An unusual cause of obstructive jaundice in a 2-year-old child

Abstract

Background and Objectives:Pancreaticobiliary ascariasis is common problem in tropical countries. The roundworm in the bile duct can cause biliary colic, obstructive jaundice, or pancreatitis. Live Ascaris worms are usually diagnosed on ultrasonography (USG) or endoscopic ultrasonographic (EUS) showing characteristic features of linear mobile echogenic structure with central anechoic lumen. However, the worm can die inside the common bile duct (CBD) and create a foreign body acting as a nidus for stone or sludge formation. Obstructive jaundice due to dead Ascaris is a rare but important cause in the developing World. As the worm shrivels up after death, accurate identification requires a high index of suspicion. The features of dead worm on EUS include hyperechoic structure without any acoustic shadow.Methods:We present a case of a 2-year-old Indian female child referred with biliary colic and jaundice for the last 3 weeks. Abdominal USG revealed multiple ill-defined, oval, hyperechoic shadows near the lower end of dilated CBD. MRCP showed multiple intraluminal curvilinear, hypointense areas in lower CBD.Results:Linear EUS from the duodenal bulb revealed dilated CBD with multiple hyperechoic structures without acoustic shadowing. It showed 2–6 mm sized curvilinear, disc-shaped, short-segment echogenic structures with central anechoic core parallel and equidistant from each other, suggestive of recently broken down parallel fragments of round worms. The central anechoic core represents the digestive tract of Ascaris. After multiple balloon sweeps on ERCP, creamy white structures and yellow-colored material were removed suggestive of recently fragmented Ascaris.Conclusions:Biliary ascariasis should be considered in any child presenting with obstructive jaundice in endemic regions.