Dear Editor, In the western world, Ascaris lumbricoides A. lumbricoides) or roundworm infestation is uncommon. It usually involves the small bowel and is diagnosed by stool examination. It is unusual to make the initial diagnosis by imaging. The detection of mobile worms within the common bile duct (CBD) on ultrasound is extremely rare. A 32-year-old male presented with a three-month history of abdominal pain and weight loss. Clinical examination was unremarkable. Abnormal laboratory findings included a mild hypochromic microcytic anaemia and mildly elevated liver function tests. A small bowel follow-through showed multiple linear filling defects in the jejunal loops in keeping with Ascaris (roundworm) infestation (see Figure 1) and barium was seen in the alimentary canal of the worm. J An upper abdominal ultrasound showed a linear echogenic luminal abnormality in the CBD suggestive of a worm (see Figure 2) . Dynamic imaging revealed antegrade movement of the worm within the bile duct. A computer tomography (CT) scan of the abdomen revealed no other cause for the biliary obstruction. It also revealed worms within the small bowel giving a `target'-like appearance (see Figure 3). An endoscopic retrograde cholangiopancreatography (ERCP) confirmed the presence of Ascaris in the CBD (see Figure 4). The offending worm was removed and the patient was treated with oral antihelminthic medication and made an uneventful recovery. A. lumbricoides typically measures about 25-35cm in length. The average worm's life span is approximately one year. The disease is more common in children under 10 years of age. The incidence varies significantly with some groups having an incidence of up to 12%;. It is found world-wide but is particularly common in poor and rural communities due to heavy faecal contamination of the immediate environment. Infection may be asymptomatic or be associated with nausea, vomiting, abdominal discomfort and anorexia. Worms may obstruct the small intestine with the most common site being the ileo-caecal valve. Occasionally they may extend into the appendix causing acute appendicitis. When Ascaris migrates from the duodenum through the ampulla of Vater to the CBD, patients may present with abdominal pain and jaundice.' Obstruction may occasionally lead to suppurative cholangitis with rigors and fever.' Mebendazole 100mg twice daily for three days is the treatment of choice but surgical or endoscopic intervention may be required for intestinal or biliary obstruction.
Read full abstract