e-ISSN: 2722-3558 Sriwijaya Journal of Surgery [SJS] https://sriwijayasurgery.
Isolated Gallbladder Ascariasis Causing Acalculous Hydrops: Management of a Rare Surgical Entity Muhammad Arisma Dwirian Putra1*.
Ahmad Fakhrozi Helmi1.
Ali Hanafiah2.
Alsen Arlan3 1Department of Surgery.
Faculty of Medicine.
Universitas Sriwijaya.
Palembang.
Indonesia 2Department of Surgery.
Dr.
Mohamad Rabain Regional General Hospital.
Muara Enim.
Indonesia 3Department of Surgery.
Faculty of Medicine.
Universitas Sriwijaya/Dr.
Mohammad Hoesin General Hospital.
Palembang.
Indonesia
ARTICLE
INFO
Keywords:
Acalculous cholecystitis Ascaris lumbricoides Cystic duct obstruction Gallbladder hydrops Neglected tropical diseases *Corresponding author:
Muhammad Arisma Dwirian Putra E-mail address:
arismadputra@gmail.
All authors have reviewed and approved the Anal version of the manuscript.
https://doi.
org/10.
37275/sjs.
ABSTRACT
Introduction: Ascariasis, caused by the nematode Ascaris lumbricoides, affects approximately one billion people globally.
While hepatobiliary involvement is a recognized complication, isolated gallbladder ascariasis is exceptionally rare, accounting for less than 2.
1% of biliary cases due to the anatomical resistance provided by the tortuous valves of Heister.
This condition presents a significant diagnostic dilemma, often mimicking acute acalculous cholecystitis, and carries a high risk of complications if Case presentation: We report the case of a 57-year-old female presenting with acute-on-chronic right upper quadrant pain.
Physical examination revealed localized tenderness without jaundice.
Laboratory investigations demonstrated leukocytosis .
,460/mmA), significant eosinophilia .
absolute count 1,236/mmA), and cholestasis with elevated Alkaline Phosphatase .
U/L).
Ultrasonography, the diagnostic gold standard, revealed a distended gallbladder consistent with hydrops and a mobile, tubular echogenic structureAithe inner tube signAiextending into the cystic duct.
The patient underwent an open cholecystectomy.
Intraoperatively, a critical retrograde milking maneuver was performed to dislodge the worm from the cystic duct back into the gallbladder to prevent The Common Bile Duct was palpated and confirmed to be free of stones or parasites.
A viable Ascaris worm was extracted from the Conclusion: Isolated gallbladder ascariasis must be considered in the differential diagnosis of acalculous biliary disease in endemic regions.
Ultrasonography is superior to other modalities for diagnosis.
Surgical intervention is mandatory when hydrops or cystic duct impaction occurs, with meticulous attention to cystic duct clearance to prevent biliary The patient was discharged on postoperative day 3 without Introduction cements ascariasis as the leading cause of parasitic The interaction between human populations and infection globally.
1 This burden is not distributed soil-transmitted helminths represents one of the most rather, it is disproportionately concentrated in enduring challenges in global public health.
Among the tropical and subtropical belts of Asia.
Africa, and these pathogens.
Ascaris lumbricoides stands as the Latin America, where the interplay of environmental preeminent agent of parasitic morbidity, exerting a conditions and socioeconomic factorsAispecifically the profound toll on human health, particularly within the lack of treated water and sanitationAifacilitates the developing world.
It is currently estimated that fecal-oral transmission cycle.
While ascariasis is approximately one billion individuals worldwide are frequently categorized as a Neglected Tropical Disease harboring this nematode, a staggering statistic that (NTD), the sheer scale of its prevalence underscores that it remains a significant and active public health contains the valves of HeisterAia series of spiral, mucosal folds that project into the lumen.
These valves In the vast majority of clinical encounters, infection Ascaris serves a physiological role in regulating bile flow but subclinical course.
