What is the treatment for a worm in the Common Bile Duct (CBD)?

Treatment of Worm in the Common Bile Duct

For biliary ascariasis (worm in the CBD), endoscopic extraction via ERCP with sphincterotomy is the primary treatment, followed by anthelmintic therapy with albendazole 400 mg or mebendazole 500 mg as a single dose to eliminate intestinal worms and prevent recurrence. 1

Primary Treatment Approach

Endoscopic Management (First-Line)

• ERCP with endoscopic extraction is the definitive treatment for removing adult Ascaris lumbricoides worms from the biliary tree 2, 3
• Biliary sphincterotomy facilitates worm extraction and ensures adequate biliary drainage 1
• This approach is successful in the majority of cases when performed by experienced endoscopists 2, 3

Key technical considerations:

• Direct visualization and extraction of the worm(s) during ERCP is diagnostic and therapeutic 1, 2
• Multiple worms may be present and require complete clearance 4
• Ensure adequate biliary drainage is achieved to prevent cholangitis 1

Medical Therapy (Essential Adjunct)

After endoscopic worm removal, anthelmintic treatment is mandatory to eliminate intestinal worms and prevent migration back into the biliary system:

• Albendazole 400 mg PO as a single dose 1
• Alternative: Mebendazole 500 mg PO as a single dose 1
• Alternative: Ivermectin 200 μg/kg PO as a single dose 1

Surgical Management (Second-Line)

When Surgery is Indicated

Surgical intervention should be considered when:

• Endoscopic extraction fails or is not technically feasible 1
• Large worm burden prevents complete endoscopic clearance 4
• Complications develop (abscess formation, bile duct perforation) 3
• Dead worms are impacted and cannot be extracted endoscopically 5

Surgical Options

Laparoscopic bile duct exploration (LBDE) is the preferred surgical approach:

• Transcystic or transductal approach for worm extraction 1
• Can be combined with choledochoscopy for direct visualization 4
• Success rates approach 95% with appropriate expertise 1
• Associated with shorter hospital stay compared to open surgery 1

Open bile duct exploration is reserved for:

• Failed laparoscopic attempts 5
• Complex cases requiring bile duct reconstruction 5
• Anatomical difficulties preventing safe laparoscopic access 5

Management of Complications

Acute Cholangitis

If cholangitis develops:

• Urgent biliary decompression via ERCP is required 1
• Endoscopic stone/worm extraction and/or biliary stenting 1
• Broad-spectrum antibiotics per local protocols 1
• Patients failing medical therapy or with septic shock require emergency intervention 1

Subhepatic Abscess

• May develop as a delayed complication after worm extraction 3
• Can often be managed conservatively with antibiotics and drainage if needed 3
• Monitor closely for 7-14 days post-procedure 3

Critical Pitfalls to Avoid

Do not use anthelmintics alone without removing worms from the biliary tree:

• Dead worms in the CBD can cause persistent obstruction and cholangitis 5
• Medical therapy only addresses intestinal worms, not those already in the biliary system 1

Ensure complete worm clearance:

• Multiple worms are common; incomplete extraction leads to recurrent symptoms 4
• Follow-up imaging or repeat ERCP may be necessary if symptoms persist 3

Consider percutaneous drainage only when other options fail:

• Percutaneous transhepatic approach has higher complication rates (6.8% major complications) 1
• Reserve for cases where ERCP and surgery are not feasible 1

Post-Treatment Management

• Verify adequate biliary drainage with follow-up imaging if symptoms persist 1
• Complete anthelmintic course to prevent reinfection 1
• In endemic areas, consider screening and treating household contacts 1
• Monitor liver function tests to ensure resolution of obstruction 3