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Ann Saudi MedAnn Saudi MedAnnals of Saudi Medicine0256-49470975-4466King Faisal Specialist Hospital and Research Centre 2258845310.5144/0256-4947.2012.325asm-3-325ImagesUnpredictable dance of worms Wani Mohd Lateef From the Sher-i-Kashmir Institute of Medical Sciences, Soura Srinigar, IndiaCorrespondence: Moh Lateed Wani, F11 B Block Married Doctors Hostel Sher-i-Kashmir Institute of Medical Sciences, Soura Srinigar, India, latifs_dr@yahoo.comMay-Jun 2012 32 3 325 326 Copyright © 2012, Annals of Saudi Medicine2012This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
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A 50-year-old female had history of recurrent episodes of right upper abdominal pain radiating to the shoulder for six months. There was history of passage of worms with stool. Physical examination revealed icterus and mild pallor. Investigations showed cholilithiasis with cholidocholithiasis. The stones could not be retrieved with endoscopic retrograde cholecystopancreaticography. Cholecystectomy and choledochotomy with T-tube drainage was performed. On the 11th postoperative day, the patient developed severe right upper abdominal pain. Abdominal sonography was was normal, and a previous cholangiogram did not show filling defects. A decision was made to remove the T-tube. Upon removal, a 5 cm long worm was found attached to the T-tube (Figure 1).

An 18-year-old female presented with a history of abdominal pain of one day duration. There was a history of anorexia. Physical examination revealed tachycardia along with rebound tenderness in the right iliac fossa. The psoas test was positive. Investigations revealed a raised white cell count with left shift. Abdominal ultrasonography showed a target sign. A diagnosis of acute appendicitis was made. During appendectomy, a 7 cm worm was found to be occluding the appendix. Appendectomy was performed and the worm was removed. Postoperatively, the patient received antihelminthic treatment (Figure 2).

A 45-year-old female patient presented with right upper quadrant pain associated with jaundice. Abdominal ultrasonography showed cholilithiasis with cholidocholithiasis. A therapeutic endoscopic retrograde cholecystopancreaticography was unsuccessful. A cholecystectomy was performed with choledochotomy. Multiple stones were removed from the common bile duct and a T-tube was inserted. A postoperative T-tube cholangiogram disclosed a long worm in the common bile duct. It was flushed out with normal saline. The T-tube was removed after a normal repeat cholangiogram. Antihelminthic treatment was commenced (Figure 3).

Figure 1 Ascaris comming out through T-Tube.

Figure 2 Ascaris causing appendicitis.

Figure 3 Ascaris in common bile duct on cholangiogram.