What is the treatment for biliary ascariasis?

Treatment of Biliary Ascariasis

The primary treatment for biliary ascariasis is endoscopic extraction of the worm via ERCP, which successfully removes worms in nearly all cases and rapidly resolves symptoms, combined with anthelmintic therapy to eliminate intestinal worms and prevent recurrence. 1, 2

Immediate Management Approach

Endoscopic Extraction (First-Line Definitive Treatment)

• ERCP with worm extraction is the treatment of choice and achieves successful removal in 99% of cases (298 of 300 patients) without procedure-related complications. 1
• Perform ERCP urgently if the patient presents with complications such as ascending cholangitis (occurs in 16% of cases), acute pancreatitis (4.3%), or obstructive jaundice (1.3%). 1
• Endoscopic management results in rapid symptom resolution and prevents development of life-threatening complications. 1, 2
• Ultrasonography should be used initially to detect worms in the biliary tract and pancreas as a noninvasive diagnostic technique before proceeding to ERCP. 2

Antibiotic Therapy for Complications

If ascending cholangitis is present (16% of biliary ascariasis cases), initiate antibiotics immediately: 1

For non-critically ill patients with cholangitis:

• Amoxicillin/clavulanate 2g/0.2g every 8 hours as first-line oral therapy for mild cases. 3, 4
• Piperacillin/tazobactam 4g/0.5g every 6 hours IV for moderate-to-severe cases. 3, 4

For critically ill patients or septic shock:

• Piperacillin/tazobactam 6g/0.75g loading dose, then 4g/0.5g every 6 hours (or 16g/2g continuous infusion). 3, 5
• Alternative: Meropenem 1g every 6 hours by extended infusion, or ertapenem 1g every 24 hours. 3, 5
• Add amikacin for enhanced gram-negative coverage if septic shock develops. 5

Duration of antibiotic therapy:

• Continue for 4 days after adequate source control (endoscopic worm extraction) in immunocompetent patients. 3
• Extend to 7 days in immunocompromised or critically ill patients based on clinical response. 3

Anthelmintic Therapy (Essential for Prevention)

After endoscopic worm extraction, administer anthelmintic drugs to eliminate intestinal worms and prevent recurrence: 2

• Albendazole (preferred): 400mg single dose or twice daily for 3 days. 2
• Mebendazole: 100mg twice daily for 3 days or 500mg single dose. 2
• Pyrantel pamoate: 11mg/kg single dose (maximum 1g). 2
• Levamisole: Alternative option for mass therapy in endemic areas. 2

Surgical Management (Reserved for Specific Situations)

Surgery is indicated only when endoscopic extraction fails or is unavailable: 1, 2

• Cholecystectomy with common bile duct exploration and T-tube choledochostomy for cases where ERCP is unsuccessful or unavailable. 6
• Open surgical exploration carries 20-40% morbidity and 1.3-4% mortality, making it inferior to endoscopic management. 7
• Laparoscopic CBD exploration has 95% success rates with 5-18% complication rates if endoscopic approach fails. 7

Critical Clinical Pitfalls to Avoid

Never delay biliary drainage in patients with cholangitis - antibiotics alone without worm extraction will not resolve the obstruction or sterilize the biliary tract. 3, 5

Always suspect biliary ascariasis in endemic areas when patients present with biliary symptoms, especially if they have undergone previous cholecystectomy (80% of cases) or sphincterotomy (77% of cases), as these procedures ablate the normal sphincter mechanism and facilitate worm migration. 1, 8

Do not forget anthelmintic therapy after worm extraction - failure to treat intestinal ascariasis allows recurrent biliary invasion. 2

Consider biliary ascariasis in the differential diagnosis of obstructive jaundice in patients from endemic areas, as this is a rare but important cause. 6

Special Populations and Risk Factors

• Biliary ascariasis occurs predominantly in adult women in endemic areas. 2
• History of worm emesis is present in 25% of cases and should raise suspicion. 1
• Previous biliary surgery (cholecystectomy or sphincterotomy) dramatically increases risk due to loss of sphincter barrier function. 1, 8
• Recurrent biliary invasion can lead to recurrent pyogenic cholangitis and hepatic duct stone formation as a long-term complication. 2, 9