Hepatholithiasis with biliary ascariasis - A case report

Background: Biliary ascariasis is regarded as possible etiological factor for hepatolithiasis. Here we report one case of hepatolithiasis with biliary ascariasis who developed liver abscess, which was treated with partial hepatectomy. Case: A young adult female presented with epigastric pain, vomiting with repeated attacks of cholangitis. ERCP showed evidence of multiple intrahepatic calculi with the development of abscess in the left lobe of liver. Patient underwent partial hepatectomy and was found to have biliary ascariasis on histology. She was treated with antihelmenthic therapy with uneventful postoperative period for last 2 years. Conclusion: In endemic countries hepatolithiasis can be associated with biliary ascariasis. Introduction: Hepatolithiasis is more prevalent in Asian countries and can be associated with helminthiasis. 1, 2 In India biliary ascariasis has been reported as endemic in Kashmir valley. 4 Elsewhere in country there are only few reports of biliary ascariasis. 5 We report a case of hepatolithiasis with ascariasis who developed liver abscess and was treated with surgical resection. Case Report: A 35 years old female presented with dull aching epigastric pain and vomiting for 2 days. There was history of repeated attacks of cholangitis over 2 years period for which she was getting investigated. The patient was averagely built and poorly nourished. Jaundice was present without signs of liver cell failure. Vital parameters were within normal limits. On investigation, hemoglobin was 10.5 gm%, total WBC count was 18,500 /cmm. Liver function tests showed serum bilirubin 4.8 mg/dl, alkaline phosphatase 24 I.U., AST 110 U/L and ALT 86 U/L. Ultrasonography showed right and left intrahepatic calculi with an abscess in left lobe of liver, dilated common bile duct (CBD) and gallstones. CT scan showed an abscess in the left lobe of liver with multiple bilateral intrahepatic calculi. ERCP revealed dilated CBD, biliary strictures with dilatation of some of the intrahepatic biliary radicals. An attempt was made to remove some of the calculi. In view of hepatolithiasis with development of an abscess in left lobe, patient was taken up for surgery. Segment 2 and 3 were resected with subtotal excision of CBD and Roux-en-Y hepaticojejunostomy. Macroscopic examination of left hepatectomy specimen was dark green and measuring 12 cm x 4 cm x 3 cm in dimensions. A localized area of 4 cm x 3 cm x 3 cm was grayish, dull and friable which was interpreted as abscess. The wall of an abscess was irregular, necrotic and smooth at places. Surrounding parenchyma showed dilated biliary radicals, some were impacted with black stones. Histopathology revealed multiple dilated bile ducts. One of which showed extensive ulceration of mucosa, dense mixed inflammation, filled with bile that was corresponding to an area of abscess. Lumina of some of the larger bile ducts were filled with tubular structures having smooth, long, linear defects with tapering ends that were surrounded by bile sludge and inflammatory cell reaction suggestive of adult helminthes with possibility of ascariasis. Surrounding liver showed features of secondary biliary cirrhosis. Postoperative period was uneventful. The patient was given broad-spectrum antihelminthic treatment orally and discharged. She is on regular follow-up for next 2 years without any complications. Discussion: Biliary ascariasis is a common problem in certain areas of world. Although it is not common in developed countries, with increasing air travel and immigration, one must be aware of this condition. It is predominantly a disease of adult women. 3 Duration of symptoms vary from few months to few years. These patients usually present with biliary colic (56%), acute cholangitis (25%), acute cholecystitis (13%), acute pancreatitis (6%) and rarely hepatic abscesses (less than 1%). 4 Our case also presented with recurrent attacks of cholangitis. Worms in the duodenum and invading the ampulla of Vater usually present as biliary colic or acute pancreatitis due to blocked CBD or pancreatic duct. Presence of dead worms form nidus for the CBD or hepatic stone formation. Further migration of worms into the intrahepatic duct causes secondary biliary cirrhosis, stricture formation, bile duct stenosis, hepatolithiasis and abscess formation. These worms also have high glucoronidase activity that deconjugates bilirubin and form pigment stones. The diagnosis of hepatolithiasis with ascariasis is usually possible on ultrasonography of the abdomen and ERCP. However in our case intrahepatic calculi were diagnosed on CT scan and ERCP but the presence of parasite (ascariasis) was noticed only after histopathology of the resected specimen. Though ERCP plays a major diagnostic and therapeutic role at times it may not help in the diagnosis of biliary ascariasis. This is due to active movement of the worms, which are going into and out of the biliary tract. 4 The treatment of hepatolithiasis with biliary ascariasis is endoscopic extraction of calculi and worms from the bile duct with or with out sphincterotomy which gives immediate relief. However in presence of complications hepatectomy is the only treatment of choice. Sphincteromy has got disadvantage in endemic areas, as these patients are prone to develop remigration of worms into biliary tree. Supportive anthelminthic treatment for long time is required in these cases. Improvement in sanitation plays crucial role in the epidemiological control of these hepatobiliary diseases. References: 1. Leung J W, Yu AS. Hepatolithiasis and biliary parasites. Baillieres Clin gastroenterol 1997; 11: 681-706. 2. Albert E, Yellin, Arthur J. Donovan. Biliary lithiasis and helminthiasis. Am J Surgery 1981; 142: 128-136. 3. Mohd Sultan Khuroo, Shawkat Ali Zargar. Biliary ascariasis. A common cause of biliary and pancreatic disease in an endemic area. Gastroenterol 1985; 88: 418423. 4. Khuroo MS, Zargar SA, Mahajan R. Hepatobiliary and pancreatic ascariasis in India. Lancet 1990; 29: 1503-1506. 5. Mishra SP, Dwivedi M. Clinical features and management of biliary ascariasis in non-endemic area. Postgraduate Med J 2000; 76: 29-32.