Retrograde Cystic Duct Milking Before Ligation for Isolated Gallbladder Ascariasis with Acute Acalculous Hydrops: An Observational Analytic Case Study

Abstract

Background: Ascaris lumbricoides infects an estimated 700 million to one billion people, but gallbladder involvement accounts for only about 2.1% of hepatobiliary ascariasis. A worm impacted in the cystic duct can cause acute acalculous hydrops and may be transected during cholecystectomy.

Objective: To describe the presentation, open surgical management with retrograde cystic duct milking, and six-month course of isolated gallbladder ascariasis with acute acalculous hydrops.

Methods: This study describes a 57-year-old woman with acute-on-chronic right upper quadrant pain in Indonesia, assessed clinically, biochemically, and sonographically from admission (T₀) to month 6 (T₆).

Results: At admission, pain was 8/10, leukocytes 15,460/mm³, eosinophils 8.0% (1,236/mm³), C-reactive protein (CRP) 45.0 mg/L, and alkaline phosphatase 133 U/L, with normal bilirubin (0.8 mg/dL). Ultrasonography showed a tense, stone-free gallbladder (10.5 × 4.5 cm; estimated volume 111.3 cm³; wall 4.5 mm) with the inner tube and stripe signs of a live worm impacted in the cystic duct. Under rapid sequence induction without nitrous oxide, open cholecystectomy with retrograde cystic duct milking displaced an intact 22.0-cm A. lumbricoides into the gallbladder before ligation. Albendazole 400 mg was given on postoperative day 1 after flatus; she was discharged on day 3. At month 6, she was asymptomatic, CRP (−96.9%) and eosinophils (−88.9%) had fallen, and liver enzymes were normal.

Conclusion: In this patient, retrograde cystic duct milking during open cholecystectomy, followed by albendazole after the return of bowel function, removed the impacted worm intact and was followed by full recovery.