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Ascariasis of gallbladder: a rare case report and a review of the literature

Sachin Khanduri, Umesh C Parashari, Deepak Agrawal and Samarjit Bhadury
Trop Doct 2014 44: 50 originally published online 19 November 2013
DOI: 10.1177/0049475513512637

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Case Report
Tropical Doctor
2014, Vol 44(1) 50–52
! The Author(s) 2013
Ascariasis of gallbladder: a rare case Reprints and permissions:
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report and a review of the literature DOI: 10.1177/0049475513512637
tdo.sagepub.com

Sachin Khanduri1, Umesh C Parashari2, Deepak Agrawal3

and Samarjit Bhadury1

Abstract
Ascariasis of the gallbladder is a very rare presentation. We report a case of a 15-year-old boy who presented with
complaints of pain in the abdomen, vomiting, pruritus, and fever on-and-off for 10 days. On radiological examination, an
ultrasonography of the abdomen showed a dilated gallbladder with multiple linear echogenic, tubular, parallel lines inside
the lumen of the gallbladder, common bile duct and intrahepatic biliary radicles. The zigzag and coiling movement of a
worm was noted in the lumen of the gallbladder on real time B-mode ultrasonography. The patient was successfully
treated with an anthelminthic drug. On follow up no evidence of the worm was noted in the gallbladder or common bile
duct lumen.

Keywords
Gallbladder ascariasis, zigzag, coiling, anthelminthic drug

Introduction
The round worm named as ascaris lumbricoides is the
most common helminthic infection (nematode) in
humans.1 The adult nematode worm is mainly present
in the small intestine.1,2
Sometimes the worm enters into the common bile
duct, passing through the papilla of water present in
the second part of duodenum and then into the gall-
bladder lumen through the cystic duct. This is a very
rare presentation. We report a rare case of gallbladder
ascariasis with intrahepatic biliary radicles ascariasis.
Case report
A 15-year-old boy presented to the outpatient clinic
with complaints of pain in the abdomen, vomiting, prur-
itus, and fever on-and-off for 10 days. There was also
history of multiple episodes of passing worms in the
stool for 20 days. On examination he was thin and
toxic in appearance and jaundice was present. His
vitals were normal except for a raised temperature. On
laboratory investigation, his haemoglobin was 10 gm%,
total white blood count (WBC) – 20,000/mm3. A
liver function test (LFT) showed serum bilirubin –
5.6 mg/dL, alkaline phosphatase (ALP) – 160 IU/L,
angiotensin sensitivity test (AST) – 140 IU/L, and ala-
nine aminotransferase (ALT) – 98 IU/L.
On radiological examination, an ultrasonography of
the abdomen showed a dilated gallbladder with mul-
tiple linear echogenic, tubular, parallel lines inside the
lumen of the gallbladder, common bile duct and intra-
hepatic biliary radicles (Figures 1 and 2). The common
bile duct was dilated with a diameter of approximately
12 mm with dilatation of the biliary radicles. The zigzag
and coiling movement of the worm was noted in the
lumen of the gallbladder on real time B-mode ultrason-
ography. Mild hepatomegaly was also noted. There was
no evidence of cholecystitis.
A diagnosis of ascariasis of the gallbladder and
common bile duct was made and the anthelminthic
drug albendazole (400 mg/day) was given. The patient
improved after 10 days of multiple episodes of the pas-
sage of worms in his stools.
1
Professor, Department of Radio Diagnosis, Era’s Lucknow Medical
College, Lucknow, India
2
Associate Professor, Department of Radio Diagnosis, Era’s Lucknow
Medical College, Lucknow, India
3
Junior Resident, Department of Radio Diagnosis, Era Lucknow’s Medical
College, Lucknow, India
Corresponding author:
Dr Umesh Chandra Parashari, Department of Radio Diagnosis, Era’s
Lucknow Medical College, Lucknow, India.
Email: drumesh.rd@gmail.com

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Khanduri et al. 51

Figure 1. Ultrasonography of the abdomen showing a dilated gallbladder with linear echogenic, tubular, parallel lines inside the
lumen of the gallbladder, common bile duct and intrahepatic biliary radicles (black arrow). The common bile duct is dilated with a
diameter of approximately 12 mm with dilatation of the biliary radicles.

Figure 2. Ultrasonography of the abdomen showing dilated intrahepatic biliary radicles with multiple linear echogenic, tubular and
parallel lines inside the lumen.

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52
Discussion
Ascariasis is caused by Ascaris lumbricoides round-
worms which belong to the phylum nematode and is
the most common helminthic infection in humans.1 The
prevalence is worldwide but occurs most often in trop-
ical and subtropical countries. The adult worm is usu-
ally seen in the small intestine, mainly in the jejunum.
The infection occurs mainly in developing countries due
to poor sanitation, unhygienic conditions, and over-
crowding, as the route of transmission is faeco-oral.
The adult worm enters the common bile duct and
main pancreatic duct from the second part of the duo-
denum through an ampulla of water and then goes into
the gallbladder lumen through the cystic duct which is
relatively rare. Only 2.1% of all cases involve the biliary
tract.3 The incidence is low because of tortuous and
narrow cystic duct.4
Biliary ascariasis presents with complaints of right
upper abdominal quadrant pain, low grade fever,
vomiting, tenderness of the abdomen, and multiple epi-
sodes of passage of worms in the stools. The complica-
tions can look like acute cholangitis if the obstruction
occurs in the common bile duct and presents with fever,
jaundice, and tender hepatomegaly. Sometimes it can
cause acute cholecystits due to the obstruction of the
cystic duct and as acute pancreatitis due to the obstruc-
tion of the main pancreatic duct.5,6
On radiological examination, ultrasonography is the
modality of choice for the diagnosis of gallbladder
ascariasis because the appearance and movement of
live worms can be seen.5 The live worm presents as
linear, tubular, parallel, non-shadowing echogenic
lines inside the gallbladder lumen and shows coiling,
zigzag and non-directional movements which confirm
that the worm is alive.7
A computed tomography (CT) scan shows tubular
hyperdense foci in the gallbladder and common bile
duct lumen with dilatation of the intrahepatic biliary
radicles.
Conclusion
Treatment includes anthelminthic drugs. Most com-
monly albendazole is given and in most cases the
patient responds well to medical management.
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Tropical Doctor 44(1)
Sometimes surgery is required, usually laparoscopic
or endoscopic procedures such as endoscopic retro-
grade cholangiopancreatographic (ERCP) examin-
ation8,9 if the worm is dead and causing obstructive
in the biliary system. However, in this case the patient
responded well to anthelminthic drugs and no interven-
tion was required. On follow-up, no evidence of the
worm was noted in the gallbladder or the common
bile duct lumen.
Declaration of conflicting interests
None declared.
Funding
This research received no specific grant from any funding
agency in the public, commercial or not-for-profit sectors.
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