3 The adult worms typically reside acts as a potent physical deterrent against the entry of within the lumen of the jejunum and ileum, coexisting large nematodes.
Given that adult Ascaris worms can with the host without causing acute distress.
However, measure between 15 to 20 centimeters or more in the clinical picture shifts dramatically when the length, the tortuosity of the valves of Heister usually effectively prevents their ingress.
Consequently, while statistically correlated with a high worm burdenAi the common bile duct is a frequent site of infestation, typically defined as a load exceeding 1,000 worms.
the gallbladder remains an anatomical fortress.
Under these conditions, or in response to physiological breached only in exceptional circumstances.
create a narrow, tortuous, and spiraled pathway that Complications stress, the adult nematodes exhibit an erratic When an Ascaris worm successfully navigates the 4 Driven by overcrowding or environmental anatomical challenge of the cystic duct and invades perturbations, the worms migrate proximally from the small intestine, seeking refuge in the biliary or immediate and severe.
The presence of the worm pancreatic ducts.
This upward migration necessitates initiates a cascade of pathological events driven by the passage of the nematode through the Ampulla of both mechanical and chemical factors.
9 The worm acts Vater, a critical anatomical gateway.
Normally, the as a physical plug.
By lodging within the gallbladder Sphincter of Oddi acts as a competent barrier or becoming entrapped in the cystic duct, it obstructs However, under the the physiologic outflow of bile.
This obstruction is pressure of a high worm load, previous interventions while the outflow is blocked, the gallbladder such as sphincterotomy or physiological relaxation, mucosa continues its physiological secretion of mucin.
the sphincter is breached, allowing the worm access to In the closed system of an obstructed gallbladder, this the biliary tree.
This invasion precipitates a spectrum of disease known collectively as hepatobiliary and resulting in the formation of a mucocele, or gallbladder Beyond simple mechanics, the worm is a manifestations of HPA are diverse and severe, ranging biological irritant.
The excretion of metabolic waste products by the live parasite, combined with the cholecystitis and pancreatitis, depending on the release of somatic antigens, incites an intense precise location and degree of obstruction caused by inflammatory response from the gallbladder mucosa.
the parasite.
This results in acalculous cholecystitisAiinflammation preventing duodenal (HPA).
The Within the spectrum of HPA, the involvement of the of the gallbladder without the presence of gallstones.
gallbladder itself represents a distinct and exceedingly Over time, the worm or its fragments can serve as a nidus for stone formation.
The worm may eventually perish, and the necrotic remnants can act as a core gallbladder ascariasis accounts for only approximately upon which calcium bilirubinate precipitates, leading 1% of all cases of hepatobiliary ascariasis.
This to the formation of brown pigment stones.
Clinical statistical rarity is not a matter of chance but is The diagnosis of isolated gallbladder ascariasis dictated by rigorous anatomical constraints.
7 To enter requires a high index of suspicion, particularly the gallbladder, a worm must navigate the cystic duct.
Unlike the common bile duct, the cystic duct presents quadrant (RUQ) pain and leukocytosisAimimics that of a formidable mechanical challenge to the parasite.
classic calculous cholecystitis.
Accurate diagnosis presentationAiRight relies Ultrasonography in endemic regions.
established as the gold standard in this context, favored for its ability to visualize the characteristic Case Presentation morphology of the worm and, crucially, its motility in Written informed consent was obtained from the real-time.
The sonographic identification of the stripe patient for the publication of this case report and sign or the inner tube sign .
tubular echogenic accompanying intraoperative images.
All procedures structure with a central anechoic cana.
allows for the performed were in accordance with the ethical differentiation of the parasite from biliary sludge or standards of the institutional research committee and organized hematoma.
with the 1964 Helsinki Declaration and its later Therapeutically, this condition presents a complex While intestinal ascariasis is effectively Department of a tertiary care academic medical center management of biliary entrapment is controversial.
in Indonesia, seeking urgent evaluation for an acute Conservative management with anthelmintics carries demographic profile provided crucial initial clues Killing the worm while it is entrapped regarding the potential etiology of her condition.
