Biliary ascariasis and severe bacterial outcomes: Report of three cases from a paediatric hospital in Brazil

INTRODUCTION

Biliary ascariasis, although uncommon, can lead to infectious complications and severe outcomes. This study reported three patients with biliary ascariasis and who were admitted to a paediatric hospital in Salvador, Brazil.

CASE REPORTS

Case 1: A 1-year-old boy, with HIV, hospitalised with diarrhoea, fever, pain, and abdominal distension. He underwent an exploratory laparotomy, which showed peritonitis secondary to a perforation of the hepatic duct by ascaris. Case 2: A 3-year-old boy admitted with fever, abdominal pain and jaundice. Imaging examination was suggestive of ascaris in the intrahepatic biliary tract and a hepatic abscess. Case 3: A 7-year-old boy who was hospitalised with a history of abdominal colic, jaundice and fever, with a suggestive image of ascaris in the biliary tract and evolution to sepsis.

DISCUSSION

Three cases of biliary ascariasis were reported with severe infectious complications involving peritonitis, hepatic abscess and sepsis.

CONCLUSION

In endemic regions, biliary ascariasis should be considered in cases with jaundice, abdominal pain and fever, due to its morbidity and risk of complications.

Fasciola hepatica-a "Diver" in the Biliary Tree

Fasciola hepatica is an endemic trematode that affects millions of people worldwide. The human being can be an accidental host through consumption of contaminated food or water. The authors present a case of hepatic fascioliasis in a 69-year-old Portuguese woman who recently traveled from Egypt, Brazil, and India.

Emergence of the Zoonotic Biliary Trematode Pseudamphistomum truncatum in Grey Seals (Halichoerus grypus) in the Baltic Sea

The biliary trematode Pseudamphistomum truncatum parasitizes a wide range of fish-eating mammals, including humans. Here we report the emergence of this parasite in grey seals (Halichoerus grypus) in the Baltic Sea. One hundred eighty-three of 1 554 grey seals (11.9%) examined from 2002-2013 had detectable hepatobiliary trematode infection. Parasite identification was confirmed as P. truncatum by sequencing the ITS2 region of a pool of five to 10 trematodes from each of ten seals collected off the coast of seven different Swedish counties. The proportion of seals parasitized by P. truncatum increased significantly over time and with increasing age of seals. Males were 3.1 times more likely to be parasitized than females and animals killed in fishery interactions were less likely to be parasitized than animals found dead or hunted. There was no significant difference in parasitism of seals examined from the Gulf of Bothnia versus those examined from the Baltic Proper. Although the majority of infections were mild, P. truncatum can cause severe hepatobiliary disease and resulted in liver failure in at least one seal. Because cyprinid fish are the second intermediate host for opisthorchiid trematodes, diets of grey seals from the Baltic Sea were analysed regarding presence of cyprinids. The proportion of gastrointestinal tracts containing cyprinid remains was ten times higher in seals examined from 2008 to 2013 (12.2%) than those examined from 2002 to 2007 (1.2%) and coincided with a general increase of trematode parasitism in the host population. The emergence and relatively common occurrence of P. truncatum in grey seals signals the presence of this parasite in the Baltic Sea ecosystem and demonstrates how aquatic mammals can serve as excellent sentinels of marine ecosystem change. Investigation of drivers behind P. truncatum emergence and infection risk for other mammals, including humans, is highly warranted.

Hepatobiliary complications of alveolar echinococcosis: A long-term follow-up study

AIM: To determine the long-term hepatobiliary complications of alveolar echinococcosis (AE) and treatment options using interventional methods.

METHODS: Included in the study were 35 patients with AE enrolled in the Echinococcus Multilocularis Data Bank of the University Hospital of Ulm. Patients underwent endoscopic intervention for treatment of hepatobiliary complications between 1979 and 2012. Patients’ epidemiologic data, clinical symptoms, and indications for the intervention, the type of intervention and any additional procedures, hepatic laboratory parameters (pre- and post-intervention), medication and surgical treatment (pre- and post-intervention), as well as complications associated with the intervention and patients‘ subsequent clinical courses were analyzed. In order to compare patients with AE with and without history of intervention, data from an additional 322 patients with AE who had not experienced hepatobiliary complications and had not undergone endoscopic intervention were retrieved and analyzed.

