Bilo-pancreatic Ascaris Lumbricoides infestation. Endoscopic discovery and removal

Ascaris Lumbricoides infestation is relatively rare in industrialized countries, and it occurs mainly in conditions in which hygiene is lacking. We describe here a case of a 39-year-old female from ex-Jugoslavia affected by recurrent hepatic colic. At entry ultrasonography revealed microlithiasis in the gallbladder and widening of the pancreatic head. The subsequent ERCP showed slight filling defects in the choledochus and an inflammation-like stricture of the papilla of Vater, and after endoscopic sphincterotomy we saw an outflow of dense bile and microlitholits. Thus, a standard surgical cholecystectomy was carried out and the patient was dismissed on the 3rd postoperative day without any symptoms. However, the patient was admitted again after four days for a new coliky pain attack. An upper endoscopy showed a 23 cm long mobile parasite in the duodenum: it was caught with the polypectomy loap, extracted and identified as A. Lumbricoides. The patient's symptoms disappeared after the endoscopic removal of the worm and she was dismissed the day after the worm's removal. No recurrence of symptoms was noted during a 1-year follow-up. This case showed that A. Lumbricoides infestation of the biliary tree should be considered when biliary and/or pancreatic symptoms recur, especially in patients coming from undeveloped countries. At the same time we showed that endoscopic removal is a safe and effective treatment for this infestation.