Gallbladder surgery reveals Ascaris lumbricoides

Abstract

A 54-year-old woman in Calcutta, India, presented with reports of pain in the right upper quadrant of the abdomen, with radiating pain to the back of an intermittent nature and low intensity over a 6-month period. Two weeks before admission, the patient had one episode of severe abdominal pain associated with the appearance of a mass. On examination, a mass was observed in the right upper quadrant extending to the right iliac fossa. A right Kocher’s incision was performed, revealing a huge distended gallbladder extending to the right iliac fossa. The gallbladder contained multiple stones and a large papillary tumor, consisting of well-to-moderately differentiated adenocarcinoma of the gallbladder obstructing the neck of the gallbladder. The common bile duct was dilated. The only other pathology identified in the abdomen was a large Ascaris lumbricoides in the small intestine (Figure). A cholecystectomy and exploration of the common bile duct were performed, revealing sludge and tumor fragments in the duct. A stent was placed in the common bile duct, and the patient was well at 6 months postoperation. Ascaris is widespread in tropical and subtropical climates, especially in areas of economic hardship, where incidence has been reported as high as 100%. The peak incidence is in children aged 2 to 5 years, where massive infestation may lead to small intestinal obstruction, volvulus, intusseption, gangrene, and perforation. These complications may be from the physical mass of paralyzed worms, local inflammation, or muscle spasm. In these cases, mortality can be from 20% to 50%, from systemic symptoms associated with bowel problems, and toxemia from systemic absorption of byproducts of living and dead worms. Toxins associated with Ascaris lumbricoides may cause a meningeal inflammation. The diagnosis can be substantiated by a typical bulls-eye or railroad-track pattern on ultrasonographic examination. Unless an operation is necessary for management of obstruction, therapy with oral antihelminthic agents such as piperazine is preferred.