What is the recommended management of biliary ascariasis, including anti‑helminthic therapy, indications for endoscopic retrograde cholangiopancreatography, antibiotic treatment for cholangitis, supportive care, and preventive measures?

Management of Biliary Ascariasis

Initial Conservative Management

The majority of biliary ascariasis patients (72%) respond to conservative management with spontaneous passage of worms, making this the first-line approach in most cases. 1

Immediate Supportive Care

• Admit all patients to hospital for close monitoring and initiate nothing per os (NPO) status until symptoms resolve 1
• Administer intravenous fluids to maintain hydration during the NPO period 1
• Provide antispasmodics to relieve biliary colic and facilitate spontaneous worm migration 1
• Control pain with appropriate analgesics as upper abdominal pain occurs in 59% of patients 1

Antibiotic Therapy

• Initiate broad-spectrum antibiotics immediately in all hospitalized patients with biliary ascariasis 1

• Recommended regimens include:

  • Piperacillin/tazobactam 2
  • Imipenem/cilastatin 2
  • Meropenem 2
  • Ertapenem 2
  • 4th-generation cephalosporins 3

• For patients with cholangitis complications (13% of cases), administer antibiotics within 1 hour if septic shock is present, or within 4-6 hours for less severe presentations 3

• Continue antibiotics for 5-7 days for biliary peritonitis or biloma 2, 4

• Extend treatment to 2 weeks if Enterococcus or Streptococcus is isolated to prevent infectious endocarditis 2

Antihelminthic Therapy

• Administer albendazole 400 mg as soon as the patient can tolerate oral medication 1
• Do not delay antihelminthic therapy once oral intake is possible, as this facilitates worm expulsion 1
• Continue conservative management until patients are symptom-free before considering invasive interventions 1

Diagnostic Approach

Ultrasonography as Primary Tool

• Ultrasonography is the most reliable diagnostic modality for detecting worms in the biliary tree, with 100% detection rate in documented cases 1, 5
• Ultrasound findings include linear tubular echogenic structures within the common bile duct 6
• Use ultrasound for serial monitoring to track spontaneous worm passage during conservative management 7

Advanced Imaging When Needed

• Abdominal triphasic CT can detect ductal dilation and complications such as abscesses or fluid collections 2
• ERCP confirms diagnosis and allows therapeutic intervention when conservative management fails 5, 8

Endoscopic Intervention

Indications for ERCP

Defer endoscopic extraction until 3 weeks after initiating conservative management, except in patients with pyogenic cholangitis who require urgent endoscopic intervention. 1

• Perform urgent ERCP in patients with:
  • Pyogenic cholangitis (13% of cases) 1
  • Failed conservative management after 3 weeks 1
  • Persistent or worsening symptoms despite medical therapy 1
  • Obstructive jaundice (11% of cases) 1

Endoscopic Technique

• ERCP is the treatment of choice for biliary decompression with success rates exceeding 90% 3
• Extract worms using balloon catheter and/or snare during ERCP 8
• Endoscopic extraction provides prompt symptom relief in 67% of patients who require intervention 5
• Success rate for endoscopic extraction is 13% of total cases, as most resolve spontaneously 1

Special Considerations

• Patients with prior biliary sphincterotomy or choledochoduodenostomy are at higher risk for biliary ascariasis and should be monitored closely 5
• In pregnancy, use lead shielding and limit fluoroscopic exposure during ERCP to minimize teratogenic risk 7

Surgical Intervention

Indications for Surgery

Reserve surgical intervention for patients who fail both conservative management and endoscopic extraction, or when ERCP cannot be performed for technical reasons. 1

• Surgical treatment is required in approximately 15% of cases 1
• Operate urgently if complications develop:
  • Hepatic abscess (1.6% of cases) 1
  • Acute pancreatitis unresponsive to medical management (1.6% of cases) 1
  • Biliary peritonitis 2

Surgical Risks in Pregnancy

• Surgery carries significant risks of fetal wastage and premature labor in pregnant patients 7
• One case series reported 6.6% spontaneous abortion and 6.6% premature labor with surgical intervention 7

Management of Specific Complications

Cholangitis

• Early biliary drainage is essential for survival in severe cholangitis 3
• ERCP is the treatment of choice with success rates exceeding 90% 3
• Obtain bile cultures during drainage procedures for targeted antimicrobial therapy 3

Acute Pancreatitis

• Manage with enteral nutrition, IV pain medications, and fluid resuscitation 2
• Perform ERCP in patients with acute biliary pancreatitis and common bile duct obstruction as soon as possible 2
• Do not use prophylactic antibiotics routinely for acute pancreatitis 2

Preventive Measures

• Routine deworming of women in child-bearing years is recommended in endemic areas 7
• Maintain high index of suspicion in patients from endemic areas presenting with biliary symptoms 1, 7
• Consider biliary ascariasis even in urban populations due to increased travel and migration 8

Common Pitfalls to Avoid

• Do not delay antihelminthic therapy once oral intake is possible, as this is critical for worm expulsion 1
• Do not rush to endoscopic intervention in uncomplicated cases, as 72% resolve with conservative management alone 1
• Do not overlook biliary ascariasis in patients with prior sphincterotomy, as they are at higher risk 5
• Do not perform surgery prematurely in pregnant patients, as this significantly increases fetal risks 7
• Do not forget to obtain bile cultures in patients requiring drainage for cholangitis 3