Biliary ascariasis: surgical aspects

Viability of six species of larval and non-larval helminth eggs for different conditions of temperature, pH and dryness

Helminth eggs are the most difficult biological parasites to inactivate in wastewater and sludge. In developing countries, in particular, they are present in high concentrations and are the cause of many diseases that impact seriously on the human population. The process conditions for affordable inactivation are very variable, leading to different inactivation efficiencies. Temperature, dryness, pH and the developmental stage of the eggs must be taken into consideration to achieve complete inactivation. The objective of this research was to study the inactivation of six species of larval and non-larval helminth eggs of medical importance in developing countries under controlled conditions of temperature, pH, dryness and contact time. Results showed considerable differences in inactivation conditions among helminth eggs and a high level of resistance was confirmed for the eggs of Ascaris lumbricoides and Ascaris suum. The appropriate conditions for inactivation of all types of eggs were found by applying combinations of pH, temperature and dryness. At 45 °C it was possible to inactivate all species with a pH of 5.3 and 90% dryness within 6 days. If alkalization was applied, a pH of 12.7 was sufficient over 19 days at the same conditions of dryness and temperature. From these results it is proposed that both Ascaris spp. and Taenia solium may be used as indicators of biological contamination in wastewater and sludge.

Risk factors for hilar cholangiocarcinoma: A case-control study in China

AIM: To study the association between hilar cholangiocarcinoma (HC) and pre-existing medical conditions.

METHODS: Three hundred and thirteen HC patients admitted to the Eastern Hepatobiliary Surgery Hospital (Shanghai, China) in 2000-2005 and 608 healthy controls were enrolled in this study. Association between HC and pre-existing medical conditions was studied with their adjusted odds ratio (OR) calculated by logistic regression analysis.

RESULTS: The prevalence of choledocholithiasis (adjusted OR = 2.704, P = 0.039), hepatolithiasis (adjusted OR = 3.278, P = 0.018), cholecystolithiasis (adjusted OR = 4.499, P < 0.0001), cholecystectomy (adjusted OR = 7.012, P = 0.004), biliary ascariasis (adjusted OR = 7.188, P = 0.001), liver fluke (adjusted OR = 10.088, P = 0.042) and liver schistosomiasis (adjusted OR = 9.913, P = 0.001) was higher in HC patients than in healthy controls.

CONCLUSION: Biliary tract stone disease (choledocholithiasis, hepatolithiasis, cholecystolithiasis) and parasitic liver disease (biliary ascariasis, liver fluke, liver schistosomiasis) are the risk factors for HC in Chinese population.

Ascariasis in the hepatobiliary system: laparoscopic management

BACKGROUND

Ascariasis is an endemic disease in developing countries. The parasite can invade the hepatobiliary tree and cause symptoms. Medical therapy can be ineffective in these patients and intervention techniques required.

STUDY DESIGN

A retrospective review of patient charts between February 1992 and February 2007 in the Hospital Latinoamericano, Cuenca, Ecuador, was performed to identify patients having surgical or endoscopic treatment for hepatobiliary ascariasis. Patient demographics, treatment algorithms, and outcomes are described and analyzed.

RESULTS

There were 13 cases of hepatobiliary infestation by ascaris treated through endoscopy or operation. All patients presented with colicky abdominal pain in the right upper quadrant. Hepatic and biliary ultrasonography identified parasites in 12 patients. In the other patient, a hepatic abscess containing ascaris was found incidentally during cholecystectomy. There were 11 patients with ascariasis in the common bile duct, 1 in whom the cystic duct was occluded, causing acute cholecystitis. In 12 patients, conservative management was attempted and was unsuccessful. Endoscopic extraction was successful in four of these patients. Six patients underwent laparoscopic cholecystectomy, common bile duct exploration with parasite extraction, and T-tube placement. Parasite extraction through common bile duct exploration followed by primary closure was performed in one patient. Cholecystotomy and parasite extraction followed by cholecystectomy were performed in one patient. The final patient had cholecystectomy and parasite extraction from a liver abscess without earlier medical therapy.

CONCLUSIONS

Ascariasis in the hepatobiliary system should be considered in the differential diagnosis of upper abdominal pain for patients in populations at risk. When an operation is indicated, it can be accomplished by endoscopic or laparoscopic approach.

