Post written by Zaheer Nabi, MD, DNB, from the Asian Institute of Gastroenterology, Hyderabad, India.

The video case describes a 3-year-old child presenting with recurrent episodes of acute pancreatitis. Etiological evaluation revealed multiple calculi in the gallbladder on transabdominal ultrasonography. Expecting a calculus in the bile duct, we performed an endosonography to confirm. Surprisingly, endosonography revealed a parallel and linear echogenic structure with an anechoic center in the bile duct suggestive of a biliary Ascaris worm. There was no obvious calculus in the bile duct. Subsequently, endoscopic retrograde cholangiopancreatography was performed, and a total of 4 Ascaris worms were extracted: 2 from the second part of duodenum and 2 from the bile duct. In brief, endotherapy included guidewire-assisted biliary cannulation, sphincterotomy, and balloon sweep for clearance of the bile duct. De-worming of the child as well as the family members was advised. This child did not suffer any further episodes of pancreatitis through last follow-up.

This video highlights the importance of adequate biliary imaging for the evaluation of recurrent pancreatitis in children. In this case, gallbladder calculi were initially thought to be the cause of recurrent pancreatitis. However, endosonography revealed biliary Ascariasis, and the child improved with endotherapy alone. The characteristic appearance of an Ascaris worm on endosonography is a hyperechoic structure with a central hypoechoic tube and without acoustic shadowing. Endosonography is helpful in selecting cases that require subsequent endotherapy. Endoscopic retrograde cholangiopancreatography is not risk free and should be performed only when a therapeutic intervention is expected.

Biliary Ascariasis is not an uncommon cause of pancreatitis and should be considered in endemic regions. Transabdominal ultrasonography is a useful initial modality to screen bile ducts. However, ultrasonography may not detect worms in the duodenum or at the ampullary orifice. Therefore, endosonography or magnetic resonance cholangiopancreatography should be considered as a part of an etiological work-up in children with suspected biliary and pancreatic Ascariasis. Endosonography can be safely performed in small children, and endotherapy can be contemplated under the same sedation if required. Although endotherapy is usually successful in such cases, re-infestation is not uncommon and periodic deworming should be done.

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