She within the narrow cystic duct or gallbladder lumen can was a long-term resident of a rural, agricultural be catastrophic.
the resulting necrotic foreign body Her primary source of potable water A 57-year-old female presented to the Emergency The patientAos was an untreated shallow well, and she lived in close Therefore, when the worm is entrapped or associated proximity to agricultural lands where the use of human waste as fertilizer .
ight soi.
is occasionally intervention becomes the indicated approach.
This This environmental context is of paramount epidemiological significance.
In such tropical settings, manifesting as severe gallbladder hydrops in a 57- documented high-risk factor for the ingestion of year-old female without pre-existing cholelithiasis.
embryonated Ascaris lumbricoides eggs.
The fecal-oral While hepatobiliary ascariasis is well-documented, the transmission route remains the dominant vector for isolation of the parasite within the gallbladder causing ascariasis in this region, where the interplay of soil acalculous hydrops is an exceptional finding that humidity, temperature, and sanitation gaps creates an challenges standard diagnostic algorithms.
Beyond optimal incubator for geo-helminths.
While the patient the clinical description, this report provides a critical had no recent travel history or contact with known sick analysis of the surgical methodology required to contacts, her daily environmental exposure placed her manage this entity.
We specifically highlight the in a high-risk category for parasitic infestation, a necessity of the retrograde milking maneuver during factor that would later guide the differential diagnosis open cholecystectomy to prevent the transection of the beyond standard metabolic or neoplastic etiologies.
worm within the cystic ductAia technical nuance often The clinical trajectory of this patient offered a under-described in the literature.
Furthermore, we classic study in the dual-phase presentation of biliary discuss the diagnostic utility of ultrasonography in parasitosis: a chronic, indolent phase followed by an identifying the inner tube sign and underscore the acute, catastrophic obstructive event.
The patient pathophysiology of acalculous hydrops driven by reported a one-year history of digestive discomfort localized to the right upper quadrant (RUQ).
She management protocols for acalculous biliary disease described this pain as dull, gnawing, and intermittent, typically manifesting 30 to 60 minutes after meals theory that this was a sterile, pressure-induced (Table .
This post-prandial timing mimics the bacterial infection at this stage.
The abdominal exam provided localized and specific findings.
The abdomen was non-distended, ruling out bowel obstruction or For twelve months, she had self-managed massive ascites.
Palpation revealed exquisite, localized these episodes with over-the-counter analgesics and dietary modifications, assuming the symptoms were importantly, deep palpation identified a palpable related to indigestion or gastritis.
In retrospect, this fullness in the gallbladder fossa.
This finding is highly period likely corresponded to the presence of the suggestive of a significantly distended gallbladder.
Ascaris worm freely inhabiting the gallbladder lumen, consistent with hydrops.
A nuanced finding in this causing sporadic irritation of the mucosa without case was the equivocal nature of MurphyAos sign.
While frank obstruction.
Forty-eight hours prior to her the patient exhibited tenderness during inspiration, admission, the clinical picture shifted drastically.
The the classic abrupt inspiratory arrest associated with pain lost its intermittent nature and transformed into bacterial cholecystitis was not distinct.
This subtlety a continuous, unrelenting agony, rated by the patient is clinically relevant.
In classic acute cholecystitis, the as 8 out of 10 on the Visual Analog Scale.
The pain inflammation is often transmural and bacterial, radiated distinctly to the right scapular region (Boas' causing severe parietal peritoneal irritation.
In this sig.
, a somatic referral pattern indicative of phrenic case of parasitic hydrops, the pain was driven nerve irritation via the inflamed gallbladder capsule.
primarily by rapid capsular distension .
isceral pai.
