OVERVIEW
Biliary ascariasis is the most serious complication of intestinal ascariasis. It is most common in schoolchildren aged 6 to 8 years, farmers and late pregnant women. It is an acute epigastric pain or biliary tract infection caused by active motility of intestinal roundworms that burrow into the biliary tract for various reasons. During the attack, the patient’s pain is unbearable, crying and screaming, very painful. If the treatment measures can not keep up, the advanced patients may have different degrees of dehydration and acidosis, and even life-threatening.
Questions you may be concerned about
What are the clinical features of biliary ascariasis?
The main clinical features of biliary ascariasis are paroxysmal subxiphoid drill-like pain, digestive tract irritation symptoms, fever and so on.
1. Abdominal pain: paroxysmal, severe abdominal pain, usually located in the subxiphoid process, the duration of pain varies, but after the pain is not obvious other abnormal phenomena.
2. Gastrointestinal tract irritation: after suffering from biliary roundworms, some patients may experience gastrointestinal tract irritation symptoms such as nausea and vomiting.
3. Fever: after suffering from biliary roundworm, if there is secondary bacterial infection, the patient will also have fever.
The severity of biliary ascariasis is not the same, the patient’s physical condition is different, there are differences in the clinical characteristics of biliary ascariasis.
What are the characteristics of abdominal pain in biliary ascariasis?
The main feature of abdominal pain in biliary ascariasis is a sharp pain in the right upper abdomen.
The patient will feel a sharp pain in the right upper abdomen, which is often characterized by moaning, sweating, vomiting, nausea, etc. The pain often appears on the right shoulder or the right side of the shoulder. The pain often radiates from the right shoulder or right back, and the abdominal pain may suddenly decrease, with relief lasting for an indeterminate period of time.
However, most of the patients feel severe abdominal pain, but the doctor for the patient to carry out specialized abdominal examination, the signs are not obvious obvious, do not show pressure pain, rebound pain and so on.
If the patient appears biliary ascariasis, it is recommended to consult the doctor in time, under the guidance of the doctor, choose the appropriate program, and actively carry out the treatment.
Causes
Adult Ascaris lumbricoides parasites in the middle and lower part of the small intestine, when the human body and the digestive tract dysfunction, such as high fever, diarrhea, starvation, gastric acidity, dietary disorders, inappropriate deworming, surgical stimulation, etc., can provoke the abnormal activity of worms, up the biliary tract; in addition to the Ascaris lumbricoides have a love of alkali and hate of acid, there are drilling habits, in the bile duct inflammation, stones, and sphincter relaxation, etc., more likely to cause the adult worms to drill bile. 80% of the roundworms that enter the bile duct are in the bile duct, which can be 1 to more than 100. Ascaris lumbricoides enter the bile duct, its mechanical stimulation, causing strong spasmodic contraction of the sphincter, biliary colic, especially partially drilled into the person, the stimulation of the symptoms are more frequent, in its complete entry into the bile duct or self-exit, the symptoms can be relieved or disappeared. Most of the roundworms that enter the bile ducts die in the bile ducts, and their body fragments, keratinized skin, and eggs will become the core of later stones. The bile duct obstruction caused by Ascaris lumbricoides drilling into the bile duct is incomplete, so jaundice rarely occurs, mainly due to the bacteria brought in by Ascaris lumbricoides leading to inflammation of the bile ducts, and can cause acute severe cholangitis, liver abscess, subdiaphragmatic abscess, cholestatic peritonitis, acute pancreatitis, biliary hemorrhage, toxic shock, and even death.
Symptoms
1. Abdominal pain
Ascaris lumbricoides burrow into the bile duct, stimulate the sphincter of the pot-bellied part of the common bile duct, make it produce spasmodic contraction, so the patient has sudden severe colic under the sword, the pain lasts for a different period of time, and after the pain can be as normal, which is the characteristic of the symptom of biliary ascaris lumbricoides. The degree of abdominal pain and physical signs of the patient do not match, often abdominal pain is severe, but the physical signs are slight. At the beginning of the disease, the abdomen likes to be pressed, but refuses to be pressed with the occurrence of biliary tract inflammation.
2. Nausea and vomiting
Most of the vomit is gastric contents, which may contain bile or roundworms. It is reported that the vomited roundworms can be as many as dozens or even hundreds of roundworms, and children can crawl out roundworms from the nasal cavity due to the poor sensitivity of the pharyngeal reflex.
3. Chills and fever
The body temperature of patients with biliary roundworms is mostly within the normal range. When combined with infection, patients may have chills and fever, but the rise in body temperature is not proportional to the degree of abdominal pain. Ascaris lumbricoides burrow into the bile duct and cause cholangitis. Unless the worms exit the bile duct and the inflammation is relieved, the body temperature will not subside.