RESULTS: Included in the study were 22 male and 13 female patients whose average age at first diagnosis was 48.1 years and 52.7 years at the time of intervention. The average time elapsed between first diagnosis and onset of hepatobiliary complications was 3.7 years. The most common symptoms were jaundice, abdominal pains, and weight loss. The number of interventions per patient ranged from one to ten. Endoscopic retrograde cholangiopancreatography (ERCP) was most frequently performed in combination with stent placement (82.9%), followed by percutaneous transhepatic cholangiodrainage (31.4%) and ERCP without stent placement (22.9%). In 14.3% of cases, magnetic resonance cholangiopancreatography was performed. A total of eight patients received a biliary stent. A comparison of biochemical hepatic function parameters at first diagnosis between patients who had or had not undergone intervention revealed that these were significantly elevated in six patients who had undergone intervention. Complications (cholangitis, pancreatitis) occurred in six patients during and in 12 patients following the intervention. The average survival following onset of hepatobiliary complications was 8.8 years.

CONCLUSION: Hepatobiliary complications occur in about 10% of patients. A significant increase in hepatic transaminase concentrations facilitates the diagnosis. Interventional methods represent viable management options.

Biliary ascariasis in a bile duct stones-removed female patient

Biliary ascariasis is a common problem in rural areas in China. The common presentations include biliary colic, acute cholangitis, obstructive jaundice, choledocholithiasis and acute cholecystitis. Here, we describe a case with biliary ascariasis two days after endoscopic sphincterotomy for choledocholithiasis. A living ascaris was successfully removed by endoscopic retrograde cholangiopancreatography. This case indicated that biliary ascariasis is not an uncommon complication of endoscopic sphincterotomy in some regions where ascariasis is epidemic.

Sonographic features of intestinal and biliary ascariasis in childhood: case report and review of the literature

Despite the fact that Ascaris lumbricoides is one of the commonest intestinal infections in developing countries, there are very few reports in the literature about the sonographic findings of intestinal and biliary ascariasis in childhood. The clinical manifestations, diagnostic procedures and imaging appearance of intestinal and biliary ascariasis in two patients are discussed with a brief review of the literature.

Human fascioliasis with biliary complications

We report a case of human fascioliasis adding to the few of the previously reported cases in India. A young boy from rural background in Bihar presented with diarrhea, vomiting, hepatic tenderness, jaundice and fever along with peripheral eosinophilia. Examination of stool revealed yellow-brown eggs of Fasciola hepatica. Human fascioliasis should be kept in mind in patients with cholangitis and eosinophilia especially in areas of sporadic occurrence.

Biliary ascariasis--role of endoscopic intervention

AIM

This study was undertaken to review the predisposing factors, presentation and management of patients diagnosed with biliary ascariasis while specifically emphasizing the role played by endoscopy.

METHODS

We performed a retrospective analysis of nine patients diagnosed and admitted with biliary ascariasis at our center. The diagnosis was based on ultrasound findings and confirmed by detection of round worms in the biliary tract or the descending duodenum. The clinical presentation and management were reviewed.

RESULTS

Five of the nine patients had prior biliary sphincter ablative/bypass procedures for choledocholithiasis; including endoscopic sphincterotomy in four and lateral choledochoduodenostomy in one patient. All but one patient presented with acute onset pain abdomen radiating to the back. One patient presented with features of acute cholecystitis. Ultrasound detected the presence of round worms in all the patients. Endoscopic retrograde cholangio-pancreatogram confirmed presence of worm in the biliary tree. Endoscopic extraction of the worm from the biliary tree or duodenum was successfully undertaken in all the patients and provided prompt relief. One patient had recurrence of infection after eight months which was re-treated by endoscopic extraction. Antihelminthics were instituted in all patients.

CONCLUSION

Biliary ascariasis, should be considered in the differential diagnosis of acute abdomen, particularly in patients who have undergone prior biliary sphincter ablation/bypass procedures like sphincterotomy or choledochoduodenostomy. Ultrasonography is a reliable diagnostic modality. Endoscopic retrograde cholangiogram confirms the diagnosis and precedes endoscopic extraction of the worm. This offers prompt relief from symptoms.

Comparative study on presentation of biliary ascariasis with dead and living worms

BACKGROUND/AIM

Ascariasis is a common parasitic infestation in Asia and Latin America. The most serious presentation is biliary and pancreatic ascariasis (BPA). The aim of the present study was to compare the clinical presentation of BPA with dead worms with that with living worms.