This transition from a dull ache to incapacitating pain due to mucus accumulation, rather than a purulent marked a critical pathophysiological turning point: the bacterial infection involving the peritoneum.
This migration of the nematode from a floating existence in distinction explains why the tenderness was severe yet the gallbladder lumen to a position of impaction within lacked the precise peritoneal catch of a classic the cystic duct.
Despite the severity of the pain, the MurphyAos sign.
The absence of scleral icterus and patient denied nausea, vomiting, or fever, suggesting palmar erythema confirmed the historical report of no that the process had not yet progressed to systemic jaundice, reinforcing the localized nature of the sepsis or generalized peritonitis.
Clinically pivotal was More the absence of jaundice, dark urine .
, or pale The laboratory workup provided the first concrete stools .
This negative finding was of immense evidence pointing toward a parasitic etiology rather diagnostic value.
It strongly suggested that the than standard lithogenic disease.
The hematological Common Bile Duct remained patent.
The obstruction was essentially off-line, confined to the gallbladder and signaling an active inflammatory response.
However, cystic duct, thereby sparing the patient from the the differential count contained the diagnostic key:
Eosinophilia of 8%, with an absolute eosinophil count choledocholithiasis or distal CBD obstruction.
Upon admission, the patient appeared in acute Leukocytosis .
,460/mmA), of 1,236/mmA.
In the context of an acute abdomen, this profound eosinophilia is a significant biomarker.
distress due to pain but remained hemodynamically While Her vital signsAiBlood Pressure 120/80 mmHg, .
, they do not trigger eosinophilia.
This Heart Rate 83 beats per minute, and Respiratory Rate Th2-mediated immune response is characteristic of 21 breaths per minuteAiindicated that she was tissue-invasive compensating well, without signs of septic shock.
Her detecting the somatic antigens of the Ascaris cuticle, temperature was 36.
1AC, further supporting the upregulates eosinophil production in an attempt to The combat the parasite.
as an echogenic .
ring representing the thick The liver function tests presented a pattern of parasitic cuticle, surrounding a central anechoic dissociation that mirrored the physical exam: .
AST .
dot representing the worm's fluid-filled digestive .
U/L) and ALT .
U/L): Mildly elevated, suggesting .
The stripe sign: In longitudinal section, the reactive non-specific hepatocellular stress or local worm appeared as a long, linear, tubular structure.
mg/dL):
Real-Time Motility: Perhaps the most critical finding Completely normal, confirming the patency of the was the observation of non-directional, writhing main biliary channel.
Alkaline Phosphatase (ALP) movement of the tubular structure.
This erratic .
U/L): Clearly elevated.
This combinationAi motility definitively distinguished the mass from biliary sludge, organized hematoma, or gangrenous biochemical hallmark of a localized, partial biliary mucosal sloughing, confirming the presence of a live It indicates that while the main flow of macro-organism.
The ultrasound also elucidated the bile is uninterrupted .
ormal bilirubi.
, there is a focal mechanism of the hydrops.
The cephalad end of the area of the biliary tree .
he gallbladder and cystic duc.
worm was visualized extending into the cystic duct.
under significant pressure, causing the induction and This release of ALP from the biliary epithelium.
pathophysiological puzzle: the worm had acted as a ALP Total Bilirubin .
BilirubinAiis A preoperative stool examination for ova and cork, mechanically occluding the narrow cystic duct.
parasites was negative.
In clinical practice, this is a This prevented bile egress while the gallbladder frequent false negative that can mislead clinicians.
The mucosa continued to secrete mucin, leading to the absence of eggs in the stool does not rule out high-pressure hydrops that brought the patient to the This phenomenon can occur if the infection Emergency Department.
involves only male worms .
hich cannot produce Following the definitive sonographic diagnosis of egg.
