Management of biliary Ascaris lumbricoides in Kabul, Afghanistan: crossroads of advancing technology

Abstract

The case is presented of the successful removal of a dead Ascaris lumbricoides from the right hepatic duct of a middle aged woman from a rural province in Afghanistan. The case was started laparoscopically, but converted to an open procedure because of difficulty identifying the anatomic landmarks required to safely perform laparoscopic cholecystectomy. After worm removal, the common bile duct (CBD) was reconstructed with a Roux-en-Y hepaticojejunostomy. The patient was discharged on postoperative day 7 and was doing well when seen in the outpatient clinic 2 weeks later.

Background

Health care professionals play an important role in rebuilding the infrastructure of nations devastated by war, such as Afghanistan. Inevitably, their efforts promote the use of advanced technologies which when used reveal the interconnectedness of other supporting technologies.

With respect to hepatobiliary disease, laparoscopic surgery was first introduced to Afghanistan in 2006.¹ Other supporting technologies such as endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous cholangiography (PTC) have not yet been introduced. This case highlights the difficulties encountered by surgeons seeking to implement laparoscopic surgery in a developing nation because in the developed world, ERCP and PTC play an integral supporting role in managing biliary disease, including biliary ascaris which is far more common in developing nations. The laparoscopic surgeon must have a lower threshold for converting to an open cholecystectomy to minimise avoidable complications and a high index of suspicion regarding helminth infections to avoid missing its diagnosis. Rebuilding developing nations requires introduction of new technologies, but in the health care sector, clinicians must proceed with caution.

Case presentation

A middle age woman who worked with livestock in one of Afghanistan’s rural provinces presented with a 3 month history of intermittent, moderately severe right upper quadrant pain. The pain was not related to eating. There was no history of fever, chills, or jaundice. The patient’s further medical history and family history were unremarkable. Physical examination was unremarkable except for right upper quadrant tenderness with deep palpation.

Investigations

Laboratory data were unremarkable including normal liver function tests (LFTs) and white blood cell count (WBC). A sonogram showed a contracted gallbladder. The common bile duct (CBD) was described as normal and 1 cm in size. No gallstones were seen.

Differential diagnosis

• Calculous biliary colic

• Acalculous cholecystitis

• Gallbladder carcinoma

• Helminth infection of the biliary system.

Treatment

Laparoscopic cholecystectomy was planned. At laparoscopy, identification of the cystic/CBD junction was not possible and after conversion to an open procedure, dissection revealed that the gallbladder was fused with the CBD at the level of the infundibulum. While completing the cholecystectomy, the CBD was opened at the area of fusion with the CBD and exploration revealed a dead ascaris (fig 1) entirely within the right hepatic radical of the CBD. The worm was extracted intact and the CBD reconstructed with a Roux-en-Y choledochojejunostomy. The patient was treated with anti-helminth medications postoperatively.

Figure 1.

Ascaris lumbricoides removed from common bile duct.

Outcome and follow-up

The patient was discharged from the hospital after a 1 week stay and was fine 2 weeks later in the outpatient clinic.

Discussion

The majority of the world’s inhabitants remain at serious risk of dying from treatable infectious diseases. Ascaris lumbricoides, a soil transmitted helminth, is one such example of an illness affecting approximately 1472 million people worldwide.² This parasitic roundworm is endemic in developing nations and tropical regions, and is also being diagnosed with increasing frequency in developed nations due to the increasing cross cultural mobility of the world’s population.^3–5

Although usually asymptomatic at minimal worm burden, inflammation, fever and diarrhea may be presented. Serious complications are usually associated within hosts harbouring larger worm burdens, but may also occur from the migration of a single adult ascaris beyond the intestinal tract.^6,7 Cases of acute pancreatitis, obstructive jaundice, hepatic abscess, and post-cholecystectomy syndrome have been described.^8–12 In the developed world, diagnosis is dependent on a high index of suspicion based on a history of travel to areas where ascaris is endemic. Diagnosis can be facilitated by microscopic examination of a stool smear. The utility of ultrasonography as the initial imaging modality to confirm biliary ascaris has been well documented.^13–16 Likewise, management of biliary ascaris with ERCP both as a diagnostic and therapeutic modality to remove ascaris from the papillary orifice, CBD and pancreatic duct has been well documented.^3–10,17 However, complete worm extraction either by ERCP or surgery is only necessary to treat complications. The mainstay of management is administration of anti-helminth drugs and at times is all that is required in cases of uncomplicated biliary ascaris.^18–20 The finding of a dead ascaris has been described by others and often leads to subsequent development of liver abscess.^21–23 ERCP has found its greatest utility in the management of severe complications secondary to biliary ascaris such as ascending cholangitis, CBD stricture, and pancreatitis. In cases refractory to management by ERCP or where it is not available, surgical exploration of the CBD, either by laparoscopy or laparotomy, is indicated.^24,25 We recently reported the experience of the first training programme for laparoscopic cholecystectomy in Afghanistan.¹ Because of the biomedical and equipment challenges inherent in laparoscopy, maintaining this programme so that it continues to achieve results similar to those in the developed world is a constant challenge. Without the support of ERCP, PTC or other higher end technologies, CBD injury must be assiduously avoided. The surgeon must have a low threshold for deciding when to convert the laparoscopic procedure to an open one. Cases of severe acute, gangrenous, and pyogenic cholecystitis should be converted quickly as should any case with findings suggestive of choledocholithiasis. Likewise, in cases such as this where cholecystectomy cannot be safely accomplished due to obscuring of normal anatomic landmarks, conversion to open cholecystectomy is mandatory and may lead to the diagnosis of intrabiliary helminth infection.

Learning points

• Advancing medical technology in developing nations requires caution.

• Biliary surgeons must have a high degree of suspicion for helminth infections in the developing world.

• Microscopic examination of stool specimens is an effective and inexpensive way to screen for gastrointestinal helminth infection.

• Conversion from laparoscopic to open cholecystectomy will be required more often in the developing world.

• Sonography is the non-invasive diagnostic modality of choice for uncomplicated intrabiliary helminth infection.

• ERCP is the diagnostic procedure of choice for complicated intrabiliary infection in the developed countries.