MATERIALS AND METHODS

We included 138 consecutive cases of BPA that occured during the period January 2005 to July 2009. All the patients had endoscopically proven BPA consisting of living or dead worms. Comparison was done by chi-square and independent t tests.

RESULTS

The age (mean +/- SD) of the patients was 36.8 +/- 16.1 years. Prevalence ratio between male and female patients was 1:5. Ninety eight patients contained living worms and 40 had dead worms. Males were more prone to develop dead worm BPA. The commonest presentation was biliary colic (131; 94.9%); others were acute cholangitis (30; 21.7%), obstructive jaundice (19; 13.8%), choledocholithiasis (20; 14.5%), acute pancreatitis (10; 7.2%), acute cholecystitis (6; 4.3%), liver abscess (2; 1.4%), hepatolithiasis (3; 2.2%), stricture of common bile duct (2; 1.4%), pancreatic abscess (1; 0.7%) and cirrhosis of liver (1; 0.7%). Choledocholithiasis, hepatolithiasis, liver abscess and cirrhosis were associated only with dead worms. We could successfully remove all the worms with endoscopic interventions, but 5 patients required surgical intervention as there were strictures and stones within the biliary tree or Ascaris were in gallbladder. Recurrences of stone and cholangitis occurred only in those with dead worms.

CONCLUSION

Biliary ascariasis with dead worms is more dangerous than that with living worms. Endoscopic or surgical intervention may be required repeatedly in those with dead worms.

[Coincidental finding of biliary ascariasis]

We describe a case of biliary ascariasis in a 27-year-old Philippine au-pair with recurrent upper abdominal pain. Hepatobiliary ascariasis is rarely seen in non-endemic areas. The diagnosis is important because severe complications can occur. If migrated into the biliary tree, it is recommended to perform endoscopic extraction combined with antihelmintic therapy. In severe cases, the recommendation is laparoscopic cholecystectomy and peroperative exploration of the common hepatic duct.

[Principles of therapy of hepatobiliary and pancreatic pathology in elderly people with chronic opisthorchiasis]

THE PURPOSE OF RESEARCH: studying of features of clinical current, diagnostics, treatment chronic opisthorchiasis at persons of elderly and senile age. 117 patients are surveyed. In bile in 100% of cases, a sladg-syndrome in 66.6%, infringement of motor function of a bilious bubble in 92.3%, macrobiocenosis in 98.3%, an allergic syndrome--microscopic changes are found out in 93%. The diagnostic importance of triad Paltseva at observable patients is confirmed. It is shown, that chronic [Russian characters: see text] is system disease at which leading value the pathology hepatobiliar and pancreatic system has.

[Intrabiliary rupture of hepatic hydatid cysts: results of 17 years' experience]

Between 1990 and 2006 in the III-rd Surgical Clinic Cluj-Napoca, 366 pacients with hepatic hydatid cyst were admitted and underwent surgery; 81 (22.13%) of them, who had a cyst-biliary comunication, were retrospectively reviewed: 52 (64.2%) had an occult communications and 29 (35.8%) had a frank intrabiliary rupture. The sex ratio was M/F=46/35 with a mean age of 44.5 years and with ages between 17 and 73 years. Choledochotomy, evacuation of parasitic material and lavage of the CBP were performed in all patients with frank intrabiliary rupture. In 25 patients, partial pericystectomy and choledochoduodenostomy/T-tube drainage of CBP was performed. Internal drainage by a Roux-en-Y pericystectojejunostomy and biliodigestive anastomosis was carried out in 2 patients, while other two patients underwent external drainage of cystic cavity and T-tube drainage of CBP. 15 patients (51.7%) had postoperative external bile leaks (fistulas). Occult communications were managed by partial pericystectomy +/- narrowing of the residual cavity (capitonage with an omentum flap or invagination of the fibrosis capsule margins into the cavity) in 35 patients (67.3%) while in 10 patients (19.2%) internal drainage by a Roux-en-Y pericystectojejunostomy was carried out. Regional resection of the liver was performed in 4 cases (7.7%) and external drainage of residual cavity in 3 patients (5.7%). 13 patients (25%) had postoperative external bile leaks (fistulas). The mean postoperative hospitalisation was 20 days with the range 5-85 days. The mortality rate was 2.4% (2 patients): one died due to septicemia and MOFS and the other due to pulmonary thromboembolism.