, if the female worms are immature, or if the gallbladder hydrops secondary to parasitic impaction, worms are located in the biliary tree rather than the the patient was immediately admitted for preoperative intestine, where egg shedding is intermittent or Thus, the negative stool test necessitated optimize the patientAos fluid status and mitigate the risk reliance on imaging.
of septic progression.
She was placed on a strict nil per The two-fold:
Abdominal ultrasonography (USG) served as the os regimen to rest the gastrointestinal tract and definitive diagnostic modality.
Given the patientAos lean minimize gallbladder stimulation.
Intravenous fluid body habitus and the specific RUQ localization.
USG resuscitation with crystalloids was initiated to correct offered superior resolution to computed tomography for visualizing the internal structure of the gallbladder.
The scan revealed a gallbladder that had lost its superinfection in the setting of stasisAieven in a physiologic pyriform shape, appearing instead as a tense, cylindrical structure measuring 10.
5 cm x 4.
spectrum antibiotic coverage was instated The gallbladder wall was thickened to 4.
5 mm Ceftriaxone .
ormal <3 m.
, indicating edema.
Crucially, the cephalosporin was selected for its excellent biliary lumen was devoid of the acoustic shadowing typical of penetration and efficacy against common enteric gallstones, ruling out calculous cholecystitis.
Within pathogens such as Escherichia coli and Klebsiella this fluid-filled, anechoic background, the ultrasound species, which frequently colonize obstructed biliary visualized the parasite with remarkable clarity: .
The Given etiologyAiprophylactic This third-generation Inner Tube Sign: In cross-section, the worm appeared The anesthetic management of biliary ascariasis migratory response in the nematodes.
Literature presents unique challenges that differentiate it from documents catastrophic instances where worms have standard cholecystectomy.
The primary concern is the retrogradely migrated from the duodenum into the Ascaris physiological stress.
Sub-optimal sedation or the precipitating acute laryngospasm or upper airway excitatory phase of induction can trigger a violent To mitigate this, a Rapid Sequence Induction strategy was employed.
This approach The serosal surface was injected, reflecting acute venous congestion.
Notably, there were no dense fast-acting neuromuscular blocker to secure the airway rapidly, minimizing the window of potential worm migration duodenum, a finding that corroborated the clinical and preventing gastric aspiration.
Furthermore, the history of an acute obstructive event superimposed on a non-inflammatory chronic carriage.
Nitrous The dissection of CalotAos triangleAithe anatomical The pathophysiology behind this space bounded by the cystic duct, common hepatic exclusion lies in the differential solubility of gases.
duct, and the liver edgeAiwas performed with extreme Nitrous The priority was not to ligate, but to clear the significantly faster than nitrogen can diffuse out.
In a The cystic duct was identified and noted to be patient with ascariasis, the wormsAo digestive tracts and significantly dilated and edematous, a reactive change the surrounding intestinal loops contain gas.
The use to the parasite's presence.
Before applying any of nitrous oxide can lead to the rapid expansion of instruments, the surgeon performed a gentle digital these gas-filled spaces.
In the context of a worm palpation of the cystic duct.
This confirmed the trapped in a narrow cystic duct, such expansion could presence of a firm, tubular, rubbery structure theoretically lead to the rupture of the worm's cuticle occupying the lumen, extending from the gallbladder .
eleasing highly immunogenic and toxic body fluid.
neck toward the common bile duct junction.
To safely ligate the duct, the worm had to be displaced.
Using a Therefore, soft, atraumatic bowel grasper on the gallbladder neck anesthesia was maintained using volatile agents and and digital pressure on the distal cystic duct, the oxygen/air mixtures only.
surgeon performed a milking maneuver.
Pressure was The air-filled Oxide applied in a retrograde fashion, pushing the worm cholecystectomy rather than a laparoscopic approach upwards from the cystic duct back into the wider body While of the gallbladder.
The tactile sensation of the worm laparoscopic cholecystectomy is the gold standard for slipping back into the gallbladder confirmed the lithogenic disease, the presence of a live macro- success of the maneuver.
