Indian Journal of Radiology and Imaging Indian Journal of Radiology and Imaging

GASTROINTESTINAL
Year
: 2006  |  Volume : 16  |  Issue : 4  |  Page : 571--572

Isolated pancreatic duct ascariasis in a child


S Sardessai, M Sharma, G Barreto 
 Dept of Radiology, Goa Medical College, Bambolim, Goa, India

Correspondence Address:
M Sharma
Room No217, RMO«SQ»s Hostel, GMC, Bambolim, Goa
India




How to cite this article:
Sardessai S, Sharma M, Barreto G. Isolated pancreatic duct ascariasis in a child.Indian J Radiol Imaging 2006;16:571-572


How to cite this URL:
Sardessai S, Sharma M, Barreto G. Isolated pancreatic duct ascariasis in a child. Indian J Radiol Imaging [serial online] 2006 [cited 2019 Nov 20 ];16:571-572
Available from: http://www.ijri.org/text.asp?2006/16/4/571/32271


Full Text

 Introduction



The global incidence of acute pancreatitis as a result of Ascaris infection is unknown because many cases go largely undiagnosed [2]. Although Ascaris-induced pancreatitis is predominantly diagnosed in tropical countries, it has been reported in the developed world, as well [7]. To our knowledge, only four cases of isolated pancreatic duct ascariasis, in all age groups, have been reported earlier in India [3].

 Case Report



A 10-year-old boy presented with H/O pain in upper abdomen associated with vomiting of round worms. Per abdomen, there was fullness in the epigastrium with tenderness and guarding. No rebound tenderness was present and bowel sounds were normal. Preliminary blood investigations including blood counts and renal functions revealed no abnormality. However, serum amylase and urinary amylase were markedly elevated. Liver function tests were normal. RBC's, pus cells and roundworm ova were detected in the routine stool examination. An abdominal USG was requested.

The ultrasound revealed the pancreas to be bulky and hypoechoic with a linear, echogenic structure in the pancreatic duct [Figure 1] s/o round worm. A small collection in the region of the tail of pancreas was noted. The CBD and IHBR's were normal.

The patient was managed conservatively with nasogastric suction, IV fluids and antibiotics. Piperazine was used as well. The boy made a complete clinical recovery with the repeat ultrasound done after one week showing no evidence of the worm in the duct.

 Discussion



Ascaris lumbricoides causes pancreatitis due to obstruction of papilla of Vater, invasion of common bile duct, or invasion of pancreatic duct. Ascension of the parasite into the pancreatic ducts and calcified worm and ova remains are implicated in pancreatitis [1].

The worm enters the pancreatic duct only as a result of abnormal migration. The clinical diagnosis of Ascaris pancreatitis requires a high degree of suspicion. While intestinal obstruction is more common in children, pancreatic ascariasis, unlike in adults, is rare. The hepatobiliary duct network in children is smaller and thus more difficult for worm entry. The mean age of patients who present with HPA is 35 years (range, 4 to 70 years), with a female-to-male ratio of nearly 3:1 [1].Previous surgeries as well as endoscopic sphincterotomy result in widened ampullary diameter; facilitating entry for roundworms.

Ascaris related clinical disease is not just restricted to patients with a heavy worm load [6] but may be seen with a single worm lodged in the biliary tract and negative parasitic tests in the stools [7].

Pain is sudden in onset but may be gradual, the epigastrium being the commonest location. Other accompanying symptoms are vomiting, nausea and anorexia [6], jaundice with fever being a sign of associated biliary tract involvement.

In the biochemical evaluation, the sensitivity of amylase in pediatric acute pancreatitis is less than in adults. Even then, it remains the most widely used single test in acute pancreatitis. The serum level rises within 2 to 12 hours.

Some studies claim that stool examination lacks sensitivity and specificity [3], however in our case; the diagnosis was substantiated further with the stool report.

Diagnostic ultrasonography is a simple, non-invasive test with a sensitivity of 50% to 86% for worms in the biliary tree; but the sensitivity for detecting worms in the pancreatic duct is unknown [3],[4].

The two major sonographic findings are:

1) increased bulk and decreased echogenicity of pancreas.( Fleischer AC,et al, 1983)

2) Long, linear, echogenic strips in the pancreatic duct, that may show acoustic shadowing [7].

A CT scan can also be useful but has a lower sensitivity than ultrasonography [2].

Conservative, supportive management of pediatric pancreatitis is still an accepted form of therapy [5]. Relief of pain, reduction of exocrine pancreatic secretion, by keeping the patient nil by mouth with nasogastric suction, and intravenous fluids to correct shock and electrolyte abnormalities, are required for more than five days. Anthelmintic therapy with piperazine is preferred though mebendazole or albendazole is effective in eradicating ascariasis in 84% to 100% of cases [4]. Feedings should be restarted when abdominal tenderness has disappeared, any ileus has resolved, and urinary amylase clearance has become normal.

The prognosis of Ascaris-induced pancreatitis is excellent if the patient is diagnosed and treated early. It requires prompt recognition and treatment to prevent complications [2].

References

1Khuroo MS: Ascariasis. Gastroenterol Clin North Am 1996; 25:553-577
2Sandouk F, Haffar S, Zada M, et al: Pancreatic-biliary ascariasis: experience of 300 cases. Am J Gastroenterol 1997; 92:2264-2267
3Khuroo MS, Zargar SA, Yatoo P, et al: Ascaris-induced acute pancreatitis. Br J Surg 1992; 79:1335-1338
4Larrubia JR, Ladero JM, Mendoza JL, et al: The role of sonography in the early diagnosis of biliopancreatic Ascaris infestation. J Clin Gastroenterol 1996; 22:48-50
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