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Recurrent Acute Pancreatitis in Children

Do not forget the “Worms”

Nabi, Zaheer; Reddy, Duvvur Nageshwar; Lakhtakia, Sundeep

Journal of Pediatric Gastroenterology and Nutrition: January 2018 - Volume 66 - Issue 1 - p e20
doi: 10.1097/MPG.0000000000001791
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Asian Institute of Gastroenterology, Hyderabad, India.

Address correspondence and reprint requests to Zaheer Nabi, MD, DNB, Asian Institute of Gastroenterology, 6-3-661, Somajiguda, Hyderabad 500 082, India (e-mail:

Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal's Web site (

The authors report no conflicts of interest.

Submissions for the Image of the Month should include high-quality TIF endoscopic images of unusual or informative findings. In addition, 1 or 2 other associated photographs, such as radiological or pathological images, can be submitted. A brief description of no more than 200 words should accompany the images. Submissions are to be made online at, and will undergo peer review by members of the NASPGHAN Endoscopy and Procedures Committee, as well as by the Journal.

A 14-year-old girl presented with recurrent episodes of acute pancreatitis for 2 years. For the past week she had intermittent fever with chills. Abdominal ultrasonography revealed a dilated common bile duct (8 mm), but no choledocholithiasis. Evaluation for other etiologies including serum calcium, serum parathormone, and serum triglyceride levels were normal. Serum bilirubin (total, 3.5 mg/dL; direct, 2.1 mg/dL) and transaminases were slightly elevated (alanine aminotransferase, 64 U/L; aspartate aminotransferase, 78 U/L), whereas serum alkaline phosphatase (ALP) was about 3 times upper limit of normal (ALP, 450 U/L). Endoscopic retrograde cholangiopancreatography revealed a linear filling defect in the bile duct. Endoscopic sphincterotomy followed by balloon sweep was performed and a dead Ascaris worm was extracted from the bile duct with rat tooth forceps. The worm was about 15 cm long. The child and the family members were prescribed anti-helminthic therapy to prevent re-infestation. At a follow-up 7 months later, the child remains asymptomatic. Parasitic infestations of gastrointestinal tract are relatively common in developing countries. Of these, Ascaris lumbricoides has been implicated as one of the causative factors for recurrent bouts of pancreatitis (1). Endotherapy is indicated if conservative treatment is not successful (Supplemental Digital Content, Video,

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1. Javid G, Zargar S, Shah A, et al. Etiology and outcome of acute pancreatitis in children in Kashmir (India). An endemic area of hepatobiliary ascariasis. World J Surg 2013; 37:1133–1140.

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