Introduction

Ascariasis is a common intestinal parasitic infection inchildren in the developing world [1]. Biliary ascariasiswith associated cholangitis is a well-recognised compli-cation [1, 2]. We present a case of acute haemobilia dueto an intrahepatic pseudoaneurysm following treatmentfor biliary ascariasis. The haemobilia was successfullytreated by embolisation of the aneurysm.

Case report

A 5-year-old girl presented with a history of abdominal pain, feverand vomiting up worms. Examination detected right upper quad-rant tenderness. The patient was treated for ascariasis with me-bendazole (Rhone Poulenc Rhorer, Johannesburg). The fever andpain persisted. Ultrasound examination (Fig. 1a) showed ascarisin the main bile duct and in the left biliary tree, with intrahepaticbiliary dilatation. The patient was treated with intravenous antibi-otics for ascaris-induced cholangitis. There was a marked improve-ment in her condition, but during the third week after admissionshe collapsed after haematemesis. Emergency endoscopy con-firmed active haemorrhage from the ampulla of Vater. Emergencyselective hepatic arteriography demonstrated a pseudoaneurysm

arising from a branch of the left hepatic artery, with extravasationof contrast medium into the biliary tree (Fig. 1b, c). Superselectiveembolisation of the feeding artery was performed using a coaxialtechnique with the aid of a tracker 18 microcatheter (Target, Tre-mont, Calif.), which was passed through a 5-F femoral visceralcatheter and placed selectively in the left hepatic artery. Embolisa-tion was performed with a microcoil (Tornado Micro Coil, Target),successfully occluding the aneurysm. Haemobilia stopped almostimmediately. The patient made a complete recovery, and follow-up ultrasound of the liver 2 weeks later was unremarkable.

Discussion

This case report highlights the development of apseudoaneurysm following ascaris-related cholangitisand its subsequent treatment by embolisation. The adultascaris usually resides in the bowel lumen. Migration inand out of the biliary tree is well documented and in en-demic areas may be the most common cause of biliarydisease in childhood. Usually the worm manages tomove out of the biliary tree; however, occasionally it be-comes trapped, dies and eventually disintegrates [1].Worm migration can result in biliary obstruction, sec-ondary pyogenic cholangitis and, rarely, liver abscesses

Peter CorrJan SmitG. Larry Hadley

An unusual cause of haemobilia:biliary ascariasis

Received: 12 February 1996Accepted: 9 March 1996

P. Corr ()) ⋅ J. SmitDepartment of Radiology,University of Natal Medical School,PO Box 17039, Congella 4013, Durban,South Africa

G. HadleyDepartment of Paediatric Surgery,University of Natal Medical School,Durban, South Africa

Abstract A case of haemobiliafollowing biliary ascariasis is pre-sented. Angiography confirmed ananeurysm of the left hepatic artery,which was successfully embolised.The patient made an uneventfulrecovery.

Pediatr Radiol (1997) 27: 348–349 Springer-Verlag 1997

[1–3]. Patients usually present with biliary colic, feverand jaundice. The diagnosis can easily be made on ultra-sound by the echogenic “tramline” or “bull’s eye” ap-pearance of the worms in the bile ducts. ERCP is usefulas a therapeutic tool to snare the worm and extract itfrom the duct [1].

The development of a pseudoaneurysm following bil-iary ascariasis appears to be extremely rare. In the casepresented here, we presume the pseudoaneurysm form-

ed after inflammatory involvement of the artery by acontiguous liver abscess. We feel the most importantpoint we learnt was the effectiveness of selective hepaticembolisation, which, in our patient, was life saving. Em-bolisation is well established as the optimum treatmentfor all intrahepatic aneurysms. Improvements in cathe-ter design, such as the introduction of microcatheters,plastic-coated guidewires and microcoils, have madeembolisation technically easier and more effective.

349

a

b c

Fig. 1 a An axial ultrasound scan through the left lobe of the liver.Note the abscess and the Ascaris worm in the biliary tree (ar-rows). b A selective hepatic arteriogram demonstrates active con-trast medium extravasation from the left hepatic pseudoaneurysm(arrow) into the biliary tree. c A selective left hepatic arteriogramdemonstrates a pseudoaneurysm (arrow)

References

1. Khurro M, Zargar A, Mahajan R (1990)Hepatobiliary and pancreatic ascariasisin India. Lancet 335: 1503–1506

2. Rezaul Karim M (1991) Biliary ascaria-sis. Int Surg 76: 27–29

3. Louw JH (1966) Abdominal complica-tions of Ascaris lumbricoides infestationin childhood. Br J Surg 53: 510–521