Biliary Ascariasis Diagnosed and Extracted by ERCP in the United States

A 53-year-old female Bangladeshi immigrant to the United States, status post uncomplicated laparoscopic cholecystectomy without sphincterotomy 6 months earlier for cholelithiasis, presented with colicky abdominal pain for 6 weeks. Physical examination revealed a soft, non-tender abdomen, and esophagogastroduodenoscopy revealed no endoscopic abnormalities. Laboratory testing revealed leukocytes 16,100/mm with no eosinophilia, serum alkaline phosphatase 321 U/L, aspartate aminotransferase 428 U/L, alanine aminotransferase 232 U/L, total bilirubin 1.5 mg/dL, and lipase 30 U/L. Abdominal ultrasound revealed a 9-mm choledochus containing long, parallel segments of non-shadowing echogenic material, initially thought to represent choledochal sludge (Figure 1). Abdominal computed tomography and magnetic resonance cholangiopancreatography revealed only mild extrahepatic biliary dilatation, attributed to prior cholecystectomy.