Ascaris lumbricoides affects up to 70% of children in the tropics¹. Poor sanitation, malnutrition, heavy rainfall and untreated sewage disposal favour its transmission. In addition to its wandering nature,various conditions such as fever, drug intake, general anaesthesia at the time of surgery, as well as intestinal surgery potentiate its migration to ectopic sites². In children, the most frequent serious complication is intestinal obstruction, however, hepatobiliary and pancreatic complications are relatively rare^3,4. 

A four-year-old boy, belonging to lower socioeconomic status, with habitual pica eating, presented with a history of diffuse abdominal pain for 15 days which subsequently localised to the right upper quadrant along with high-grade fever accompanied by chills and rigor for the last 5 days. He also had a history of non-bilious vomiting with one episode expelling a round worm. His weight (10.6 kg) and height (89 cm) were below 3 standard deviations for his age. On examination, he had fever (101°F), moderate pallor, icterus and tender, soft hepatomegaly. Other systems were normal. On evaluation, haemogram showed polymorphonuclear leucocytosis, eosinophilia (TLC- 31,600/mm³; polymorphs 80% and eosinophils 12%), thrombocytosis (platelet count- 11.8 lakhs/mm³) and microcytic hypochromic anaemia (Hb 5.6 g/dl, MCV 59 fl, MCHC 24 g/dl). His liver function tests revealed a total serum bilirubin of 3.2mg/dl, direct bilirubin of 2.6 mg/dl, normal transaminases (AST-34 IU/L, ALT-21 IU/L) with markedly raised alkaline phosphatase (860 IU/L). Serum amylase (77 IU/L) and lipase (56 IU/L)were normal. Blood and urine cultures were normal. Initial ultrasonogram (USG) of the abdomen revealed multiple echogenic linear shadows in the bowel lumen, common bile duct (CBD) and both hepatic ducts with mildly dilated intrahepatic biliary radicles (figures 1a, 1b). Child was started on 1st line antibiotics, PRBC transfusion, antispasmodics and an antihelminthic drug (albendazole 400 mg stat followed by 15 mg/kg/day 2 divided doses). Despite passage of multiple worms in the stool and vomitus, he remained symptomatic. Meanwhile, antibiotics were upgraded but serial USGs showed persistence of worm in the common hepatic duct (figure 2a) with cholangitis (TLC-19750/mm³, bilirubin-3.4 mg/dl) even after two weeks of treatment. Magnetic resonance cholangiopancreatography (MRCP) also revealed the persistence of biliary worm (figure 2b). On 15th day, the child was planned for endoscopic worm extraction. Olympus 180 (Olympus Ltd., Tokyo, Japan) sideviewing ERCP scope was used. A large round worm was noted projecting partly into the duodenal lumen through the ampulla. CBD cannulation and sphincterotomy was done. Repeated balloon sweeps (figure 3a) removed one large ascaris (figure 3b). Further balloon sweeps were done but no stent was placed. However, post removal of the worm, cholangiogram was deferred in view of pre-existing cholangitis. Post ERCP, USG showed absence of ascaris in the biliary system. Child became afebrile after 24 hrs; he was subsequently discharged with iron supplementation, deworming advice and health education to the entire family.

Ascariasis is common in children aged 2 to 10 years and ingestion of contaminated water initiates the infection cycle. It is widely prevalent in India with higher prevalence rate seen in Tamil Nadu (85%) and Kashmir (70%)⁶.

Hepatobiliary ascariasis is the second most common cause of acute biliary symptoms after cholelithiasis. Biliary colic, cholangitis, acalculous cholecystitis, pancreatitis, liver abscess and recurrent pyogenic cholangitis are the various modes of presentation^7,8. However, biliary complications of ascariasis are less frequent in children (5%) as compared to adults (53%)⁴. Migration through the ampulla initiates marked sphincter spasm resulting in complications^9,10.

In adults, endotherapy is recommended after at least 3 weeks of conservative medical management⁷. However, clear guidance regarding childhood biliary ascariasis is lacking. A large number of reports in adults outlined the role of ERCP in biliary ascariasis, but experiences from children are very few^4,14. Recently, de Almeida et al. reported three cases of paediatric biliary ascariasis managed with conservative and surgical intervention resulting in significant morbidity and prolonged PICU stay¹⁵. Wani et al. in their report of 198 children (age 4-15 years) from Kashmir with biliary ascariasis showed the need of surgery in 11.6 % cases as they did not opt for ERCP claiming difficulty of the procedure in children¹³. Bahú Mda et al. from Brazil  reported 57% success rate (4 out of 7) in paediatric complicated biliary ascariasis and advocated prompt ERCP removal of worms as they performed ERCP within three days of diagnosis of biliary ascariasis⁴. Dahale et al. showed successful worm removal in seven patients in their review of 164 ERCPs in 126 children (range 1-15 years; 13 below 5 years)¹⁴. Presently, surgical intervention is recommended only in case of ERCP failure or if it is not feasible. Endoscopic extraction of worms, appears to be a better substitute for expeditious recovery regardless of duration of the disease¹³.

Experiences of endoscopic removal of biliary ascaris are scarce in younger children. Prompt endotherapy is worthwhile for successful outcomes even in younger kids.