A 25 yrs female was referred to us for the favor of EUS sos ERCP for suspected block in the CBD leading to recurrent epigastric pain with mild LFT abnormality and no stones were seen in Gall bladder on USG abdomen, however, mild dilatation of CBD was seen without any obvious stone or filling defects. EUS at Endoscopy Asia revealed a large tubular structure in the dilated CBD and this was suspected to be a large round worm. There was no other pathology in the pancreato-biliary system apart from this findings and therefore ERCP was considered. ERCP showed a filling defect on cholangiogram and confirmed the EUS findings. Biliary sphincterotomy was performed and the round worm was extracted using a stone extraction balloon catheter. Few more live round worms were also seen in the third part of duodenum and therefore after ductal clearance a 7 fr stent was placed to ensure effective ductal drainage. Patient was treated on an OPD basis and sent home the same day.
Expert Comments
As we have seen in the previous case that patients with obstructive jaundice without a definitive diagnosis of etiology of obstructive jaundice can be diagnosed accurately on EUS.
Here we managed to clear the duct of a live round worm which was causing intermittent obstruction of the bile flow leading to mild LFT abnormality and severe epigastric pain. This patient was then given oral antihelminthic medication to take care of rest of the round worms. Since there are still some serious hygienic issues in our society especially in the rural and slum areas that we have to keep such pathology in mind at the time of management of such patients.
I would like to share here with our readers that it is a standard protocol at Endoscopy Asia that unless EUS proves that there is a definitive pathology in the bile duct that needs treatment we will not proceed with ERCP. In other words we at Endoscopy Asia do not have negative ERCP so to speak and in the era of such accurate modalities such as EUS & MRCP, diagnostic ERCP has no role in most cases.