Once the worm was organism impacted in the cystic duct alters the risk dislodged, the cystic duct was re-palpated.
It was Laparoscopic graspers reduce tactile feedback, confirmed to be flat, empty, and pliable.
This creating a significant risk of inadvertently crushing the worm or, worse, transecting it across the cystic duct subsequent application of surgical clips or ligatures during clipping.
A transected worm leaves a necrotic creates a hermetic seal on the duct tissue alone, rather remnant in the common bile duct, a guaranteed recipe than crushing the worm or leaving a gap that would result in a bile leak .
iliary peritoniti.
Consequently, a right subcostal KocherAos incision was With the cystic duct secured and divided, attention utilized to afford the surgeon precise manual palpation turned to the common bile duct (CBD).
In endemic and direct control over the extrahepatic biliary tree.
areas, synchronous infection .
orms in both the Upon entering the peritoneal cavity and retracting the gallbladder and the CBD) is common.
The surgeon liver, the pathology was immediately evident.
The palpated the CBD along its entire supraduodenal gallbladder did not exhibit the chronic, scarred, and The duct was found to be soft, non-dilated shrunken appearance typical of recurrent lithiasis.
iameter less than 6 m.
, and free of any palpable Instead, it was tensely distended, edematous, and This intraoperative finding, combined with hyperemic, consistent the patient's normal preoperative bilirubin and the acute, high-pressure absence of distal obstruction signs on ultrasound, length, was evacuated from the lumen (Figure .
The provided high confidence that the CBD was clear.
worm was active, confirming the recent nature of the Therefore, invasive interrogation of the CBD via Inspection of the gallbladder mucosa choledochotomy or intraoperative cholangiography revealed patchy areas of erythema and edema, indicative of chemical irritation from the parasiteAos additional morbidity.
The gallbladder was dissected Crucially, no cholesterol calculi, pigment from the liver bed and removed.
On the back table, stones, or biliary sludge were found.
This definitive away from the surgical field, the specimen was incised A large, viable Ascaris lumbricoides of isolated parasitic acalculous cholecystitis.
worm, measuring approximately 22 centimeters in Figure 1.
The gallbladder extraction and the evacuation of Ascaris lumbricoides.
The patientAos single 400 mg dose of albendazole.
This timing ensures uncomplicated, validating the decision for immediate the paralysis and expulsion of intestinal worms occur surgical intervention.
A critical component of the postoperative care was the timing of anthelmintic The patient tolerated a solid diet on While the offending worm was removed, the Postoperative patient undoubtedly harbored an intestinal reservoir Postoperative Day 3.
At the 6-month follow-up, the of worms.
Administering anthelmintics immediately before or during surgery is generally avoided, as dying ultrasonography was performed to ensure no late worms in the intestine can release toxins or become sequelae, such as stricture formation or recurrent agitated, potentially migrating into the biliary tree stone disease .
ost-cholecystectomy syndrom.
The through the sphincter of Oddi during the stress of scan showed a normal caliber CBD with no residual Therapy was delayed until the return of Liver enzymes had completely normalized, normal bowel function.
On postoperative Day 1, confirming the resolution of the cholestatic injury.
peristalsis is Day following the passage of flatus, the patient received a Discussion understand the rarity of this condition, one must first The pathogenesis of isolated gallbladder ascariasis deviation from the more common presentation of choledochal (Common Bile Duc.
appreciate the anatomical gauntlet the parasite must In the physiological baseline, the Sphincter Oddi regulating the flow of bile into the duodenum and preventing the reflux of duodenal contents.
However, common bile duct, the cystic duct is guarded by the the integrity of this barrier is compromised by specific valves of HeisterAia series of spiraling mucosal folds risk factors: a high parasitic load .
hich creates that create a tortuous, narrow channel.