4. Jaundice
Simple biliary roundworms are not likely to form complete biliary obstruction because of the smooth surface of the worm. However, after Ascaris lumbricoides burrow into the biliary tract, if the number of Ascaris lumbricoides is large, the Ascaris lumbricoides die in the biliary tract, or the recurrent episodes of biliary Ascaris lumbricoides cause cholangitis, it can cause biliary obstruction, and jaundice can appear 24-48 hours after the obstruction. Patients may also develop hepatomegaly.
Examination
1. Laboratory examination
The patient’s white blood cell count may be mildly increased. Eosinophil count is increased. Gastroduodenal fluid and fecal microscopy may reveal eggs.
2. Imaging examination
(1) ultrasound clinical ultrasound examination of biliary roundworm diagnosis is more valuable, the accuracy rate of up to 95.6%, biliary roundworm ultrasound imaging features are: ① bile ducts have mild or moderate dilatation, wall thickening; ② bile ducts can be seen on both sides of the two echogenic bands of light, ascaris lumbricoides in the middle of the bile ducts in the middle of the strips of the non-echoic area; ③ can be seen curled, retracted, and even are wriggling ascaris lumbricoides.
(2) X-ray intravenous cholangiography The biliary tract will be visualized 5 minutes after the injection of contrast medium, and the best state of visualization is 45 minutes later. After 60 minutes, the contrast medium will be gradually discharged and the effect of visualization will be affected; therefore, it is best to choose to take the film within 1 hour of the injection of contrast medium, and the discovery rate of Ascaris lumbricoides is about 50%.
(3) Endoscopic retrograde cholangiopancreatography (ERCP) ERCP can be performed by injecting contrast medium from the duodenal papilla, which can obtain clear images and assist in diagnosis.
Diagnosis
It is mainly based on the following 3 points:
(1) Sudden, paroxysmal, drill-like biliary colic;
(2) Inter-episode intervals as normal, with some patients having a history of ascaris lumbricoides expulsion;
(3) Ultrasound shows slight thickening of the bile ducts and double linear echoes in the lumen.
Complications
Ascaris lumbricoides can burrow into the liver along the bile ducts to cause liver abscess, and can also penetrate the bile ducts to form bile leakage, or penetrate into the hepatic veins, and in severe cases, it can penetrate into the liver and then into the lungs, causing hemorrhagic infarction of the lungs and lung abscesses. Serious complications of ascariasis can be fatal.
Treatment
The principles of treatment for this disease are antispasmodic, analgesic, cholagogic, deworming, infection control and correction of water and electrolyte imbalances. Unless serious complications arise, most patients can be treated non-surgically.
1. Internal medicine treatment
(1) antispasmodic and analgesic ① antispasmodic and analgesic drugs: commonly used drugs are: atropine, 654-2, vitamin K3, etc., can relieve smooth muscle spasm caused by colic. Strong colic, when the diagnosis is clear, with the application of dulcolax, ipecac, phenobarbital and so on. ② Acupuncture treatment: the early stage of the disease can be treated with acupuncture and moxibustion, commonly used points are foot Sanli, epigastric, Taichong, Hatsuo, umbilical yu, Neiguan and so on. (iii) Take 50ml of vinegar and 25ml of sesame oil orally.
(2) biliary deworming ① Chinese medicine Wu Mei Tang. ② biliary tract roundworm soup. (iii) Deworming drugs: Levamisole, Deworming net (tetramisole), Deworming roundworm spirit, etc. ④ Oxygen deworming: after inserting nasogastric tube, adults slowly inject 3000ml of oxygen at one time, and reduce it for children. ⑤ Apply 33% magnesium sulfate. (6) Duodenoscopy to remove worms under direct vision.
(3) Prevention and control of infection: antibiotics such as aminoglycosides, quinolones and metronidazole or tinidazole can be used.
2. Surgical treatment
If the symptoms of biliary roundworms are not relieved or aggravated after 2-5 days of non-surgical treatment, or if the symptoms are complicated by acute suppurative cholangitis, or if there are still roundworms in the bile ducts or gallstones after treatment after the acute phase, surgical treatment should be considered. Surgical treatment consists of exploration of the common bile duct, removal of worms and drainage of the bile duct. Postoperative deworming treatment is also needed to avoid recurrence of ascariasis.
Prevention
1. Adopt good hygiene habits, wash hands before and after meals. Biliary ascariasis originates from patients with roundworms in the intestines, and intestinal ascariasis is a kind of infectious disease, the source of infection is ascariasis patients or carriers, and the infectious eggs are swallowed into the intestines through the mouth and become carriers. Therefore, only the good source of infection, cut off the transmission pathway can completely eradicate the occurrence of intestinal roundworm.
2. patients with intestinal roundworms, in the deworming treatment, the dosage should be sufficient to kill completely, otherwise, due to the mild intoxication of ascaris lumbricoides and active movement, scurrying around, it is very likely to burrow into the biliary tract and the occurrence of biliary ascariasis.