01Approach to the Critical Patient/attcp47

Immediate priorities

›Red flag recognition

›Charcot's triad — fever, jaundice, RUQ pain — acute cholangitis

›Immediate biliary decompression planning

›IV antibiotics within 1 hour

›Reynolds' pentad — Charcot's triad plus hypotension and altered mental status

›Suppurative cholangitis or sepsis

›ICU-level care, emergent ERCP or surgical consult

›Hemodynamic instability

›SBP < 90 mmHg

›MAP < 65 mmHg

›Peritoneal signs

›Guarding or rigidity suggests biliary perforation

›Emergent surgical consult

Resuscitation and stabilization

›Initial measures

›IV access and fluid resuscitation

›Crystalloid bolus 30 ml/kg if septic shock

›Reassess after each bolus

›NPO status

›Pancreatitis or cholangitis suspected

›Pre-procedural preparation

›IV analgesia

›IV opioid for biliary colic

›IV antispasmodic — hyoscine butylbromide for ductal spasm

›Broad-spectrum antibiotics if cholangitis or sepsis

›Piperacillin-tazobactam 4.5 g IV every 6 hours first-line

›Target gram-negative enteric organisms and anaerobes

02History/hx75

Presenting symptoms

›Core pain pattern

›RUQ or epigastric colicky pain

›Often severe and episodic

›Mimics choledocholithiasis

›Timing and recurrence

›Acute onset, may recur over weeks to months

›Repeated worm migration pattern

›Radiation

›Epigastric pain radiating to back — pancreatitis concern

›Shoulder tip pain — diaphragmatic irritation

›Associated symptoms

›Nausea and vomiting

›Vomiting of roundworms in 25 to 48% of cases

›Highly suggestive of ascariasis when present

›Fever and chills

›Rigors suggest cholangitis or abscess

›High fever with rigors — pyogenic cholangitis

›Jaundice

›Dark urine and pale stools

›Obstructive pattern

›Passage of worms in stool

›Directly confirms active ascariasis

›Enquire specifically

Risk factors

›Epidemiological exposures

›Residence in or travel to endemic regions

›South and Southeast Asia

03Physical Exam/exam54

Vital signs and hemodynamic assessment

›Hemodynamic stability

›Blood pressure

›SBP < 90 mmHg — septic shock

›MAP < 65 mmHg — organ perfusion threshold

›Heart rate

›Tachycardia — pain, sepsis, dehydration

›Bradycardia — rare, exclude cardiac cause

›Temperature

›Fever > 38.5 C — cholangitis or abscess

›Hypothermia — severe sepsis marker

›Respiratory rate

›Tachypnea with sepsis

›Assess work of breathing

Abdominal exam

›RUQ and epigastric findings

›RUQ tenderness

›Localized tenderness — biliary or hepatic involvement

›Murphy's sign — acute cholecystitis concern

›Epigastric tenderness

›Pancreatitis pattern

›Radiation to back

›Peritoneal signs

›Guarding — involuntary muscle rigidity

›Rigidity suggests perforation or peritonitis

›Hepatobiliary findings

›Hepatomegaly

›Hepatic abscess concern

04Differential Diagnosis/ddx50

Life-threatening diagnoses

›Acute cholangitis

›ICD-10 K83.0

›Charcot's triad in 70% of cases

›Biliary ascariasis accounts for up to 37% of biliary disease in endemic areas

›Suppurative cholangitis

›Reynolds' pentad

›Mortality risk without biliary decompression

›Acute biliary pancreatitis

›ICD-10 K85.1

›Worm in pancreatic duct or ampulla

›Elevated lipase and amylase

›Severe acute pancreatitis criteria

›Organ failure by Atlanta classification

›Necrosis on CT

›Hepatic abscess

›ICD-10 K75.0

›Dead worm as nidus for bacterial seeding

›Right lobe predominance

›Sepsis from hepatic abscess

›High mortality if not drained

›CT or ultrasound-guided drainage required

Common mimics

›Choledocholithiasis

›ICD-10 K80.5

›Most important mimic

›Acoustic shadowing on ultrasound — stones; no shadowing — worms

›Clinical overlap complete

05Laboratory Tests/lt55

Infection and inflammation

›Complete blood count

›Leukocytosis — bacterial infection, cholangitis, abscess

