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Abdomen » Hepatobiliary
Biliary and Hepatic Ascariasis with Cholangitis and Hepatic Abscess.
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Author(s) :
Leandro Fernandez, MD
 
Presentation 4 year old female patient with severe illness, high fever, pain in right hypochondrium, extended to the rest of the abdomen. She had low growth rate and malnutrition.
 
 
 
Caption: Oblique view, right lobe of the liver
Description: The hepatic parenchyma appears heterogeneous. Within the liver there is a tubular structure with echogenic walls and a hypoechoic central line. This pattern suggests an Ascaris worm within a dilated biliary channel. Posterior to the location of the parasite there is a poorly defined area of heterogeneity representing a hepatic abscess.
 
 
 
Caption: Transverse view, left hepatic lobe
Description: A serpiginous echogenic structure surrounded by a hypoechoic halo is seen embedded in the liver parenchyma. This is compatible with an Ascaris worm and adjacent inflammatory reaction or biliary fluid.
 
 
 
Caption: Transverse view, right hypochondrium, mid-clavicular line
Description: The hepatic parenchyma is heterogeneous appearing. A typical double-line echo pattern representing an Ascaris worm extends from the right lobe into the porta hepatis.
 
 
 
Caption: Sagittal liver through porta hepatis
Description: Multiple Ascaris worms occupying the lumen of a dilated common bile duct.
 
Differential Diagnosis

 

  1. Ascariasis
  2. Foreign body: catheter
  3. Hepatolithiasis
 
Final Diagnosis

Biliary and Hepatic Ascariasis with Cholangitis and Hepatic Abscess.

 
Discussion

Ascariasis is one of the most common helminthic diseases worldwide. One third of the world population has or have previously experienced an infestation by Ascaris lumbricoides, but the disease has a higher prevalence in developing countries, especially in communities with poor economic conditions. Parasitic infestations of the biliary tree are a common cause of biliary obstruction in tropical countries and can lead to complications such as recurrent pyogenic cholangitis, pancreatitis, hepatic abscesses, and septicemia.  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 and secondary infection.

The diagnosis of biliary Ascariasis is usually made by ultrasound. The roundworms can be observed by ultrasound as tubular structures with echogenic walls and a hypoechogenic line inside, in the biliary ducts and the gallbladder. Sometimes movement can be seen in these images. It is less frequent to observe the parasites in the liver parenchyma, where they cause secondary abscesses. This condition is more commonly seen in children with malnutrition.

 
Case References
  1. Fernandez L. “Ascariasis” in Manual of Diagnostic Ultrasound in Infectious Tropical Diseases. Lutz HT Gharbi HA. Springer. Berlin 2006 p.109-115
  2. Rana SS et al. Parasitic infestations of the biliary tract. Curr Gastroenterol Rep. 2007; 9(2):156-64  (http://www.medscape.com/medline/abstract/17418062)


 
Technical Details

ATL HDI 5000 ultrasound system with a C5-2 (5 to 2 Mhz) curved linear transducer and a P7-4 transducer (phased array 7 to 4 Mhz).

 
Follow Up

Antibiotics and anti-helminthic drugs were used but Endoscopic biliary drainage and the extraction of worms were necessary.

The ultrasonographic diagnostic was confirmed.

 
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