Endoscopic diagnosis and management of biliary parasitosis
- D Nageshwar Reddy, MD
D Nageshwar Reddy, MD
- Director & Chief Gastroenterologist
- Asian Institute of Gastroenterology
- Hyderabad, India
- Amitabh Monga, MBBS, MD, MRCP (UK), FAMS
Amitabh Monga, MBBS, MD, MRCP (UK), FAMS
- Consultant, Dept. of Gastroenterology & Hepatology
- Raffles Internal Medicine Centre, Singapore
Parasitic infections of the biliary tract are a major concern in the tropical and subtropical countries with significant morbidity and mortality. Clinicians in other parts of the world should also be aware of these infections in view of increasing travel and migration.
Infestations of the hepatic and extrahepatic biliary tree occur most commonly with Ascaris lumbricoides, Clonorchis sinensis, Opisthorchis felineus, and Fasciola hepatica. Other hepatobiliary parasites include Opisthorchis viverrini, Fasciola gigantica, and Dicrocoelium dendriticum.
Helminthic infestation affects the liver and the biliary tract either during transit of worms or because these organs serve as natural habitats. Worms in the bile ducts may produce features of recurrent pyogenic cholangitis or acute pancreatitis [1,2], liver cysts and abscesses may occur due to ascariasis or liver flukes , and hepatic Echinococcal cysts can rupture into the biliary tract, producing cholangitis. Endoscopic retrograde cholangiopancreatography has now become the main diagnostic and therapeutic tool in these patients.
This topic will review the endoscopic diagnosis and management of biliary parasitosis. Detailed discussions of the various parasites and a discussion of recurrent pyogenic cholangitis can be found elsewhere. (See "Ascariasis" and "Epidemiology and control of echinococcosis" and "Treatment of echinococcosis" and "Liver flukes: Clonorchis, Opisthorchis, and Metorchis" and "Liver flukes: Fascioliasis" and "Recurrent pyogenic cholangitis".)
The roundworm, A. lumbricoides, is globally one of the most highly prevalent helminthic parasites in humans, infecting an estimated one billion people (see "Ascariasis"). Fortunately, it only infrequently produces symptomatic disease. A. lumbricoides organisms normally reside in the jejunum but are actively motile and can invade the papilla, thus migrating into the bile duct and causing biliary obstruction with a variety of hepatobiliary complications. The following disease associations were observed in a series from Kashmir, India of 500 patients with hepatobiliary and pancreatic disease due to Ascaris :
- Yellin AE, Donovan AJ. Biliary lithiasis and helminthiasis. Am J Surg 1981; 142:128.
- Belkouch A, Mouhsine A. Hydatid cyst ruptured in the biliary duct: an exceptional cause of acute pancreatitis. Pan Afr Med J 2014; 18:298.
- Schulman A. Non-western patterns of biliary stones and the role of ascariasis. Radiology 1987; 162:425.
- Khuroo MS, Zargar SA, Mahajan R. Hepatobiliary and pancreatic ascariasis in India. Lancet 1990; 335:1503.
- Javid G, Zargar S, Shah A, et al. Etiology and outcome of acute pancreatitis in children in Kashmir (India). An endemic area of hepatobiliary ascariasis. World J Surg 2013; 37:1133.
- Wani NA, Shah OJ, Naqash SH. Postoperative biliary ascariasis: presentation and management--experience. World J Surg 2000; 24:1143.
- Khuroo MS, Zargar SA, Mahajan R, et al. Sonographic appearances in biliary ascariasis. Gastroenterology 1987; 93:267.
- Ding ZX, Yuan JH, Chong V, et al. 3 T MR cholangiopancreatography appearances of biliary ascariasis. Clin Radiol 2011; 66:275.
- Mijandrusić-Sincić B, Stimac D, Kezele B, et al. Acute pancreatitis caused by Ascaris lumbricoides: a case report. Gastrointest Endosc 2008; 67:541.
- Beckingham IJ, Cullis SN, Krige JE, et al. Management of hepatobiliary and pancreatic Ascaris infestation in adults after failed medical treatment. Br J Surg 1998; 85:907.
- Sandouk F, Haffar S, Zada MM, et al. Pancreatic-biliary ascariasis: experience of 300 cases. Am J Gastroenterol 1997; 92:2264.
- Thandassery RB, Jha AK, Goenka MK. Biliary ascariasis: an uncommon cause for recurrent biliary colic after biliary sphincterotomy and common bile duct stone removal. Trop Doct 2014; 44:108.
- Alam S, Mustafa G, Ahmad N, Khan M. Presentation and endoscopic management of biliary ascariasis. Southeast Asian J Trop Med Public Health 2007; 38:631.
- Bektaş M, Dökmeci A, Cinar K, et al. Endoscopic management of biliary parasitic diseases. Dig Dis Sci 2010; 55:1472.
- Magistrelli P, Masetti R, Coppola R, et al. Value of ERCP in the diagnosis and management of pre- and postoperative biliary complications in hydatid disease of the liver. Gastrointest Radiol 1989; 14:315.
