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BILIARY ASCARIASIS AN UNUSUAL PRESENTATION AS A DUODENAL ULCER

Ravid Bapat*, Anand P Iyer**, Chetan Kantharia***,B S Acharya****, Girish Bakshi**, Satish Ranka*****
*Professor and Head; **Resident; ***Associate Professor; ****Lecturer; *****Medical Officer, Department of General Surgery, Seth GS Medical College and KEM Hospital, Mumbai 400 012.
Biliary tract is the commonest extraintestinal manifestation of roundworms. We report a case of multiple ascariasis in common bile duct causing obstructive jaundice with epitheloid granulomas in the liver with a cholecystoduodenal fistula due to penetrating duodenal ulcer causing diagnostic dilemma.

INTRODUCTION

The commonest extraintestinal location of ascaris lumbricoides is the biliary tract.[1] They are usually diagnosed with a high degree of sensitivity by ultrasonography,[2] in the endemic areas. However, it poses a diagnostic dilemma when the same is coupled with lesions in the liver, air in the biliary tree and significant pericholedochal inflammation. No investigative modality can conclusively reach the diagnosis and the dilemma is solved only on the operation table.

CASE REPORT

A 58 year old male from Sindhudurg, Maharashtra, a known case of peptic ulcer disease, was admitted with complains of fever since 15 days, pain since 1 month, jaundice since 20 days. Per abdominal examination was normal and on per rectal examination there was melaena. Biochemical investigations done revealed obstructive jaundice with a T. bilirubin of 8.6 and D. bilirubin of 5.2. Alkaline phosphatase was 294 KA units. Emergency upper gastro intestinal scopy revealed a 1.5 cm x 2 cm ulcer in the first part of duodenum with a deformed pylorus.

Ultrasonography done revealed

1. Soft tissue mass in CBD with CBD dilatation of 15 mm.

2. Central intrahepatic biliary radical dilatation and pneumobilia.

CT scan done was suggestive of choledochoduodenal fistula with soft tissue mass in CBD, air in gall bladder and intrahepatic biliary radicles with multiple small lesions in left lobe of liver believed to be metastases (Fig. 1).

The differential diagnosis considered were:

1. Chronic duodenal ulcer with bleed with clot in CBD and a choledochoduodenal fistula.

2. Cholangiocarcinoma.

Patient was operated upon and on surgery, a cholecystoduodenal fistula with CBD ascariasis were revealed. Cholecystectomy with sphincterotomy with removal of 7 worms (Fig. 2) was performed. Trunkal Vagotomy with pyloroplasty was also added to the procedure and a liver biopsy was taken which revealed epitheloid granulomas (Fig. 3). Postoperative recovery was uneventful.

DISCUSSION

Biliary ascariasis giving rise to obstructive jaundice is rather uncommon.[3] Ascariasis lumbricoides enters the CBD via the ampulla of vater and usually, only the proximal 1/3 lies in the duct.[4] Bacteria introduced by the worm may cause suppurative cholangitis and liver abscesses.[1] Occasionally, there are only bouts of ascending cholangitis.[2] Our patient was a known case of acid peptic disease, melaena was due to penetration of the duodenal ulcer into the gall bladder or a bleeding duodenal ulcer. The complication of anterior wall duodenal ulcer penetrating into the biliary tree is known to occur.[5] The incidence of penetration of duodenal ulcer into the biliary tree is 12.5%.6 This also gives rise to pneumobilia into the biliary tree, the differential of which includes passage of stones through the ampulla, papillotomy or surgical biliary enteric bypass.[7] CT may be misleading some times as in our case. The worms cause stasis of bile and dilatation of bile ducts, the cause of which may be from mechanical stimulation of choledochal sphincter[8] or papillitis with pericholedochal inflammation.[3] The worms either die or disintegrate, but deposit ova before doing so. Both viable and dead ova tend to produce a nonspecific foreign body reaction and formation of chronic granulomatous foci in liver parenchyma4 as was in our case which could be misinterpreted as metastasis. The ova usually enter the left lobe of liver via the branches of the left hepatic duct. The worms along with infection might also cause choledocholithiasis without cholelithiasis.[9] Thus inspite of extensive modern investigative modalities this case caused a significant diagnostic dilemma which was solved only on exploration.

Fig. 1
Fig. 1 CT scan suggestive of choledochoduodenal fistula with soft tissue mass in CBD and pneumobilia

Fig. 2
Fig. 2 Round worm in CBD after a sphincterotomy.

Fig. 3
Fig. 3 Histology of biopsy : gramulomas in liver. Original magnification HE x 160

REFERENCES

  1. Piggot J, Hausbarger EA Jr, Naejie RC. Human ascariasis. Am J Clin Pathol 1970; 53 : 223-34.
  2. Vijay KH, Indira K, Khan M. Biliary ascariasis. Indian Journal of Gastroenterology 1989; 8 (4) : 265-66.
  3. Maki T. Cholelithiasis in the Japanese. Archives of Surgery 1961; 82 : 599-612.
  4. Lauw JH. Abdominal complications of ascaris lumbricoides infestation in children. British Journal of Surgery 1966; 53 : 510-21.
  5. Haile TD, Sean JM. Complications of peptic ulcer. In Maingots abdominal operations complications of peptic ulcer Vol. 10th edition. Newyork : Prentice-Hall International Inc. 1998; Vol. 1 : 986-88.
  6. Norris JR, Haubrick WS. The incidence and clinical features of penetration in peptic ulceration. JAMA 1961; 178 : 386-89.
  7. Topal, Savci G. Choledochoduodenal fistula secondary to duodenal peptic ulcer. Acta Radiologica 1997; 38 : 1007-1009.
  8. Pillay SP, Baker LW, Angorn IB. Ascaris lumbricoides producing obstructive jaundice. Journal of Royal College of Surgeons of Edinburgh 1978; 23 : 25-29.
  9. Raney R, Lilly J. Biliary calculus of round worm origin. Annals of Internal Medicine 1970; 72 : 405-7.
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