Prevalence of biliary ascariasis and its relation to biliary lithiasis

Hepatobiliary ultrasound was carried out on 2224 consecutive patients at the Center for Nuclear Medicine and Ultrasound and at one private diagnostic center in Mymensingh for ultrasound examination of different systems. The purpose of this study was to investigate the prevalence of biliary ascariasis and its association with other biliary diseases, specially biliary lithiasis. Data regarding the presence of stone, worm or other diseases were recorded accordingly in this prospective study. There were 952 male and 1272 female patients with an age range of 5-90 years. Biliary diseases were detected in 305 patients (13.71%), of whom 97 were male (10.19%) and 208 were female (16.35%). The most common biliary disease in both sexes was cholelithiasis (11.87%), which was found in 84 male patients (8.82%) and in 180 female patients (14.15%). Other diseases found were choledocholithiasis in 14 patients (3 males, 11 females), gall bladder mass in 9 patients (3 males, 6 females), common bile duct mass in 7 patients (4 male, 3 female) and biliary ascariasis in 10 patients (3 male, 7 female). Overall prevalence of biliary ascariasis was 0.45% (0.31% in male patients and 0.55% in female patients), and age range of patients with the condition was 6-50 years. No case of biliary ascariasis was associated with cholelithiasis or choledocholithiasis. Acute cholecystitis was associated with 8 cases (80%) of biliary ascariasis. Common sonographic findings in patients with biliary ascariasis were a single long, linear or curved echogenic structure within the bile duct, without acoustic shadowing. Other findings were gall bladder distention with sludge inside, an edematous wall and mildly dilated biliary tree. Prevalence of biliary ascariasis in the study was 0.45%, with incidence being higher in female subjects (0.55%). No correlation was found between biliary ascariasis and biliary lithiasis. Most of the cases of biliary ascariasis were associated with acute cholecystitis. We concluded that a careful search for biliary ascariasis should be considered for patients with acute acalculus cholecystitis, especially in areas in which ascariasis is endemic, such as Bangladesh.

Management of hepatobiliary and pancreatic ascariasis in children of an endemic area

Ascariasis is the most common parasitic infestation in endemic areas and accounts for 50-60% of pediatric admissions in the surgical emergency department. Hepatobiliary and pancreatic ascariasis accounts for about 10% of such admissions. The present study was undertaken to evaluate the clinical features, investigations, and management of hepatobiliary and pancreatic ascariasis. The study was conducted in the endemic areas of Kashmir in northern India over a period of 3 years. During the study period (May 2001 to April 2004), 214 children with hepatobiliary and pancreatic ascariasis were admitted in the department. These children underwent complete clinical evaluation, investigation including ultrasound, and ERCP when required. Surgical intervention was done in patients who failed to settle with medical treatment. Ninety percent of our admissions were from rural areas and 86% of the children presented with pain in the right hypochondrium. Twenty-two percent of patients presented with cholangitis, whereas 39% of the children had mild icterus at presentation. Thirty-eight percent of the children had vomited worms during the episode of illness. Ultrasound was the diagnostic method of choice, which revealed the worms in the CBD in 80% of the patients, and in gall bladder in 16% of the children. Eight patients had worms in the main pancreatic duct while seven (4%) had multiple small liver abscesses. Serum alkaline phosphatase was raised in majority of children (80%). Twenty (9%) children were referred for ERCP. Medical treatment including endoscopic management was successful in 97% of the children. Seven (4%) children had to be operated upon due to complications of the disease. We conclude that the majority of the children with hepatobiliary and pancreatic ascariasis respond to conservative treatment, and surgical treatment is rarely needed.

Management of biliary ascariasis in pregnancy

Ascariasis is a helminthic infection of humans caused by the nematode Ascaris lumbricoides. Biliary ascariasis is one of the most common and well described entities caused by ascaris. In endemic areas pregnant women are prone to develop biliary ascariasis. Its management poses a great challenge to both the attending surgeon and the endoscopist. Between January 1993 and March 2003, 15 cases of biliary ascariasis were seen in pregnant patients in our institution. Ultrasonography was used as the main investigative tool. Treatment involved management by conservative, endoscopic, and surgical methods, taking due care of both the mother and the fetus. Ten patients (66.6%) were in the third trimester of pregnancy, and 10 (66.6%) patients were in their third pregnancy. Ultrasonography proved to be the best tool for diagnosing and monitoring worms inside the biliary ductal system. Nine (60%) patients responded to the conservative treatment; endoscopic extraction was successful in 4 (66.6%) patients. Surgical treatment was required in 2 (13.3%) patients. One (6.6%) patient had had spontaneous abortion at 12 weeks gestation, and one (6.6%) patient had a premature labor. The remaining patients had normal pregnancies. Management of biliary ascariasis in pregnancy is a challenge for both the attending surgeon and the endoscopist. Safe and effective management requires special attention to the gestational age and accurate recognition of the specific pathology in the patient. The majority of patients respond to conservative treatment, but endoscopic extraction may be needed in nonresponsive cases. Lead shielding of the fetus and limitation of the total fluoroscopic exposure during therapeutic endoscopy can minimize the teratogenic risk of ionizing radiation. Failures of endoscopic extraction may lead to surgical intervention, which carries risks of fetal wastage and premature labor. Routine worming of women in the child-bearing years is recommended in endemic areas of ascariasis. Though ascariasis is a problem in developing countries, because of increased travel and population migration, clinicians elsewhere should be aware of the problems associated with ascariasis.

