A 2-year-old Indian girl was referred with symptoms of biliary colic and obstructive
jaundice of 3 weeks’ duration. Abdominal ultrasonography revealed dilation of intrahepatic
biliary radicles, a distended gallbladder, and a dilated common bile duct (CBD) of
15 mm (normal diameter up to 6 mm) containing multiple ill-defined, oval, hyperechoic
shadows near the lower end ([Fig. 1]). Magnetic resonance cholangiopancreatography (MRCP) showed multiple intraluminal
curvilinear, hypointense areas in the lower CBD consistent with stones or worm ([Fig. 2]). Linear endoscopic ultrasound (EUS) was performed for evaluation of the CBD filling
defects visualized on abdominal ultrasound and MRCP. Linear EUS from the stomach and
duodenal bulb revealed a dilated CBD with multiple hyperechoic structures without
acoustic shadowing. EUS showed curvilinear, disc-shaped short-segment echogenic structures,
2 – 6 mm in size, with a central anechoic core and parallel and equidistant from each
other; this was suggestive of recently broken down soft parallel fragments of roundworms
([Fig. 3], [Video 1]). The central anechoic core represented the digestive tract of Ascaris lumbricoides. Cholangiography revealed a dilated CBD with tapering at the lower end showing multiple
filling defects ([Fig. 4]). After multiple balloon sweeps on endoscopic retrograde cholangiopancreatography
(ERCP), creamy white structures and yellow-colored material were removed that were
suggestive of recently fragmented roundworm ([Fig. 5], [Video 1]). The patient’s clinical condition improved significantly after ERCP, and repeat
abdominal ultrasound after 1 week demonstrated decreased size of the CBD. The patient
underwent deworming with albendazole, with the passage of multiple roundworms in stools
further confirming the diagnosis of obstructive jaundice due to Ascaris.
Fig. 1 In a 2-year-old Indian girl with symptoms of biliary colic and obstructive jaundice
of 3 weeks’ duration, abdominal ultrasonography showed a dilated common bile duct
(CBD) with multiple ill-defined, oval, hyperechoic shadows near the lower end.
Fig. 2 Magnetic resonance cholangiopancreatography (MRCP) showed dilation of intrahepatic
biliary radicles with a distended gallbladder and dilated CBD and common hepatic duct.
There are multiple intraluminal curvilinear, hypointense areas in the lower CBD, consistent
with stones or worm.
Fig. 3 Endoscopic ultrasound (EUS) shows multiple disc-shaped echogenic structures with/without
a central anechoic core in a dilated CBD. PV, portal vein; PD, pancreatic duct; IVC,
inferior vena cava.
Video 1 Appearance at linear endoscopic ultrasonography (EUS) of dead Ascarislumbricoides
causing obstructive jaundice in a 2-year-old girl, and removal of thefragmented roundworm
at endoscopic retrograde cholangiopancreatography (ERCP). CD, cysticduct; CBD, common
bile duct; IVC, inferior vena cava.
Fig. 4 Cholangiography revealed a dilated CBD with tapering at the lower end showing multiple
filling defects.
Fig. 5 At endoscopic retrograde cholangiopancreatography (ERCP) creamy white structures
and yellow-colored material, suggestive of recently fragmented roundworm, were removed
from the CBD.
Pancreaticobiliary ascariasis is a common problem in tropical countries [1]. Dead Ascaris is a rare but an important cause of obstructive jaundice in the developing world
[2]. In conclusion, we describe an unusual appearance of recently dead Ascaris lumbricoides on abdominal ultrasound, MRCP, and EUS. In endemic regions, biliary ascariasis should
be considered in any child presenting with obstructive jaundice [3].
Endoscopy_UCTN_Code_CCL_1AF_2AF_3AD
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