CONCLUSION

Postoperative bile leaks (fistulas) fallowing conservative surgery of ruptured hydatid hepatic cyst into the biliary tract are not rare regardless of the type of rupture (frank or occult). Although the opening of the biliary duct is sutured, the risk of biliary fistulas is not clearly corelated with this approach; in such cases internal drainage provides a good alternative with low morbidity.

Myxidium scripta n. sp. identified in urinary and biliary tract of Louisiana-farmed red-eared slider turtles Trachemys scripta elegans

During a necropsy investigation of a mortality event occurring at a turtle farm in Assumption Parish, Louisiana, spores of a myxozoan were identified in the renal tubules in 3 of 6, the gall bladder lumen in 2 of 6, and the bile ductule in 1 of 6 red eared slider turtles Trachemys scripta elegans. In total, myxozoa were identified in 4 of 6 turtles. In 1 turtle, renal tubules contained numerous mature spores, had epithelial hyperplasia, granulomatous transformation, compression of adjacent tubules and interstitial lymphocytic nephritis. The genus of myxozoan was Myxidium, based on spore morphology in cytological preparations, in histologic section, and by electron microscopy. In cytological preparation the spores had mean dimensions of 18.8 x 5.1 microm and a mean polar capsule dimension of 6.6 x 3.5 microm. Electron microscopy showed renal tubules contained plasmodia with disporoblasts with spores in various stages of maturation. Ultrastructure of mature spores demonstrated a capsule containing 2 asymmetrical overlapping valves and polar capsules containing a polar filament coiled 6 to 8 times and surrounded by a membrane composed of a double layer wall. The small subunit rDNA gene sequence was distinct from all other Myxidium species for which sequences are available. Additionally, this is the first Myxidium species recovered from a North American chelonian to receive genetic analysis. Although T. s. elegans is listed as a host for Myxidium chelonarum, this newly described species of Myxidium possessed larger spores with tapered ends; thus, we described it as a new species, Myxidium scripta n. sp. This report documents a clinically significant nephropathy and genetic sequence from a Myxidium parasite affecting a freshwater turtle species in North America.

Presentation and endoscopic management of biliary ascariasis

Ascaris lumbricoides is a common parasite and the most serious and dramatic presentation is hepatobiliary and pancreatic ascariasis (HPA). Therefore, this study was planned prospectively to elucidate the clinical presentation of HPA and evaluate the efficacy and safety of endoscopic intervention. In this study we documented 77 consecutive patients with HPA from January 2000 to November 2005. All the patients had endoscopically proven HPA. A total of 77 patients were included in the study. The age ranged from 6 to 80 years, with the third decade most commonly (28.6%) affected. Females were 6 times more likely to be affected than males. The commonest presentation was biliary colic (97.4%); other presentations were acute cholangitis (15.6%), obstructive jaundice (9.1%), acute pancreatitis (6.5%), choledocholithiasis (6.5%), acute cholecystitis (6.5%) and liver abscess (2.6%). In this report 51 (66.2%) had living, 10 (13%) had dead and 16 (20.8%) had both living and dead worms. Choledocholithiasis was associated only with dead worms. From one to 23 worms were found in the biliary tree. In 94.8% of cases we had to remove the worm by wide papillotomy followed by basket extraction. We did not experience any major complications during or following the procedures. Three patients had recurrent HPA during the course of follow-up (1 to 12 months). The majority of patients with HPA presented with biliary colic. This should be kept in mind in the management of an acute abdomen, especially in tropical countries. Endoscopic extraction is a safe and effective procedure for the treatment of HPA.

Parasitic diseases of the biliary tract

OBJECTIVE

Parasites residing in the biliary tree include Clonorchis sinensis, Opisthorchis viverrini, Opisthorchis felineus, and Fasciola hepatica. They are willowy, leaf-like, flat flukes dwelling in the bile ducts and gallbladder. Human ascarides, Ascaris lumbricoides, dwelling in the small intestine, inadvertently migrate into the bile ducts and cause biliary obstruction. The purpose of this article is to illustrate typical imaging findings of liver fluke infection and biliary ascariasis.

