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

Extra-intestinal complications of Ascaris lumbricoides infections in India: A systematic review and meta-analysis

The aberrant migration of Ascaris lumbricoides may cause extra-intestinal ascariasis (EIA) involving hepato-biliary-pancreatic (HBP) or other extra-gastro-intestinal (EGI) organs. We performed a systematic review and meta-analysis to study the risk factors and clinical presentations of EIA, and differences in HBP and EGI ascariasis. Medline, Web of Science and Embase were searched for cases of EIA in the English language from India. From 1204 articles, 86 studies (105 cases) were included. The majority of the cases involved the HBP system (78%). Among HBP ascariasis, the most commonly involved site was the bile duct (53.6%). Females had 11.3 times higher odds (95% CI 2.852 to 44.856; p=0.001) of HBP ascariasis, while the pediatric population had lower odds (OR=0.323). Previous gallbladder disease was significantly associated with HBP ascariasis in adults (p=0.046), while a significantly higher number of cases of EGI ascariasis were observed among pediatric patients (p=0.003). Ocular symptoms occurred exclusively in the pediatric population (p=0.017). Overall, death was reported in 3.8% of patients (n=4). This review emphasizes the importance of the complications of EIA. It encourages future research into issues such as the reasons of higher gall bladder ascariasis in females and the implications of Ascaris-related complications following biliary tract interventions. It also suggests considering Ascaris as a differential diagnosis for airway obstuction in intubated critically ill patients.

My 40-Year Encounter with ERCP: A Saga of Service, Syndromes, and Solutions

Endoscopic retrograde cholangiopancreatography (ERCP) has been a significant development in gastrointestinal endoscopy. I did my first ERCP at SKIMS on December 5, 1982, and over the last 40 years, I have performed 10,100 ERCP procedures, including 600 Sphincter of Oddi manometries (SOM), and 3200 therapeutic ERCPs. We were confronted with many clinical challenges that needed answers by applying ERCP as a primary diagnostic tool. These studies gave birth to and/or recognition of several clinical syndromes. The hepatobiliary and pancreatic ascariasis (HBPA) as a clinical disease was recognized in 1985. The nematode, Ascaris lumbricoides, was the most common cause of hepatobiliary and pancreatic diseases in Kashmir, and its impact on healthcare, clinical profile, management policies, and control measures was identified. Kashmir was recognized as an endemic zone for recurrent pyogenic cholangitis (RPC), which constituted 12.5% of all biliary diseases. RPC in this population was found essentially to be an aftermath of HBPA. A subset of patients with hepatic hydatidosis with rupture into the biliary tract was recognized at ERCP and primarily treated by endotherapy. Cholangiographic abnormalities in children with portal cavernoma evolved into the recognition of portal biliopathy. Extensive studies of the sphincter of Oddi manometry in patients with unexplained biliary and/or pancreatic pain following cholecystectomy identified the entity of the sphincter of Oddi dyskinesia (SOD). In a cross-over trial, Nifedipine, compared with a placebo, showed a significant clinical response in 20 of 28 such patients. ERCP studies done in patients with tropical calcific pancreatitis showed an anomalous union of bile and pancreatic ducts. Forty of the 220 patients with liver transplantation had biliary complications namely biliary leaks, bile duct strictures, SOD, and recurrence of underlying primary biliary cholangitis. Biliary complications caused considerable morbidity and mortality in patients with liver transplantation.

[Ascaris lumbricoides-induced pancreatic lesion]

Ascaris lumbricoides is nematode localized in human small bowel in most cases. This nematode is capable for migration. Pancreatitis is one of the most common surgical diseases. One of the causes of this pancreatitis may be migration of Ascaris lumbricoides from small bowel through the major duodenal papilla to the pancreatic ducts. This migration is provided by complex of morphological and functional disorders of digestive system associated with this helminthiasis, as well as certain risk factors. These are previous cholecystectomy, sphincterotomy, living in endemic areas, massive Ascaris lumbricoides invasion, pregnancy. Damage of the pancreas develops due to direct mechanical effect of nematodes and allergic reactions, papillitis and functional disorders of digestive tract. Pancreatitis is usually mild, but severe course of disease is also possible. A typical symptom of pancreatitis caused by Ascaris lumbricoides is helminths in vomit and/or feces.