These valves function physiologically to prevent the collapse of the endoscopic interventions such as sphincterotomy duct and regulate bile viscosity, but pathologically, .
hich they serve as a formidable deterrent to the entry of mechanis.
, or physiological relaxation induced by large nematodes.
This anatomical resistance explains hormonal fluctuations or pregnancy.
Once this barrier the statistical scarcity of the condition.
is breached, the adult Ascaris worm enters the biliary clinical series indicate that less than 2.
1% of all biliary ascariasis cases involve the gallbladder itself.
The Here, the worm faces the anatomical challenge of the cystic duct.
Unlike the relatively wide and linear worm essentially has to thread the needle against the flow of bile to enter the gallbladder.
Figure 2.
Pathophysiology of gallbladder ascariasis and hydrops.
In the case of this patient, the worm successfully navigated this tortuosity but subsequently became enzymatic activity, and lithogenesis (Figure .
14 The This entrapment is not merely a positional primary driver of the acute presentation is mechanical.
it precipitates a catastrophic cascade of The worm, having entered the cystic duct, acts as a pathology driven by three distinct mechanisms:
biological plug.
Unlike a gallstone, which is rigid and often irregularAiallowing for intermittent ball-valve her at high risk for this transformation.
Early surgical obstruction or partial flowAithe nematode is soft, intervention in this case not only resolved the hydrops cylindrical, and capable of conforming to the ductal but also preemptively arrested this lithogenic phase.
lumen to form a tight, complete seal.
This obstruction The diagnostic journey in hepatobiliary ascariasis creates a closed-loop obstruction.
While bile outflow is frequently highlights the limitations of cross-sectional halted, the gallbladder mucosa is not quiescent.
imaging (CT/MRI) and the distinct superiority of continues its physiological secretion of mucin and transabdominal ultrasonography.
While Computed In the absence of an outlet, this Tomography is the modality of choice for staging accumulation of fluid leads to a rapid rise in malignancies or defining complex anatomy, its static intraluminal pressure.
The result is the distension of nature is a liability when diagnosing parasitic the gallbladder wall and the thinning of the mucosa.
A worm on CT may appear merely as a non- clinically manifesting as a mucocele or hydrops.
The specific filling defect, indistinguishable from mucus acute nature of this distension is what generates the strands or sludge.
In contrast, ultrasonography intense visceral pain and the palpable mass observed provides high-frequency, real-time imaging resolution.
on examination.
This case reinforces the status of ultrasound as the The gold standard, capable of visualizing the definitive The Ascaris worm is not an inert foreign body.
it is a signs of infestation.
In the longitudinal axis, the worm metabolically active organism.
16 The excretion of waste appears as a non-shadowing, linear, echogenic strip.
itrogenous wast.
and the shedding of This somatic antigens from the worm's cuticle incite a differentiator from gallstones, which almost always profound inflammatory response from the gallbladder cast a posterior acoustic shadow.
In the transverse This reaction is characterized as acalculous axis, the worm presents as an echogenic ring .
he cholecystitisAiinflammation in the absence of stones.
with a central anechoic dot .
he fluid-filled This mechanism elucidates the diagnostic paradox digestive trac.
This multilayered appearance is observed in this patient: the presence of significantly The sine qua non of diagnosis is elevated inflammatory markers (C-Reactive Protein of Ultrasound allows the clinician to observe 45 mg/L) and Leukocytosis, despite the initial absence the erratic, non-directional writhing of the worm.
This of bacterial superinfection.
The eosinophilia further motility distinguishes the living pathology from static corroborates that this is a specific Th2-mediated mimics like organized hematoma, arterial walls, or immune response to parasitic antigens, rather than a standard pyogenic response to bacteria.
visualization of motility not only confirmed the The third mechanism represents the long-term diagnosis but also dictated the urgency of the consequence of untreated infestation: the potential for intervention, as a mobile worm implies an active, rather than calcified, process.