Biliary ascariasis: percutaneous transhepatic management

In a 60-year-old woman who underwent cholecystectomy and T-tube drainage for biliary ascariasis, postoperative bilirubin levels continued to increase. T-tube cholangiography revealed multiple filling defects in the bile ducts, which suggested roundworm reinfestation. Because the patient could not tolerate endoscopy, a percutaneous transhepatic approach with balloon dilatation of the ampulla of Vater and subsequent advancement of roundworms into the duodenum with an embolectomy balloon was used. The procedure was successful, with no major complications. The use of a percutaneous transhepatic treatment to advancement of roundworms into the duodenum is a feasible alternative to surgery when endoscopic extraction fails.

An unusual presentation of acute cholecystitis: biliary ascariasis

A 37-year-old Malay lady from the state of Pahang was admitted to the surgical unit with colicky upper right quadrant abdominal pain radiating to the right shoulder and scapula region. This was accompanied by nausea and vomiting. She needed intramuscular analgesics for the pain. There was no past history of similar episodes. Clinically, she was not icteric, and examination of the abdomen revealed marked tenderness and guarding over the upper right quadrant with a positive Murphy's sign. Clinical diagnosis of acute cholecystitis was made, and she was commenced on intravenous antibiotics.

Sonographic diagnosis of Ascaris-induced cholecystitis and pancreatitis in a child

We describe the sonographic diagnosis of Ascaris-induced acute cholecystitis and pancreatitis in a 2-year-old girl. Abdominal sonography revealed a grossly distended gallbladder with a thick (0.5-cm) wall. The common bile duct was dilated to 0.6 cm without sludge or calculi. The pancreas was hypoechoic, with an enlarged, 3.3-cm pancreatic head. Sonography showed dilatation of the small- and large-bowel loops, with multiple roundworms in duodenal and colonic loops. Sonography has an important role not only in the diagnosis of this uncommon condition but also in the documentation of its unusual etiologic agent.

Pharmacotherapy of ascariasis

Ascaris lumbricoides, the most frequent human intestinal nematode, is the causative agent of ascariasis, with an estimated worldwide prevalence of over one billion people, especially in moist tropical and subtropical regions, but also in cooler climates. Although characterised with low morbidity and mortality rates, the global prevalence of ascariasis still results in approximately 20,000 deaths annually, primarily as a consequence of intestinal obstruction. In humans, transmission usually occurs by hand-to-mouth route by way of contaminated agricultural products and food, or from dirty hands. Three phases of ascariasis may be present, namely, the pulmonary, intestinal and the complications stage. Although generally asymptomatic, heavy infestation may cause serious pulmonary disease, or partial or complete obstruction of biliary or intestinal tracts. Anthelminthic chemotherapy is required to eradicate the parasites and prevent potentially serious complications. Mebendazole, albendazole and pyrantel pamoate are the most widely used agents to treat ascariasis. Preventive chemotherapy delivered to communities in endemic regions may serve as an affordable and cost-effective strategy to reduce the prevalence and morbidity in endemic regions. Under unusual circumstances, Ascaris suum, the cause of helminthic infection in pigs, may also cause disease in humans.

Biliary ascariasis after Roux-en-Y hepaticojejunostomy

The authors report on a 6-year-old girl with biliary ascariasis after surgical treatment of a choledochal cyst and biliary-digestive tract reconstruction by Roux-en-Y hepaticojejunostomy. A precise diagnosis can be obtained by ultrasonography. Surgical treatment is required when clinical and endoscopic treatments fail. In countries in which this disease is endemic, biliary ascariasis should be considered in the differential diagnosis of cholangitis after surgery for hepaticojejunostomy.

Subparietal hepaticojejunal access loop for the long-term management of intrahepatic stones

BACKGROUND

The subparietal hepaticojejunal biliary access loop is a recognized technique for the long-term management of primary intrahepatic stone disease. This paper assesses the results of this approach in a series of South African patients.

