Muhammad Talat Mehmood, Muhammad Shahab Athar, Ghulam Oadir Buleedi, M Sajjad Ashraf.
Biliary Ascariasis in children.
J Coll Physicians Surg Pak Nov ;12(4):247-9.

Three cases of biliary ascariasis were seen in the department of Paediatric Surgery, Dow Medical College and Civil Hospital, Karachi between September 2000 and February 2001. Two of them were females. All belong to poor socioeconomic group. They all presented with acute abdominal pain and were diagnosed on ultrasound examination. Two patients responded well to conservative treatment, while one patient required surgical intervention.

CASE 1: A 12 years old girl presented in emergency with a history of colicky pain in the upper abdomen and vomiting off and on for the last 5 months with aggravation of symptoms for the last 24 hours. There was also history of passing worms in the stool and orally one-month back. Physical examination revealed tenderness in the right hypochondrium and epigastrium. Rest of the examination was unremarkable. Haematological examination showed 525/cumm (5%) eosinophils. X-ray abdomen was unremarkable. Ultrasound examination showed linear echogenic shadow suggestive of worm in common bile duct extending into left hepatic duct. Liver function tests (LFTs) were normal. Magnetic resonance cholangiopancreatograghy (MRCP) showed linear filling defect confirming worm in common bile duct extending into left hepatic duct. Patient was kept on conservative treatment (nil per orally, intravenous fluids, anti-spasmodic and antibiotics) and she responded well. Repeat ultrasound examination performed after one week was normal and a course of antihelmentics was given.

CASE 2: A 12 years old boy was admitted through emergency with history of colicky pain in upper abdomen off and on for 24 hours and vomiting for 12 hours. There was history of passing worms in stool 5 months back. Physical examination revealed tenderness in epigastrium and right hypochondrium. Haematological examination and x-ray abdomen were normal. Ultrasound examination showed worm in common bile duct extending into left hepatic duct. LFT showed raised SGPT. Patient was kept on conservative treatment. During first 12 hours, he developed one spike of fever. He then became asymptomatic. Repeat ultrasound examination a week later showed normal biliary system and a course of antihelmenthics was given.

CASE 3: An 8-year-old girl presented in emergency with a history of severe central abdominal pain for 2 days, vomiting, constipation and fever for the last 24 hours. There was also history of passing worms in stool 1 year back. Physical examination revealed slight abdominal distention with tenderness in the umbilical region. X-ray abdomen was unremarkable. A provisional diagnosis of sub acute intestinal obstruction due to worms was made. Patient was kept on conservative treatment and she started passing worms in stool. After 72 hours she had another episode of acute abdominal pain, vomiting and fever. Repeat x-ray abdomen was unremarkable. However, ultrasound examination showed worms in gall bladder and one in left hepatic duct. She was continued on conservative treatment and became asymptomatic. Serial ultrasound examinations showed persistence of worms in gall bladder and left hepatic duct. After third week it was decided to perform surgery. She was given one course of antihelmenthics. Another ultrasound examination was performed a day before surgery which showed clearance of left hepatic duct but persistence of worms in gall bladder. At surgery gall bladder was found inflamed and cholecystostomy revealed disintegrated pieces of worms. Cholecystectomy was performed and per-operative cholangiogram was done which showed normal biliary passages. Postoperatively she developed fever, which settled down within 24 hours. Two weeks after surgery she was given a course of antihelmentics.

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