Gallbladder Ascariasis

 

• Ascariasis, a helminthic infection of man, is the most common parasitic infection of the gastrointestinal tract
• But invasion of worms into the gall bladder is rare (2.1% of the hepatobiliary ascariasis in endemic areas)
• Ascaris residing in the jejunum may invade the biliary or pancreatic ducts, resulting in bile duct obstruction, cholecystitis, cholangitis, pancreatitis, or liver abscesses.
• Acute cholecystitis in the gallbladder can be implicated by obstruction of the cystic duct, multiple worms completely distending the gallbladder, ascaris eggs causing obstruction of the cystic duct, and nidus formation
• High parasite load in the intestine  increases the chance of A. lumbricoides

Diagnosis

• Early diagnosis of A. lumbricoides infection can be difficult, particularly as a result of vague
• symptom presentations and constant mobility of the worm
• in some case reports, patient had a history of vague abdominal symptoms suggesting acid peptic disease since 4 years, which had been treated by primary care physicians as nonulcer dyspepsia.
• Imaging with ultrasound has an important role in viewing the parasite
• In high prevalence areas, stool examination for parasite ova8 and ultrasound imaging9 could prove good screening tools

Medical Treatment

• Mostly responding to conservative treatment (antihelminthics such as oral albendazole 400mg/1 day) 
• Can treat as per acalculous cholecystitis
• Initial therapy for gallbladder ascariasis should involve conservative treatment, unless an associated disease is present or a complication arises
• Ascaris lodged in the gallbladder responds poorly to medical treatment because less than 1% of the volume of antiparasitic drugs is excreted in bile
• Conservative treatment often fails in the presence of a dead worm, concomitant stones or internal structure, which prevents the return of the worm into the duodenum
• strategy for conservative management was based on the principle of the ability of the worm to wander”, leading to its spontaneous escape from the gallbladder.

Cholecystectomy

• Indications include failure of a spontaneous clearance of worms after conservative treatment, a dead worm inside the gallbladder and worm associated with calculi.
• Patients, with or without cholecystitis, with impacted bolus worms inside the gallbladder, anomalous cystic duct and established calculi, which impede the spontaneous exit of worms inside the gallbladder, should undergo cholecystectomy to avoid nidus for stone formation or a recurrent attack of cholecystitis

References:

1. Gallbladder ascariasis. Turk J Gastroenterol 2011; 22 (2): 178-182
2. CASE REPORT. HEPATOBILIARY ASCARIASIS COMPLICATED BY PANCREATITIS. J Ayub Med Coll Abbottabad 2015;27(2)
3. Eosinophilic cholecystitis along with pericarditis caused by Ascaris lumbricoides : A case report
4. http://ispub.com/IJPD/1/1/12824
5. www.uptodate.com