitic infestations and carries less morbidity and mortality than the surgical approach. Surgery is only indicated in complicated cases. Mechanisms that may be effective against parasites include: antibodies; cytotoxic T cells; T-cell-induced activated macrophages; natural killer cells, and a variety of cells that mediate antibody-dependent cell-mediated cytotoxicity and modulators of the immune system such as cytokines. Future research has to focus on the importance of these mechanisms for the immune evasion by parasites.

Laparoscopic treatment for biliary ascariasis

Biliary ascariasis is one of the most common types of ascaris infections. The current treatments are helminthic drug therapy, endoscopic extraction, and surgical extraction. A case of biliary ascariasis and cholecystocholedocholithiasis was successfully treated by laparoscopic extraction of the living worm and biliary stones. This procedure was found to be very effective for biliary ascariasis with biliary stones, and it holds promise for similar cases in the future.

Fascioliasis: sonographic abnormalities of the biliary tract and evolution after treatment with triclabendazole

Diagnosis of infection with the liver fluke Fasciola hepatica is usually difficult. Ultrasonography (US) might be a useful diagnostic alternative, and we assessed the value of sequential US in the diagnosis and monitoring of fascioliasis in 76 patients at baseline and for 60 days after treatment with triclabendazole. At baseline, biliary abnormalities were observed in 52 patients. Crescent-shaped parasites were seen in 11 patients; in 2 cases parasites were spontaneously moving and in 4 patients parasites were motionless. Postprandial examination revealed parasites adhering to the gallbladder wall in a further 5 cases. In 3 further cases, gallbladder contents were mobile but did not sediment downwards after patients changed position. Non-specific abnormalities were: impaired gallbladder contractility (n = 23), gallbladder tenderness (n = 19), debris (n = 6), calculi (n = 5), wall thickening (n = 2) and bile duct dilatation (n = 12). During day 1-7, Fasciola-like crescents in the gallbladder or passing through the bile duct were detected in another 15 patients, impaired gallbladder contractility in 16, gallbladder tenderness in 16, and bile duct dilatation in an additional 28 patients. Thirty-two patients with these US abnormalities experienced colic-like abdominal pain accompanied by increased alkaline phosphatase in 25 cases. During day 30-60, abnormalities regressed completely in 45 patients; 2/6 triclabendazole failures were evident by detection of living parasites. Biliary tract abnormalities are frequently observed by US, but the detection-rate of Fasciola hepatica is disappointingly low despite the parasite's relatively large size. US findings must therefore be interpreted together with other clinical measurements. The visualization of parasites being expelled through the dilated common bile duct allowed the causal interpretation of post-therapeutic abdominal pain and increase of liver enzymes. When triclabendazole is given on suspicion, visualization of worm expulsion and bile duct dilatation by US may be used to confirm diagnosis.