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Special Feature
Oct 2011

Picture of the Month—Diagnosis

Arch Pediatr Adolesc Med. 2011;165(10):958. doi:10.1001/archpediatrics.2011.156-b

Endoscopic US revealed multiple rounded echogenic structures with a hypoechoic center in a dilated CBD (about 14 mm), consistent with biliary ascariasis. Side-view endoscopy showed 2 live roundworms projecting from the ampullary orifice (Figure 2). Endoscopic retrograde cholangiopancreatography revealed multiple roundworms, which were extracted using a rat-tooth forceps (Figure 3). Worms inside the CBD and left hepatic duct were removed by a balloon, resulting in complete symptom relief. She received 1 dose of albendazole.

Ascariasis is the most common helminthic infection worldwide. While most cases occur in Asia and a modest number in Africa and the Middle East, some cases also occur along the Gulf Coast of the United States and in areas in Central and South America. It is acquired by consumption of food or water contaminated with eggs of Ascaris lumbricoides, a roundworm. The eggs hatch on reaching the small intestine and the resultant larvae penetrate the intestinal wall, migrating to the liver and lungs. The larvae pass up the trachea and are swallowed to reach the small intestine where they mature into adult worms.

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