A patient presenting with epigastric pain

A 14 years girl presents with epigastric pain for 3 days. Pain comes and goes frequently. She also mentioned passage of worm per mouth.

What are the diagnoses striking in your mind?
• Billiary ascariasis
• Billiary colic
• Ascariatic crisis

What key questions would you ask?
Pain- epigastric severe colicky pain with no radiation, not relieved by change of posture, several bouts of pain during the whole period- billiary ascariasis.
Similar colicky pain but does not usually persist more than 6 hours in billiary colic.
Vomiting- content of vomitus-worms
History of pruritus and urtecaria- ascariatic crisis

What will you examine?
General examination- distressed during pain.
Abdominal examination- no tenderness or any other abnormalities in biliary ascariasis.
Murphy’s sign positive if acute cholecystitis develops following billiary colic.
Scratch marks and wheals- ascariatic crisis.

Clinical diagnosis-History of colicky abdominal pain over long period, no tenderness and passage of worm per mouth suggest the diagnosis of Billiary ascariasis.
Investigation-
USG of HBS- worm in common bill duct
CBC- Eosinophilia in ascariatic crisis

Treatment-
Conservative-
• Relief of pain by antispasmodic drugs e.g. Timonium methyl sulphate.
• Anthelmintic- there is controversy regarding use of anthelmintic during pain.
(Author’s experience- the response to use of albendazole and chlorpromazine 50 mg b.i.d by mouth or injection is better than antispasmodic with or without anthelmantic regarding pain relief and spontaneous clearance of worm from CBD.)

Definitive treatment- ERCP removal of worm.