Ascariasis is the most frequent helminthic infection in humans in many developing countries. Aute pancreatitis is among the rarer causes of ascaris infestation. We report a case of acute pancreatitis, in a young man and present computed tomography (CT) appearances of abdomen, with roundworm infection.
Keywords: Albendazole, ascariasis, pancreatitis
Ascariasis is most common helminthic infection affecting more than 1.4 billion people worldwide, with the majority of infections occurring in the tropical and developing countries. The causative organism ascaris lumbricoides normally lives in the lumen of small intestine. Adult ascariasis infection causes two kinds of disease: intestinal ascariasis and ascariasis aberrance, which appears with the migration of the ascaris to organs outside the intestines. Acute pancreatitis is among the rarer causes of ascaris infestation. We report a case of acute pancreatitis in a young man with roundworm infestation.
A 27-year-old male was admitted with severe abdominal pain with vomiting and distention. The pain was dull and boring in nature having no relation to food intake, radiated to upper abdomen, and back and was not associated with fever, jaundice, or worms in stools. Patient was non-smoker and non-alcoholic. At the time of admission in medical emergency ward, he was having signs of toxemia with a pulse of 110/min and BP of 100/60 mm Hg. The abdomen was distended with mild rigidity over umbilical and epigastrium but no muscle guarding or rebound tenderness. Examination of other systems was normal. On investigations, hemoglobin – 12.0 g/dL, leucocyte count – 15,000/mm 3 , granulocyte- 85%, lymphocytes – 15%, thrombocytes – 3.5 lac/mm 3 , aspartate aminotransaminase – 145 IU/L, alanine aminotransferase – 120 IU/L, alkaline phosphatase – 758 IU/L, total bilirubin – 2.4 mg/dL, direct – 1.8 mg/dL, s. amylase – 2435 u/L. His kidney functions were normal. Stool samples were negative for occult blood and parasites. Ultrasonogram of abdomen showed bulky pancreas and gaseous distention of bowel loops. Computed tomography of abdomen was suggestive of acute pancreatitis with linear (tubular) filling defects in proximal bowel loops s/o ascaris.
He was treated with antibiotics, analgesics, and intravenous fluids. He was totally relieved of symptoms by fourth day, and was started on oral fluids. He was treated with albandazole and pyrantel palmoate. The patient passed two roundworms in stool.
Symptoms of abdominal pain, nausea, and vomiting disappeared; the leucocyte count, bilirubin, and amylase values returned to normal and the patient made a complete recovery and were discharged.
Ascaris lumbricoides is the commonest nematode infection, known to cause biliary and pancreatic system diseases in endemic areas. ,
The spectrum of acute pancreatitis ranges from congenital, structural, or inherited disorders to trauma, infections, drugs, and biliary tract diseases. Hepato-pancreatic ascariasis is an important cause of biliary and pancreatic disease in endemic areas.  It affects adults and may give rise to serious conditions such as biliary colic, acute cholecystitis, acute cholangitis, acute pancreatitis, and hepatic abscess. ,, Sandouk et al. observed hepato-pancreatic ascariasis in 18% of endoscopic retrograde cholangiopancreatography (ERCP) cases and abdominal pain with 98% of cases, ascending cholangitis in 16%, acute pancreatitis in 4.3% and obstructive jaundice in 1.3%,  similar to 300 cases reported in Damascus, in the year 1993.  In various case studies in India, hepato-pancreatic ascariasis was found responsible for 23% of acute pancreatitis and 13.6% of pyogenic cholangitis.  Ultrasonography is the investigation of choice for diagnosis and follow-up. , The only drawback that ascribed to sonography is its operator dependence. In the present case report, diagnosis could not be established by ultrasonography but, made by computed tomography of abdomen.
ERCP can help to diagnose and extract biliary and pancreatic ascariasis.  Since the patient refused ERCP, it was not attempted. Management of the acute pancreatitis is largely supportive and the intensity of therapy is dictated by the severity of disease. The conservative treatment is by keeping the patient nil by mouth, analgesics, antibiotics, and intravenous fluids. In our case, albendazole and pyrantel palmoate was given which is a broad spectrum anti-helminthic, larvicidal, and ovicidal. All patients who do not respond to conservative or endoscopic treatment should be treated with surgery. But in our case patient had responded to the medical management.
There is streaking and increased density of peripancreatic fat in the region of tail and body with thickening of Gerotas fascia. Also the pancreatic body and tail in this region appear bulky. No evidence of pancreatic necrosis is, however, seen [Figure 1].
Linear (tubular) filling defects are seen in proximal bowel loops suggestive of ascaris [Figure 2] and [Figure 3].
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3]