CONCLUSION

Adult flukes of Clonorchis and Opisthorchis measure 8-15 mm and adult flukes of Fasciola measure 20-40 mm in length. The presence of flukes in the bile ducts causes dilatation of the bile ducts, varying degrees of chronic inflammation followed by adenomatous hyperplasia, and bile duct wall thickening. Imaging findings of clonorchiasis and opisthorchiasis include visualization of adult flukes in the bile ducts and gallbladder, diffuse dilatation of the peripheral small intrahepatic bile ducts with no or minimal dilatation of the large bile ducts, and thickening of the bile duct wall. In biliary fascioliasis and ascariasis, adult worms are visualized in the dilated bile ducts and gallbladder.

Parasitic infestations of the biliary tract

Parasitic infestations of the biliary tract are a common cause of biliary obstruction in tropical countries and can lead to such serious complications as cholangitis and cholangiocarcinoma. Endoscopic therapy has helped in the management of biliary complications caused by these parasites. Ascaris lumbricoides organisms, which normally reside in the jejunum, are actively motile and can invade the papilla, thus migrating into the bile duct and causing biliary obstruction. Endoscopic retrograde cholangiopancreatography is a useful diagnostic tool with potential for therapeutic management of biliary ascariasis. Infestation with Clonorchis sinensis organisms can cause such complications as intrahepatic stones, recurrent pyogenic cholangitis, cirrhosis, cholelithiasis, pancreatitis, and cholangiocarcinoma. Opisthorchis viverrini, Opisthorchis felineus, and Dicrocoelium dendriticum are closely related to C. sinensis and can also cause serious biliary complications. Fascioliasis, caused by Fasciola hepatica and F. gigantica, is a zoonotic helminthiasis that can present as acute hepatic or chronic biliary tract infection. CT, MRI, and ultrasound guidance are useful imaging tools for identifying these parasites and their complications.

Endoscopic removal of one live biliary Fasciola gigantica

Biliary fascioliasis was diagnosed in a woman from Angthong province, who presented herself with anorexia, weight loss, and jaundice for one month. Intraoperative retrograded cholangiopancreatography revealed a filling defect considered as a stone and bile sludge. By the sphincterotomy and balloon-extraction technique, one live fluke was removed and identified as Fasciola gigantica. A single dose of praziquantel, 25 mg/kg of body weight/day, was given although the postoperative stool examination revealed no Fasciola spp. egg. The patient was doing well after the fluke removal. According to a previous review, in this country, Ayutthaya is the southernmost province for the distribution of fascioliasis.

Intrabiliary rupture of a large liver echinococcal cyst in an adolescent managed with endoscopic sphincterotomy and albendazole

We report the case of a 17-year-old male with a rupture into the biliary tract. The patient was urgently admitted to the surgical department with the clinical diagnosis of cholangitis. Modern imaging techniques and specific serologic tests established the diagnosis of intrabiliary rupture of a liver hydatid cyst due to E. granulosus. Despite the fact that surgery remains the cornerstone of treatment, conservative management was preferred, due to the location of the echinococcal cyst in the right lobe of the liver adjacent to the inferior vena cava and the age of the patient. Endoscopic sphincterotomy was performed with subsequent evacuation of the biliary tree, followed by a sixcycle treatment with albendazole. At one-year follow-up, the patient is in good health, with no radiologic or serologic evidence of relapse.

[Intrabiliary rupture of the hydatic cyst complicated with acute pancreatitis]

Acute pancreatitis is a rare complication of hydatidosis, and only few reports were published previously. We report a case of a 17-year-old man, with recurrent liver hydatid cyst, who presented with severe upper abdominal pain, vomiting, jaundice. Amylase and bilirubin were elevated. Abdominal CT scan showed a cystic lesion in the dome of the liver and a diffusely swollen pancreas. At endoscopic retrograde cholangiopancreatography (ERCP) the common bile duct was dilated with fragments of hydatid membrane. A sphincterotomy was performed and hydatid membranes were extracted, after which the patient made an uneventful recovery and the level of amylase and bilirubin normalized. After two weeks a new episode of hydatid rupture occurred with clinical presentation of cholangitis. Emergency surgery was performed, which consisted of cystectomy, suture of intracavitary bile fistula, omentoplasty, choledochotomy with extraction of the hydatid membranes and common bile duct drainage. There were no relapses during 5 years follow-up. This case report highlights that ERCP and sphincterotomy are considered the procedures of choice in acute pancreatitis induced by biliary rupture of the hydatid cyst and surgical treatment is considered to be the only definitive treatment of the hydatic cystic lesion of the liver with intrabiliary rupture.

