Hepatobiliary and pancreatic ascariasis

Table 1 Clinical syndromes related to ascariasis in endemic areas

Disease classification	Pathogenesis	Clinical syndromes
Ascaris pneumonia	Larval migration in lungs	Self-limiting pneumonia
		Status asthmaticus needing ICU admission
Intestinal ascariasis	Ascarides aggregation in small bowel lumen	Intestinal obstruction, bowel infarction and gangrene
Appendicular ascariasis	Ascaris blocking appendix orifice	Appendicular colic, appendicitis, appendicular gangrene
Peritoneal ascariasis	Ascaride-related gut perforation	Peritonitis, septic shock
Gastric ascariasis	Ascarides in stomach and esophagus	Pyloric obstruction (ascaris in antrum and blocking pylorus)
		Nocturnal chocking (ascaris traversing in to gullet at night)
		Unique retrosternal itching (ascarides in fundus and lower esophagus)
Hepatobiliary and pancreatic ascariasis	Duodenal ascariasis invading ampullary orifice	Biliary colic (duodenal ascariasis)
		Acute cholangitis (hepatic ascariasis; massive worm load can cause septic cholangitis and shock)
		Acalculous cholecystitis (choledochal or gall bladder ascariasis; ascarides in gall bladder may cause gall bladder gangrene)
		Hepatic abscess (hepatic ascariasis)
		Acute pancreatitis (duodenal ascariasis or pancreatic ascariasis, ascaride in pancreatic duct can cause necrotizing pancreatitis)
		Hepatolithiasis (dead ascarides in hepatic ducts forming nidus of sludge/stones)
Stunting of growth, cognitive dysfunction and malnutrition	High ascaride load in children	-

Table 2 Ultrasonography findings of hepatobiliary and pancreatic ascariasis

Site of ascarides	Ultrasonography findings
Stomach and duodenum	Long linear or curved echogenic strips without acoustic shadowing within water filled duodenum and stomach. The structures show active motility
Hepatobiliary ascariasis	Single or multiple long linear or curved echogenic structures without acoustic shadowing
	Thick long linear or curve non-shadowing echogenic strip containing a central longitudinal anechoic tube (four-line sign), representing the digestive tract of the worm
	Characteristic writhing movement of the echogenic strips within the ducts
	Gall bladder and cystic duct distension; gall bladder wall edema; sludge within gall bladder
	Multiple liver abscesses
Gall bladder ascariasis	Long coiled echogenic structure within gall bladder lumen
	Tubular echogenic structures within gall bladder lumen
	Echogenic structures exhibiting rapid movements
	Distended gall bladder, gall bladder wall edema
Pancreatic ascariasis	Long linear nonshadowing echogenic strips within a dilated pancreatic duct
	Edematous pancreas