Next Time Think of a Worm!

An 81 - year - old male patient presented with complaints of severe abdominal pain and yellowish discolouration of sclera since two days. The pain was insidious on onset, gradually progressive which did not relieve even on medication. The patient also had loss of weight and appetite since past six months. Lab investigations showed increased bilirubin (11.6 mg/dl), prothrombin time (17.5 sec) and total leukocyte count (14, 500 cells/cumm). The patient was advised USG initially to evaluate the cause of the pain which showed central IHBRD with a hyperechoic lesion in the mid CBD causing gross dilatation. Later CT was done which showed obstructive biliary pathology in the distal CBD causing IHBRD. To evaluate further we did MRCP which showed acute cholecystitis with large choledocholithiasis causing obstructive biliopathy. On ERCP there is a ball of dead worms with few live worms in the CBD. Balloon sphincteroplasty with biliary stenting is done.