Biliary ascariasis: an unexpected cause of abdominal pain in a non-endemic region

© Author(s) (or their employer(s)) 2021. No commercial reuse. See rights and permissions. Published by BMJ. A 24yearold man presented with 8 months of intermittent right hypochondrial pain with fever and jaundice for 1 week. Liver function tests showed a mixed hepatitic/cholestatic pattern: alanine transaminase 579 IU/L, alkaline phosphatase 183 IU/L, gammaglutamyltransferase 390 IU/L and bilirubin 126 μmol/L. Full blood count, Creactive protein, urea and electrolytes, clotting, blood cultures and hepatitis screen were normal or negative. Abdominal ultrasound (US) revealed strandlike structures within the gall bladder, but no gallstones (figure 1A,B). Magnetic resonance cholangiopancreatogram showed similar internal gallbladder strandlike structures (figure 2). The patient had travelled to Turkey 2 years previously. Regional parasitologists were consulted: despite the patient’s stool being negative for ova, cysts and parasites, gallbladder ascariasis was diagnosed. A single dose of oral albendazole 400 mg was administered. By day 3, symptoms and biochemistry had improved. US showed no worms in the gall bladder. The patient was discharged with planned outpatient cholecystectomy. Worldwide prevalence of Ascaris spp is >1.2 billion. Worms reside in the small intestine but occasionally enter the biliary tree. Ascariasis should be considered for biliarytype pain following travel to endemic regions. Gallbladder ascariasis accounts for 2.1% of hepatobiliary cases due to the narrow, tortuous cystic duct. US is the most sensitive investigation for diagnosis and monitoring. Stoolbased microscopy is insensitive because of varying egg excretion and distribution in stools. Antihelminthics such as albendazole, pyrantel pamoate and levamisole are firstline treatments, but endoscopic removal by snare, dormia basket or biopsy forceps during endoscopic resonance cholangiopancreatography can be considered for ductal worms in refractory cases. Cholecystectomy is reserved for intractable cases or when complications (eg, empyema, sepsis and pericholecystic abscess) occur.