A 36-year-old woman was admitted to our department with epigastric radiating pain,
nausea, vomiting, fever, tachycardia, and sweating. The pain radiated to the back
and had worsened. The sclera showed mild icterus. Laboratory test results showed elevated
levels of total bilirubin (38 mmol/L), serum amylase, lipase, and white blood cells.
Computed tomography scan showed an enlarged pancreatic head and a dilated pancreatic
duct. A diagnosis of acute biliary pancreatitis was considered, although the cause
of the dilated pancreatic duct was not clear. The Ranson’s prognosis scale was 4,
and therefore we performed endoscopic retrograde cholangiopancreatography (ERCP).
During ERCP, we could not find any abnormality in the papilla initially ([Fig. 1]). After pancreatic duct cannulation, a strip filling defect was seen in the main
pancreatic duct when we injected the contrast ([Fig. 2]). The Ascaris worm come out of the papilla after pancreatography ([Fig. 3]). We used a snare to grasp and remove the worm from the pancreatic duct ([Fig. 4], [Video 1]), and albendazole was given to prevent re-infection by the worms. The patient recovered
smoothly and was discharged 6 days later.
Fig. 1 During endoscopic retrograde cholangiopancreatography, no abnormality was seen in
the papilla initially.
Fig. 2 The pancreatic duct angiography revealed a strip filling defect (arrows) in the main
pancreatic duct.
Fig. 3 After pancreatography, the Ascaris came out of the papilla.
Fig. 4 After grasping the Ascaris with a snare, it was successfully removed.
Video 1 The pancreatography revealed a strip filling defect in the main pancreatic duct.
The Ascaris came out of the papilla after pancreatography. We used a snare to grasp the Ascaris and successfully remove it.
Ascariasis-induced pancreatitis commonly occurs by worm invasion of the ampullary
orifice, entering the bile duct, and blocking the pancreatic duct orifice, and rarely
by direct invasion of the pancreatic duct. It is a rare but important cause of acute
pancreatitis in developing countries. Ascaris is one of the common intestinal parasites and usually inhabits warm and humid areas
where sanitation and hygiene are poor.
The disease may remain asymptomatic, with ascarides resident in the lumen of the small
intestine. Symptoms can occur when helminths, including Ascaris, invade the biliary or pancreatic ducts. Presentation varies, the most common being
biliary colic (56 %), acute cholangitis (25 %), and acute cholecystitis (13 %); acute
pancreatitis makes up only 6 % [1]. The pancreatitis induced by ascariasis is usually mild, and diagnosis is possible
by conventional imaging [2]
[3]. ERCP is an effective diagnostic as well as treatment procedure for ascariasis in
the biliary and pancreatic ducts [4]. Antihelminthic drugs are needed to avoid ascariasis relapse.
Endoscopy_UCTN_Code_CCL_1AZ_2AF
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