Recurrent acute pancreatitis in a toddler: a “wormy surprise”

A 3-year-old child presented for medical attention because of a history of recurrent episodes of acute pancreatitis. Evaluation revealed elevated transaminases (alanine aminotransferase, 340 IU/L; aspartate aminotransferase, 400 IU/L). US of the abdomen revealed multiple gallbladder calculi and dilatation of the common bile duct. EUS was performed with a radial echoendoscope, with the patient under deep sedation, and revealed dilatation of the common bile duct (6.6 mm) (Fig. 1A) with a parallel linear echogenic structure (Video 1, available online at www.VideoGIE.org). The central portion of this linear structure was anechoic, and there was no shadow effect (Fig. 1B). These findings were suggestive of biliary ascariasis. The Ascaris worm could be traced up to the intrahepatic duct. In addition to the above findings, the gallbladder calculi were present (Fig. 1C). During the same session, endoscopic cholangiography (ERC) was performed. An adult duodenoscope was used for the procedure. On insertion of the duodenoscope into the second part of the duodenum, a long creamy white worm was seen near the papilla. This worm was extracted with rat-tooth forceps (Fig. 1D). Subsequently, the bile duct was cannulated by use of a sphincterotome-guidewire complex. Cholangiography showed a linear filling defect in the common bile duct (Fig. 1E). Endoscopic sphincterotomy was performed, and a live worm was extracted from the bile duct with a biliary balloon, followed by its removal from the duodenum with rat-tooth forceps (Fig. 1F). The duodenoscope was reinserted to obtain an occlusion cholangiogram. During the second insertion of the duodenoscope, another live worm was found in the second part of the duodenum and was extracted with forceps. Cholangiography was performed to confirm clearance of the bile duct and showed a faintly visible linear filling defect in the left hepatic duct. A balloon sweep was done, and a flat, dead, partially bile-stained worm was removed (Fig. 1G). The final occlusion cholangiogram revealed no filling defect (Fig. 1H). The child and family members were dewormed with albendazole. Deworming is recommended at regular intervals in endemic regions.