Application of Ultrasonography in the Diagnosis of Infectious Diseases in Resource-Limited Settings

Ultrasound (US) has vast potential in the field of infectious diseases, especially so in resource-limited settings. Recent technological advances have increased availability and access to ultrasound in low-resource settings, where the burden of infectious diseases is greatest. This paper collates the evidence for the utilization of ultrasound and evaluates its effectiveness in the diagnosis and management of a range of infectious diseases. This paper explores the role of ultrasound in population-based screening for specific diseases as well as highlights its benefits for individual patient management. We describe the common diagnostic signs seen on US for common and neglected parasitic, bacterial, and viral diseases. We proceed to document the emerging field of chest US which is proving to be a superior imaging modality for the diagnosis of specific pulmonary conditions. We conclude by discussing the efforts needed to formalize and rigorously evaluate the role of ultrasound in infectious diseases.

Ascariasis of the pancreatic duct

Ascariasis is a common helminthic disease worldwide, although Lithuania and other European countries are not considered endemic areas. The presence of the Ascaris worm in the biliary tree causes choledocholithiasis-like symptoms. We report a case of pancreatic duct ascariasis causing such symptoms. A 73-year-old Lithuanian woman underwent endoscopic retrograde cholangiopancreatography (ERCP) suspecting choledocholithiasis. Contrast injection into the common bile duct demonstrated a slightly dilated biliary tree without any filling defects, and the tail of an Ascaris worm protruding from the opening of the papilla Vater. The worm was captured by a snare but escaped deep into the duct. After a small wirsungotomy the worm was retrieved from the pancreatic duct. The patient received a 150 mg dose of levamisole orally repeated 7 days later and was discharged after complete resolution of symptoms. This first reported sporadic case of pancreatic duct ascariasis in Lithuania was successfully treated with ERCP and Levamisole.

Biliary ascariasis in the Indian subcontinent: a study of 42 cases

BACKGROUND/AIM

History of ascariasis is known to stretch back many centuries. One quarter of the world's population is known to be infected by ascariasis. It is endemic in various parts of the Indian subcontinent and the gangetic plain of West Bengal is one of them. We aimed to study the various types of clinical presentations, complications and different diagnostic tools and to assess various options for the management of biliary ascariasis.

MATERIALS AND METHODS

Forty-two cases of hepatobiliary ascariasis were studied over a period of 3 years. All the patients were adults aged between 20 and 50 years and all but two were admitted with acute upper abdominal pain.

RESULTS

In this study, biliary ascariasis was found to be more common in females, 73.8% (31 patients). The most common presentation was upper abdominal pain in 95.2% of the patients (40 patients). Complications observed were obstructive jaundice in 28.56% (12 patients), cholangitis in 16.7% (seven patients), acute pancreatitis in 2.4% (one patient) and hepatic abscess in 2.4% (one patient). History of worm emesis was present in 38.1% (16 patients). History of previous cholecystectomy was present in 16.7% (seven patients) and endoscopic sphincterotomy in 4.8% (two patients). Ultrasound was the diagnostic tool of choice with 100% results. Conservative management was successful in 83.3% (35 patients). During follow-up, worm reinvasion of the biliary system occurred in 7.1% (three patients).

CONCLUSION

In endemic countries, ascariasis should be suspected in patients with biliary disease, especially if a cholecystectomy or sphincterotomy has been performed in the past. Most of the patients respond to conservative management.

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.

Ascaridíase hepatobiliar complicada por pneumonia lipoídica

OBJETIVO: Apresentar um caso de ascaridíase hepatobiliar complicado por pneumonia lipoídica e discutir as implicações anestésicas envolvidas. DESCRIÇÃO DO CASO: Menina de dois anos de idade com ascaridíase hepatobiliar complicada por pneumonia lipoídica por aspiração e desnutrição grave, advinda de família em condições sociais precárias em zona rural, com quatro irmãos. Foi tratada com sucesso por uma combinação de lavados broncopulmonares sucessivos e cirurgia. COMENTÁRIOS: Ascaridíase biliar corresponde a cerca de 10% dos casos de complicações de ascaridíase. Apenas uma minoria precisa de tratamento cirúrgico. O uso de óleo mineral por via oral é um tratamento tradicional para a suboclusão intestinal pelo Ascaris lumbricoides, mas a broncoaspiração do óleo e a conseqüente pneumonia lipoídica representam um risco alto para o seu uso. Anestesia geral para laparotomia exploradora em pré-escolar desnutrido com pneumonia lipóide e ascaridíase biliar é uma situação pouco contemplada na literatura médica, o que exigiu um planejamento terapêutico específico.