[Biliary ascariasis. Case report and review of the literature]

BACKGROUND

Ascaris lumbricoides is the most common nematode found in the human gastrointestinal tract with a greater prevalence found in developing tropical and subtropical countries. Most cases of ascariasis follow a benign course. In some cases the adult parasite can invade the biliary or pancreatic ducts and cause obstruction with development of cholecystitis, cholangitis, pancreatitis, and hepatic abscesses. We report a case of a patient with biliary ascariasis.

CLINICAL CASE

A 40-year-old woman, born and residing in San Cristobal de las Casas, Chiapas, was admitted with right upper quadrant pain of 2-week duration. Pain was accompanied by nausea, vomiting and fever. Exploration revealed pain upon deep palpation of right hypochondria. Laboratory examinations demonstrated elevation of alkaline phosphatase without jaundice, leukocyte count of 14,300 and ultrasonography with ascaris within the gallbladder and intra- and extrahepatic ducts without evidence of dilatation. Medical treatment with mebendazol was begun orally; nevertheless, on the second day the patient reported an increase of the right hypochondria pain, vomiting and fever of 38 degrees C. Surgical treatment was decided upon. An open cholecystectomy was performed without evidence of parasites within the gallbladder. Expansion of the extrahepatic bile ducts was observed and a formal biliary exploration was carried out with extraction of 19 ascarids and colocalization of choledocostomy T-tube. At the third postoperative day, a T-tube cholangiography was done, showing residual ascarids in the biliary ducts that were resolved with a retrograde endoscopic cholangiopancreatography. The patient's evolution was without complications or fever and with adequate oral feeding posterior to biliary instrumentation.

CONCLUSIONS

In obstructive biliary pathology, biliary ascariasis is a diagnosis that needs to be explored in our country. Knowledge of clinical symptoms, complications, and diagnostic and therapeutic options are of paramount importance for all health professionals in our country.

Efficacy of nitazoxanide and paromomycin in biliary tract cryptosporidiosis in an immunosuppressed gerbil model

OBJECTIVES

To evaluate the efficacy of nitazoxanide and paromomycin in biliary tract cryptosporidiosis in an immunosuppressed Mongolian gerbil (Meriones unguiculatus) model.

METHODS

Gerbils (1-month-old) were dexamethasone-immunosuppressed for 10 days and challenged orally with 10(5) Cryptosporidium parvum oocysts. From day 0 to day 12 post-infection, one group (n=14) was treated with 200 mg/kg/day nitazoxanide and another (n=15) with 100 mg/kg/day paromomycin. Infection and efficacy of nitazoxanide and paromomycin were assessed by measuring oocyst shedding in faeces, biliary tract and ileum histological examination.

RESULTS

In nitazoxanide-treated and paromomycin-treated groups as compared with untreated animals (P<0.05), oocyst shedding was partially suppressed in a similar manner (P>0.05). Parasites were present in histological sections of the ileal mucosa of 16/16 infected untreated animals versus 3/14 and 6/15 in the nitazoxanide-treated and the paromomycin-treated groups, respectively (P<0.05). In addition, gall bladder infection was less frequent in nitazoxanide-treated (2/14, P<0.01) and paromomycin-treated (5/15, P=0.07) animals than in untreated controls (9/16). No histological alteration of biliary mucosa was observed in both treated and untreated infected gerbils.

CONCLUSIONS

Present data support the efficacy of nitazoxanide and, to a lesser extent, paromomycin on biliary C. parvum infection in gerbils, and prompt further investigation of the potential clinical benefits of nitazoxanide in treating human biliary cryptosporidiosis.

Acute pancreatitis caused by tapeworm in the biliary tract

Taeniasis is a helminthic infection endemic in southeast Asia, including Taiwan. Recent studies suggest that Asian Taenia is a new subspecies of Taenia saginata and has been renamed as Taenia saginata asiatica. It is usually asymptomatic or associated with only mild gastrointestinal symptoms. We report the case of a 52-year-old woman with acute epigastric pain and vomiting. Her levels of amylase and lipase were significantly elevated on admission. Gastrointestinal endoscopy showed proglottids of a tapeworm in the papilla of the duodenum. The epigastric pain subsided and the amylase and lipase levels decreased after removal of the tapeworm by endoscopy and anthelminthic treatment. Although parasites are not an uncommon cause of pancreatitis, especially in disease-endemic areas, it is rare for Taenia to cause acute pancreatitis.

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.