Parasitic infestations of the biliary tract

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2. AmoebiasisHydatidosisAscariasisFascioliasisClonorchiosisOpisthorchiosis 3. FASCIOLIASISEtiology:Zoonosis caused by trematode Fasciola hepatica Fasciola giganticaEpidemiologyF. hepatica temperate zonesF. gigantica tropical zonesNow has become global in distribution 4. Epidemiologic pattern Cases imported by migration Autochthonous isolated, sporadicinfection in areas where animal infestationis present Endemic fascioliasis Epidemic fascioliasis in animal endemicand human endemic areas 5. Life cycleF. hepatica flukesare large, flat,brown and leafshaped25 -30 mm by 10-15 mmF. gigantica upto 75mm 6. Adult flukes in common and hepaticbile ducts of human or animalEggs oval, yellowish brown; 130x60micronsEggs in tepid water miracidia (9 to14 days)Miracidia freshwater snails sporozoites and redia (4 to 7 weeks) free swimming cercaria watercress, water lettuce, alfalfa(aquatic plants) 7. Life cycleConsumption of Aquatic plantscontaminated with metacercaria excyst in the duodenum migrate through bowel wall andperitoneal cavity Glisson capsule of liver (after 4 wks)initiate larval, hepatic and invasivestages of infection 8. Extrahepatic forms or ectopicinfectionsJuvenile larva adult flukes ( 3-5months)Adult fluke worms produce eggs in 4months eggs traverse sphincter ofOddi intestineFlukes live in biliary tracts between 9-13.5 yearsWomen more affected; morecomplications 9. Risk factorsContaminated aquatic plantconsumptionDietary habitsGeographic locationTreatment of contaminated plants withhigh doses of KMnO which decreasemetacercariae viability 10. CLINICAL FEATURESAcute infection: 3-5 months Prolonged fever Hepatomegaly Abdominal pain Eosinophilia Acute cholecystitis like syndrome withsignificant eosinophilia 11. Hyperbilirubinemia is absent in acutephaseAnorexia, weight loss, nausea,vomiting, urticariaLasts from migration of immaturelarvae from duodenum to liver andbiliary duct 12. CHRONIC INFECTION3-6 months after consumption ofmetacercariaeSymptoms biliary obstruction withcolicky pain in RUQ, epigastrium;Extrahepatic cholestatic syndromeElevation of liver enzymesDilated CBD, parasites in GB andCBD, stones in GB and bile ductHemobilia 13. Acute eosinophilic cholecystitis pruritis and intermittent jaundicechronic granulomatous inflammationHepatic fibrosisCholangiocarcinoma 14. INVESTIGATIONSUSG Abdomen : AcuteFocal areas of increased echogenicityMultiple nodular lesionsSingle, complex mass in liverMimics malignancy ChronicLess specificParasites in GB and CBDThickening of GB and CBD wallsStones in CBD 15. COMPUTED TOMOGRAPHYMultiple hepatic metastasis likelesionsChange in position, attenuation, andshape over timeHepatomegalySubcapsular hematomaSub capsular Tract like hypodenselesions 16. CTStages Early : contrast enhancement of Glissoncapsule Intermediate : subcapsular multiplehypodense nodular areas, tortuous,tunnel-like lesions Late stage : necrotic granuloma as asingle, non-contrast-enhanced hypodenseirregular mass in liver Liver calcification 17. LAB. DIAGNOSISAcute phase Antibodies against Cathepsin L1 byELISA Anti-parasitic trial EosinophiliaChronic phase Visualisation of parsitic egg in stool Sedimentation technique to concentratethe eggs Serial stool specimens 18. SURGERY IN FASCIOLIASISChronic phase biliary obstruction withcholedocholithiasisIncidentally found in cholecystectomyspecimens and T-tubesERCP when there is biliary obstructionIn cholangitis antiparasites,percutaneous drainage and anti-biotics (against E. faecalis, E. coli )Incidental met. Like lesions in D-lap witheosinophilia consider fascioliasis 19. CHEMOTHERAPYTriclabendazole Single dose of 10 mg/kg Better absorption with fatty meal Adverse effect biliary colic;antispasmodic to be administeredconcurrently Other drugsBithionoldehydroemetinenitazoxanide 20. CLONORCHIASIS ANDOPISTHORCHIASISClonorchiasis Clonorchis sinensis Chinese or oriental liver flukeOpisthorchiasis Opisthorchis viverrini Opisthorchis felineusCommonly found in oriental countries China, Laos, Thailand, Korea, Japan,TaiwanEating raw and uncooked fish 21. Life cycleTwo intermediate hosts : Fresh watersnail & FishHuman host adult worms eggs instools water fresh water snail miracidia sporocyst, redia andcercaria in snail freshwater fish metacercariae in muscles of fish metacercarial cyst (acid resistant ) small intestine of human Liver 22. Metacercariae navigate throughampulla of vater