- al-Karawi M, Sanai FM, Yasawy MI, Mohammed AE. Biliary strictures and cholangitis secondary to ascariasis: endoscopic management. Gastrointest Endosc 1999; 50:695.
- Albonico M, Smith PG, Hall A, et al. A randomized controlled trial comparing mebendazole and albendazole against Ascaris, Trichuris and hookworm infections. Trans R Soc Trop Med Hyg 1994; 88:585.
- Dadoukis J, Gamvros O, Aletras H. Intrabiliary rupture of the hydatid cyst of the liver. World J Surg 1984; 8:786.
- Iscan M, Düren M. Endoscopic sphincterotomy in the management of postoperative complications of hepatic hydatid disease. Endoscopy 1991; 23:282.
- Spiliadis C, Georgopoulos S, Dailianas A, et al. The use of ERCP in the study of patients with hepatic echinococcosis before and after surgical intervention. Gastrointest Endosc 1996; 43:575.
- Dumas R, Le Gall P, Hastier P, et al. The role of endoscopic retrograde cholangiopancreatography in the management of hepatic hydatid disease. Endoscopy 1999; 31:242.
- Tarcin O. Rupture of hydatid cyst into the biliary tract. Gastrointest Endosc 2006; 63:325.
- Al Karawi MA, Mohamed AR, Yasawy I, Haleem A. Non-surgical endoscopic trans-papillary treatment of ruptured echinococcus liver cyst obstructing the biliary tree. Endoscopy 1987; 19:81.
- Khoshbaten M, Farhang S, Hajavi N. Endoscopic retrograde cholangiography for intrabiliary rupture of hydatid cyst. Dig Endosc 2009; 21:277.
- de Aretxabala X, Perez OL. The use of endoprostheses in biliary fistula of hydatid cyst. Gastrointest Endosc 1999; 49:797.
- Tekant Y, Bilge O, Acarli K, et al. Endoscopic sphincterotomy in the treatment of postoperative biliary fistulas of hepatic hydatid disease. Surg Endosc 1996; 10:909.
- Bilsel Y, Bulut T, Yamaner S, et al. ERCP in the diagnosis and management of complications after surgery for hepatic echinococcosis. Gastrointest Endosc 2003; 57:210.
- Rodriguez AN, Sánchez del Río AL, Alguacil LV, et al. Effectiveness of endoscopic sphincterotomy in complicated hepatic hydatid disease. Gastrointest Endosc 1998; 48:593.
- Yilmaz U, Sakin B, Boyacioglu S, et al. Management of postoperative biliary strictures secondary to hepatic hydatid disease by endoscopic stenting. Hepatogastroenterology 1998; 45:65.
- Eickhoff A, Schilling D, Benz CA, Riemann JF. Endoscopic stenting for postoperative biliary strictures due to hepatic hydatid disease: effectiveness and long-term outcome. J Clin Gastroenterol 2003; 37:74.
- Suarez-Munoz MA, Fernandez-Aguilar JL, Sanchez-Perez B, et al. Risk factors and classifications of hilar cholangiocarcinoma. World J Gastrointest Oncol 2013; 5:132.
- Leung JW, Sung JY, Banez VP, et al. Endoscopic cholangiopancreatography in hepatic clonorchiasis--a follow-up study. Gastrointest Endosc 1990; 36:360.
- Badalov NL, Anklesaria A, Torok A, et al. Fasciola hepatica causing acute pancreatitis complicated by biliary sepsis. Gastrointest Endosc 2009; 70:386.
- Cheung J, Enns R, Romney M, et al. Biliary fascioliasis. Gastrointest Endosc 2005; 61:596.
- Gandhi V, Jain P, Rathod V, Nagral S. Endoscopic ultrasound in biliary fasciolosis. Indian J Gastroenterol 2010; 29:128.
- Ashrafi K, Bargues MD, O'Neill S, Mas-Coma S. Fascioliasis: a worldwide parasitic disease of importance in travel medicine. Travel Med Infect Dis 2014; 12:636.
- Dowidar N, El Sayad M, Osman M, Salem A. Endoscopic therapy of fascioliasis resistant to oral therapy. Gastrointest Endosc 1999; 50:345.
- Dias LM, Silva R, Viana HL, et al. Biliary fascioliasis: diagnosis, treatment and follow-up by ERCP. Gastrointest Endosc 1996; 43:616.
- ASCARIS LUMBRICOIDES
- Radiographic imaging
- Role of ERCP
- ECHINOCOCCUS GRANULOSUS
- - Preoperative ERCP
- - Post-operative ERCP
- CLONORCHIS SINENSIS
- Pathogenesis of biliary injury
- Clinical manifestations
- Characteristics on cholangiography
- FASCIOLA HEPATICA
- Role of ERCP/endoscopic ultrasonography
- SUMMARY AND RECOMMENDATIONS