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.

Ascaridíase biliar complicada: espectro de problemas e táticas cirúrgicas

OBJETIVO: Discutir as variantes clínicas e táticas para tratamento cirúrgico da ascaridíase biliar complicada. MÉTODO: Trabalho retrospectivo de pacientes operados por complicações de ascaridíase biliar num período de cinco anos. RESULTADOS: São descritos quatro casos de ascaridíase biliar complicada em crianças (três pré escolares e um escolar), expressos através de pseudocisto pancreático, icterícia obstrutiva, colangite e múltiplos abscessos hepáticos, todos tratados cirurgicamente. Descrevemos detalhes técnicos da abordagem operatória para cada um dos casos. CONCLUSÕES: O espectro das afecções biliares secundárias à ascaridíase é variável e é necessário um arsenal de táticas operatórias para a abordagem de cada caso. É desaconselhável o uso de anti-helmínticos antes da resolução clínica da invasão da via biliar. A afecção preferencial de crianças jovens exige o uso de técnicas e materiais adequadamente delicados para a manipulação das vias biliares.

Albendazole: a new drug for human parasitoses

In 1961 Brown and his team discovered that thiobendazoles were highly effective against gastrointestinal nematodes. This discovery led to the development of albendazole, the most recent of the benzimidazolic drugs. Albendazole is used against numerous animal and human parasites and it is the authors' first choice as drug treatment of cutaneous larva migrans.

Albendazole: a broad spectrum anthelminthic for treatment of individuals and populations

PURPOSE OF REVIEW

It is over 25 years ago since the original animal research was conducted into albendazole. This review highlights some important steps in fundamental research and the management of helminth disease that have occurred in the past year, appearing in the published literature.

RECENT FINDINGS

In recent years there have been several published studies on lymphatic filariasis and on the impact of albendazole treatment on growth and nutrition. Recent work consolidates some of these data and supplies substantive evidence of benefit especially in the area of hookworm anaemia. Why treatment of helminths actually produces these effects has not been understood, but investigations have begun to highlight the underlying mechanisms that relate to immunity. During the last year several reviews of diagnosis and management of helminth diseases have been published which provide much needed guidance on the effective use of albendazole, and its place in treatment overall. In common with many other parasitic diseases, the validity of using single agents is being challenged, and combination therapy is being investigated at the experimental level and in clinical practice to improve therapeutic responses and to reduce the risk of resistance to the limited range of drugs currently available.

SUMMARY

Albendazole has changed from being a drug for individuals with worms to one to treat communities and provide benefit in public health terms. In systemic parasitic disease, however, albendazole remains a treatment for individuals. Nearly 20 years of research and of clinical use has refined the tool, but new investigations suggest that much additional study is required before we fully understand helminth parasites and the benefits of treating them.

An Update on the Geohelminths: Ascaris lumbricoides, Hookworms, Trichuris trichiura, and Strongyloides stercoralis

Geohelminths remain prevalent throughout the developing world where levels of sanitation, personal hygiene, and maternal education are low. The five species of nematodes responsible for the bulk of disease are Ascaris lumbricoides, the hookworms Ancylostoma duodenale and Necator americanus, Trichuris trichiura, and Strongyloides stercoralis. Geohelminths are acquired through ingestion of fecally contaminated food or water or through contact with infected soil. In developing countries, infection with more than one nematode species and high worm burdens are common. The morbidity is substantial, particularly among children, and deaths occur. Geohelminthic infections are encountered in industrialized countries among immigrants and long-term travelers who have lived in endemic regions where sanitation is poor, and occasionally following autochthonous transmission.