mature into adultworms in bile ductsLive for 45 years in liver1000-2500 eggs/dayReside in medium to smallintrahepatic bile ducts, extrahepaticducts, GB and pancreatic duct 23. CLINICAL FEATURESMostly asymptomatic5%-10% - non specific symptoms Fever Rash Malaise RUQ pain Flatulence Fatigue 24. Clonorchis sinensis Acute : asymptomatic and non-specificsymptoms Chronic:Recurrent cholangitisCholecystitisObstructive jaundiceHepatomegalyCholelithiasisMultiple hepatic tumoursCholangiocarcinoma 25. Opisthorchis viverrini: Acute : 5-10% have non-specificsymptoms Chronic:HepatomegalyIntrahepatic duct stonesRecurrent suppurative cholangitisCholangiocarcinoma 26. Opisthorchis felineus: Raw, salted and frozen fish consumption AcuteHigh grade feverNausea and vomitingAbdominal painMalaise, arthralgia and lymphadenopathyEosinophilia with Increased LFT ChronicLiver abscess and suppurative cholangitis 27. CHOLANGIOCARCINOMA ANDFLUKESO. viverrini ( More common )C. sinensisSecretion of parasite proteins withmitogenic properties into bile ductsOv-GRN-1Inflammation around biliary tree;epithelial hyperplasia; metaplasia ofmucin-producing cells and periductalfibrosis 28. DIAGNOSISEggs in stool sampleSerology : Ov-CP-1 based ELISA ,doesnt distinguish recent or pastinfectionUSG : Intrahepatic duct dilation;increased periductal echogenicity; GBsludgePCR to detect adult parasite DNA instool samples 29. TreatmentPraziquantelO. viverrini single dose (40-50mg/kg)C. sinensis 25 mg/kg three times at5 hour intervals in 1 day 30. BILIARY ASCARIASISAscaris lumbricoidesRoundworm 20-30 cm in lengthTropical and sub-tropical regionsPoor socioeconomic conditionsSource of infection -Fecalcontamination of soil and farmsSymptoms when worms enter biliarytree 31. Adult worm of A. lumbricoides 32. Life cycleAdult worm in human intestine Female lay eggs Feces warm moist soil maturation mature egg humaningestionHatch in duodenum larvae penetrate mucosa portal venousblood liver right heart pulm.Capillary bed trachea esophagus Jejunum 33. PathologyAscaris reach duodenum Increased load in jejnum Increased intestinal motilityOne or two worms enter biliary systemvia ampulla of vaterPart of worm may remain in intestineCommon in women and pregnantwomen (progesterone)Common after cholecystectomy,sphincterotomy, choledochostomy 34. Impacted worm sphincter of oddispasm biliary colicSuppurative cholangitis cholangiohepatic abscessAcalculous cholecystitis, empyema,perforation of bile ductAcute pancreatitisDuctal stricture and stones ( deadworms) 35. Clinical featuresChildren ; 2-8 yrsAdults in endemic areas 35 yrs(mean)Women > menHistory of previous biliary surgeryVomiting of wormsWorms in stools 36. Sudden severe upper abdominal painRUQ tenderness and guardingLow grade feverJaundice is usually absentComplications EarlyAcute suppurative cholangitisHepatic ascariasisAcute pancreatitis Late- calculi and strictures 37. DiagnosisStool analysis for ova and deadwormsLeukocytosis suppurativecomplicationsHyperbilirubinemia hepatopancreaticascariasisElevated liver enzymes in cholangitisS. amylase elevation 38. ImagingAbdominal radiographs worms canbe seenUSG dilated bile ducts containinglinear or round areas of increasedechogenicity;GB sludge, movement ofworms in biliary system; alternatingechogenic and echolucent stripsCT is less sensitiveEndoscopy worm in duodenum;protruding from ampulla of water 39. MRCP useful in pancreaticobiliaryascariasisERCP diagnostic and therapeuticEUSPTC in cases of failed ERCP 40. ManagementConservativeEndoscopic extractionSurgical intervention 41. ConservativeSpontaneous return to duodenum in98% of childrenParenteral analgesics andantispasmodics relax sphincterNGAIV fluidsPiperazine citrate through nasobiliarycatheter 42. Oral anti-helminthics: Albendazole 400 mg/day for 1 day Mebendazole 100 mg BD for 3 days and Pyrantel palmoate 11mg/kg single dose 43. Endoscopic interventionsERCP with sphinterotomy and removalof wormsExtracted from papillary opening usingdormia basketEndoscopic papillary balloon dilatationRequires multiple sessionsIndications: Severe persistent pain unresponsive toantihelminthics Symptoms or USG abnormalities persist 2wks after conservative line Increasing jaundice 44. SurgicalPTC in failed ERCP with cholangitisIndications of surgery Intrahepatic duct worms, stones, stricturesand abscess Gall bladder ascariasis Procedure:Longitudinal choledochotomyLap. Cholecystectomy with CBD explorationCholedochoscopyT-tube intra and post-operatively