METHODS

Between 1985 and 1997, 21 patients, of mean age 34 (range 24-66) years, underwent surgical extraction of intrahepatic stones and formation of an hepaticojejunal access loop. The access loop was subsequently used for further stone removal and stricture dilatation. Patients were followed prospectively (median 47 months) and details of the number and type of procedures performed, stone clearance rates, morbidity and subsequent outcome were recorded.

RESULTS

The distribution of intrahepatic stones was left lobe in 13 of 21 patients, right lobe in one and bilateral in seven. Six patients underwent additional left lobectomy at the initial operation because of associated atrophy of the left lobe. Following operation, stone removal and/or stricture dilatation was performed on 97 occasions (median 4 (range 0-24) procedures per patient). Complete stone clearance was achieved in 17 of 21 patients with partial clearance in the remaining four. There were no major complications and no deaths associated with the procedures.

CONCLUSION

The subparietal access loop permits long-term access to the intrahepatic ducts allowing removal of stones and dilatation of strictures with minimal patient discomfort and low morbidity.

Management of hepatobiliary and pancreatic Ascaris infestation in adults after failed medical treatment

BACKGROUND

The roles of endoscopy and surgery in the management of Ascaris lumbricoides affecting the hepatobiliary and pancreatic system in adults were determined.

METHODS

All patients undergoing endoscopic retrograde pancreatography for ascariasis of the biliary or pancreatic system unresponsive to standard medical therapy were analysed. Worms were extracted using snare, Dormia basket or biopsy forceps. Success was defined as clearance of worms and eradication of symptoms.

RESULTS

Endoscopic extraction was performed in 25 patients with success in 19. Failures occurred in one patient with Ascaris in the gallbladder, and in five with associated strictures or stones. All six patients were treated successfully by surgery.

CONCLUSION

Endoscopy was successful in the treatment of Ascaris infestation resistant to medical therapy in 19 of 25 patients. Surgery remains important in the management of infestations complicated by biliary or pancreatic strictures and stones, or worms in the gallbladder.

Ascaris peritonitis and peritoneal granuloma in China

This article is a survey of the Chinese literature of perforation of gastrointestinal tract by ascaris. We wish to draw attention to the acute abdominal disease of ascaris infection, and acute ascaris peritonitis as a result of perforation, most cases being found in children. The disease has very high morbidity (24/112; 21.4%) and high mortality (17/112; 15.2%). Early detection and operation are of critical importance. Perforation of gastrointestinal tract by ascaris may develop into peritoneal granuloma, which has a different clinical presentation and outcome.

Morbidity and mortality due to Ascaris-induced intestinal obstruction

We examined epidemiological aspects of Ascaris-induced intestinal obstruction (AI-IO) through analysis of published reports on the subject. In 9 studies of > or = 100 patients admitted to hospital due to ascariasis, intestinal obstruction was the single most common complication and accounted for 38-87.5% of all complications (weighted mean 72%). The proportion of intestinal obstruction caused by ascariasis was identified in 14 studies from 7 countries with varying degrees of endemic ascariasis. Using relevant data on the duration of the study, the number of beds in the reporting hospital, and the number of hospital beds/1000 population in the area, the number of cases of AI-IO/year/1000 population was estimated from 11 studies. Both the proportion of AI-IO (range 0-0.71) and the number of cases of AI-IO/year/1000 population (range 0-0.25) were significantly related, in a non-linear manner, to the local prevalence of ascariasis (range 0.01-0.92). In 12 studies of > or = 30 patients with AI-IO, the case fatality rates ranged from 0 to 8.6% (weighted mean 5.7%). The mean age of patients with AI-IO was < or = 5 years in 6 of 7 studies in which age was specified.

Forty-two patients with acute ascaris pancreatitis in China

Acute pancreatitis caused by Ascaris lumbricoides is more common in certain areas than is generally appreciated. We report a series of 42 patients, mostly young adult women, admitted to our hospital in Hunan Province, China, during the period January, 1983 to December, 1992. The diagnosis was based on the detection of worms by ultrasonography, and on the presence of severe upper abdominal pain and tenderness and raised serum amylase level without other apparent causes. Only 2 patients had necrotizing pancreatitis (4.8%). With our conservative policy, 40 patients recovered and 2 patients were operated. The mortality has remained at zero and we therefore believe that early surgical intervention is unwise. However, laparotomy should be performed if the patient fails to respond to conservative therapy, there is evidence of infection around the pancreas, bloody peritoneal fluid on aspiration, and dead worms remain within the biliary tree. We compare acute ascaris pancreatitis with acute pancreatitis caused by lithiasis.