Digital cholangioscopy-guided removal of an Ascaris worm from the biliary tree.

Abstract

A-37-year woman, who had undergone endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy for common bile duct (CBD) stones followed by cholecystectomy 3 years ago, presented to us complaining of right upper quadrant pain for 3 days. Laboratory investigations showed raised liver enzymes (alanine transaminase 100 U/L and alkaline phosphatase 320 U/L), with normal bilirubin levels. An ultrasound of the abdomen showed a mildly dilated CBD with aerobilia. Endoscopic ultrasound (EUS) was performed, which showed long, moving, linear hyperechoic strips, without any acoustic shadow within the CBD, consistent with the “strip” sign and a central, longitudinal anechoic shadow, consistent with the “inner-tube” or “double-tube” sign, which suggests a diagnosis of biliary ascariasis ([Fig. 1]). EUS examination of the ampulla showed an open biliary orifice ([Fig. 2]) owing to the previous sphincterotomy, with flow of water within the CBD on ingestion and aerobilia.