Hepatolithiasis or primary intrahepatic stones are prevalent in the Far East countries such as Japan, Korea, and Taiwan [
6]. The relative incidence of hepatolithiasis against all gall stones in western countries is approximately 1%, whereas in Taiwan, South Korea, China it has been reported to be 20%, 18%, 38–45% respectively [
6]. Biliary ascariasis is a common problem in certain areas of world. Although it is not common in developed countries, with increasing air travel and immigration, one must be aware of this condition. Ascaris
lumbricoides is a common parasite and over a billion people are estimated to be infested worldwide [
5]. It is more common than Clonarchis
sinensis and other flukes which are associated with cholangiohepatitis. Biliary ascariasis is predominantly a disease of adult women [
3]. Duration of symptoms vary from few months to few years. These patients usually present with biliary colic (56%), acute cholangitis (25%), acute cholecystitis (13%), acute pancreatitis (6%) and rarely hepatic abscesses (less than 1%) [
4]. Our case also presented with recurrent attacks of cholangitis. Adult forms of Ascaris
lumbricoides are usually passed into the intestine, however worms in the duodenum and invading the ampulla of Vater usually present as biliary colic or acute pancreatitis due to blocked CBD or pancreatic duct. These worms migrate through CBD, cystic duct and intrahepatic duct leading to biliary colic and cholangitis. Presence of dead worms form nidus for the CBD or hepatic stone formation. Further migration of worms into the intrahepatic duct causes secondary biliary cirrhosis, stricture formation, bile duct stenosis, hepatolithiasis and abscess formation. These worms also have high glucoronidase activity that deconjugates bilirubin and form pigment stones.
The diagnosis of hepatolithiasis with ascariasis is usually possible on ultrasonography of the abdomen and ERCP [
4]. However in our case intrahepatic calculi were diagnosed on CT scan and ERCP but the presence of parasite (ascariasis) was noticed only after histopathology of the resected specimen. Though ERCP plays a major diagnostic and therapeutic role at times it may not help in the diagnosis of biliary ascariasis. This is due to active movement of the worms, which are going into and out of the biliary tract [
4].
The treatment of hepatolithiasis with biliary ascariasis is endoscopic extraction of calculi and worms from the bile duct with or with out sphincterotomy which gives immediate relief. However in presence of complications hepatectomy is the only treatment of choice. Sphincterotomy has disadvantages in endemic areas, as these patients are prone to develop remigration of worms into biliary tree. Supportive anthelminthic treatment for long periods is required in these cases. Improvement in sanitation plays crucial role in the epidemiological control of these hepatobiliary diseases.