Biliary colic is a visceral pain caused by attempts of the gallbladder or bile duct to overcome the obstruction in the cystic duct or ampulla of Vater. Obstruction can be due to different etiologies such as stone, mass, worm, and rarely by mucus plug. We report the case of a 31-year-old gentleman who presented with recurrent biliary colic and weight loss. Work-up showed linear calcifications in the gallbladder extending to the common bile duct suggesting hepatobiliary ascariasis. Further investigations including stool analysis, upper endoscopy, endoscopic ultrasonography (EUS), and endoscopic retrograde cholangiopancreatography (ERCP) did not support our provisional diagnosis. Laparoscopic cholecystectomy was performed. Histopathological finding was grossly ambiguous; a rope-like mucus plug resembling ascaris worm was noted. The patient’s condition improved instantly after the procedure. To our knowledge, we are reporting the first case in the English literature describing this unique entity of symptomatic gallbladder disease to increase awareness and improve its management.
Biliary colic is usually caused by the gallbladder contraction in response to hormonal or neural stimulation, forcing a stone or possibly sludge and rarely a worm or a mucus plug against the gallbladder outlet or cystic duct opening, leading to increased intravesicular pressure [
In our manuscript, we report the case of a 31-year-old Syrian gentleman, who was previously healthy, presenting to the emergency room with repeated bouts of biliary colic. His pain was frequent, lasting for about two hours, and alleviated with pain killers and antispasmodics. The symptoms were exacerbated by heavy meals. He also reported a significant weight loss of 10 kilograms in two months. His vital signs and laboratory tests were all within the normal ranges. Ultrasound abdomen showed a contracted gallbladder with intraluminal calcification. Initial work-up began with an enhanced computed tomography (CT) scan, which revealed linear dense calcifications within the gallbladder extending into the cystic duct to the junction of the common bile duct (Figure
CT abdomen: linear calcification extending from the gallbladder through the cystic duct (dashes).
Magnetic resonance cholangiopancreatography (MRCP) demonstrating the 3-line sign typical for ascaris worm (arrow).
Gallbladder gross examination was suggestive of a parasitic worm with some sludge (Figure
Gross specimen of the gallbladder with a mucus plug mimicking a worm.
Microscopic examination of the tubular structure confirming a thick mucus content and absence of parasitic infestation.
Biliary colic can present with different manifestations and due to many causes. Our patient is a young gentleman who suffered from typical colicky right upper quadrant pain, moderate in severity over a period of six months. It was associated with weight loss, which was likely due to fear of triggering the pain, and in part due to anxiety from the extensive work-up and the unusual etiology of his condition. Our differential diagnosis leant towards a parasitic disease based on results of his imaging studies. His stool analysis, however, was negative for any egg or helminth, and upper endoscopy did not show any sign of parasites or abnormalities.
Helminthic infestation occurs most commonly with
Radiographic imaging of biliary ascariasis is usually pathognomonic. On ultrasound, we may find long, linear, parallel echogenic structures without acoustic shadowing or the presence of “four-line sign.” Nonshadowing echogenic strips with a central anechoic tube representing the parasite’s digestive tract, indicative of the worm and its intestines, may also be seen [
MR cholangiogram may show intraductal worms as a linear low-intensity filling defect in the bile ducts. The “three-line sign” appears to be a characteristic sign of biliary ascariasis on 3D magnetic resonance cholangiopancreatography (MRCP) [
Our case is ambiguous due to the paucity of these radiological signs in such a common medical illness. It is well known that ill-defined lesions may simulate the presence of a neoplasm in the absence of clinical suspicion of ascaris. We investigated the patient thoroughly for malignancy using laboratory and radiological testing, in addition to intraoperative frozen section analysis which was also negative for malignancy. Our preoperative and postoperative diagnosis favored gallbladder ascariasis as the patient was from Syria, as the condition is endemic in this region [
According to the literature, similar conditions may occur if the cystic duct is atretic or stenotic due to inspissated mucus or mucosal hyperplasia. This usually leads to a contracted gallbladder with some sludge. Our patient denied any past antecedent of jaundice or family history of cystic fibrosis or any metabolic disease [
The presence of thick mucus sludge in the gallbladder can be encountered in conditions associated with endocrine disorders, such as hypothyroidism, and in mucoceles. A mucocele refers to an overdistended gallbladder filled with mucoid fluid. It results from outlet obstruction of the gallbladder in the neck of the gallbladder or in the cystic duct [
Biliary colic is a common clinical manifestation that occurs due to various causes. Linear ground-glass opacification inside the gallbladder usually indicates hepatobiliary ascariasis. Absence of objective findings may suggest different pathologies. A rope-like mucus plug in our case was a unique entity, presented with symptomatic biliary colic with a picture resembling a parasitic worm.
The case report was approved by the local ethics committee of the Amiri Teaching Hospital (LEC Project no. 28-2015).
Written informed consent was obtained from the patient and is available upon request.
The authors declare no conflicts of interest.
Special thanks are due to Dr. Ayman Adi, Department of Histopathology, Al-Amiri Hospital, for his great efforts in sorting out the diagnosis.