Ascaris The catalyzes the deconjugation of bilirubin diglucuronide into free, unconjugated bilirubin.
This insoluble free 19 However, the isolation of the parasite bilirubin precipitates with calcium ions to form within the gallbladder fundamentally therapeutic paradigm toward surgery.
Why is surgery brown pigment stones.
While our patient presented in necessary if anthelmintics .
eworming drug.
are the acute phase of hydrops, the chronic presence of effective? The answer lies in the physics of clearance.
the worm .
uggested by the one-year histor.
placed Anthelmintics such In the biliary tree, this enzyme bilirubinateAithe shifts the as Albendazole function paralyzing the wormAos neuromuscular system.
In the before ligation.
However, it is acknowledged that in intestinal tract, the paralyzed worm is expelled via centers with advanced laparoscopic expertise, this In the common bile duct, a paralyzed procedure can be performed safely via laparoscopy, worm may be flushed into the duodenum by bile flow.
provided the surgeon is vigilant and exercises the However, a worm paralyzed inside the gallbladder or same principles of ductal clearance prior to clipping.
cystic duct has no exit route.
It becomes a trapped.
The surgical removal of the gallbladder resolves the dying foreign body.
The decomposition of the worm acute crisis, but it does not cure the patient of releases highly toxic byproducts, leading to severe The patient remains at risk for post- cholecystectomy syndrome driven by the intestinal The millions of eggs and adult worms Furthermore, the calcified remnants of a dead worm residing in the jejunum represent a persistent threat.
act as a permanent nidus for recurrent stone Without systemic treatment, new worms can migrate through the Ampulla of Vater into the biliary stump Therefore, .
ystic duct remnan.
or the hepatic ducts, causing Endoscopic retrograde cholangiopancreatography (ERCP) is the gold standard for clearing the common However.
This reality underscores the absolute in isolated necessity of the postoperative anthelmintic course gallbladder ascariasis is severely limited.
Standard (Albendazol.
Surgery treats the complication, but endoscopic accessories (Dormia baskets or balloon.
medicine treats the disease.
Long-term management cannot be easily maneuvered through the tortuous valves of Heister to capture a worm inside the community level, focusing on sanitation improvements Attempts to do so carry a high risk of (WASH protocol.
to break the fecal-oral transmission cystic duct perforation.
Moreover.
ERCP addresses cycle and prevent reinfection.
19,20
only the parasite, not the underlying complication of This report is limited by its design as a single case hydrops or the ischemic threat to the gallbladder wall.
study, which prevents the generalization of findings to In an era dominated by minimally invasive surgery, all cases of biliary ascariasis.
Additionally, the the decision to perform an open cholecystectomy assessment of common bile duct clearance relied on intraoperative palpation rather than cholangiography.
cholecystectomy is the undisputed standard for While the clinical outcome was excellent, reliance on cholelithiasis, this case presented a specific trap for tactile sensitivity alone carries a theoretical risk of the laparoscopic surgeon: the impaction of the worm missing small worm fragments or debris.
However, the in the cystic duct.
Laparoscopy relies on visual cues operatively validates the clinical decision-making in While laparoscopic graspers cannot feel the worm inside the this specific context.
There is a substantial risk that the application of a surgical clip to the cystic duct could crush the worm or, worse, transect it.
A transected worm leaves guaranteeing postoperative complications .
holangitis or lea.
The open approach .
ight subcostal incisio.
was chosen to prioritize tactile safety.
It allowed for the manual palpation of the duct and the execution of the milking maneuver, ensuring the duct was empty Conclusion Isolated gallbladder ascariasis is a rare but diagnostic acumen of the surgeon and radiologist.
presents a masquerade, mimicking the clinical and laboratory features of acute acalculous cholecystitis, yet requiring a fundamentally different management This case serves as a critical reminder that in endemic tropical regions, the differential diagnosis for and temperatures.
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