›WBC > 12 x 10^9/l typical in cholangitis

›Leukopenia in severe sepsis

›Eosinophilia

›Suggestive of helminthic infection

›May be absent in acute biliary disease — eosinophilia not reliable to exclude

›Hemoglobin

›Anemia with chronic infection or blood loss

›Thrombocytopenia in severe sepsis

›Inflammatory markers

›CRP

›Elevated in bacterial cholangitis and abscess

›Serial trend useful for treatment response

›Procalcitonin

›Bacterial infection marker

›Not a rule-out test for parasitic disease

›ESR

›Elevated in chronic parasitic infection

›Non-specific marker

Liver and biliary function

›Liver function tests

›Alkaline phosphatase

›Elevated in obstructive pattern

›GGT elevation corroborates biliary source

›Direct bilirubin

›Elevated in biliary obstruction

06Diagnostic Tests/dt87

Scoring Systems

›Biliary severity scoring

›Tokyo Guidelines 2018 — cholangitis severity grading

›Grade I — mild: responds to initial antibiotics and supportive care

›Grade II — moderate: end-organ dysfunction without failure

›Grade III — severe: organ dysfunction in one or more organ systems

›APACHE II score for ICU admission threshold

›Score >= 8 associated with increased mortality

›Used for ICU admission decision in severe cholangitis

›Pancreatitis severity tools

›Ranson criteria

›On admission: age > 55, WBC > 16 x 10^9/l, glucose > 11 mmol/l, LDH > 350 IU/l, AST > 250 IU/l

›At 48 hours: hematocrit decrease > 10%, BUN rise > 1.8 mmol/l, calcium < 2 mmol/l, PaO2 < 60 mmHg

›Score >= 3 indicates severe pancreatitis

›BISAP score

›BUN > 8.9 mmol/l

›Impaired mental status

›SIRS criteria met

›Age > 60 years

›Pleural effusion on imaging

›Score >= 3 predicts increased mortality

MRI

›MRCP indications

›Intraductal worm characterization

›Confirms worm extending into intrahepatic ducts

›Excellent for surgical planning when ERCP not feasible

›Advantages over other modalities

›No radiation

›Multiplanar ductal anatomy visualization

›Identification of worm in second and third order ducts

›Findings on MRCP

›Long tubular filling defect in CBD

›Characteristic T2-bright central canal within the worm

›Ductal dilatation proximal to worm

›Limitations

›Availability constraints in acute setting

›Motion artifact risk in uncooperative or unstable patients

›Claustrophobia and implant contraindications

›Metal implant contraindication screening

›Pacemaker and ferromagnetic implant review

›Prior surgical hardware assessment

CT

›CT abdomen and pelvis indications

›Complication evaluation

›Hepatic abscess diagnosis and characterization

›Acute pancreatitis severity and necrosis quantification

›Perforation or free air detection

›Diagnostic uncertainty

›Ultrasound non-diagnostic

›Failure to improve on medical therapy at 48 to 72 hours

›CT findings in biliary ascariasis

›Tubular low-density structure within the CBD

›Biliary dilatation

›Hepatic abscess — hypodense rim-enhancing lesion

›Protocol considerations

›Contrast-enhanced CT preferred for abscess characterization

›Portal venous phase for liver parenchyma

›Renal function assessment before contrast

›CT pancreatography

›CT severity index — Balthazar grading for pancreatitis

›Grade E — > 30% necrosis carries 17% mortality

Ultrasound

›Abdominal ultrasound — first-line diagnostic tool

›Sensitivity approximately 86% for biliary worms

›Operator and technique dependent

›Real-time worm movement characteristic

›Classic ultrasound findings

›Long linear echogenic structure without acoustic shadowing in the CBD

›Inner tube sign — central anechoic canal within the echogenic strip

›Represents the worm's own digestive tract

›Additional findings

›CBD dilatation

›Gallbladder wall thickening and distension

›Biliary sludge

›Intrahepatic ductal dilatation

›Differentiating ascariasis from choledocholithiasis

›Choledocholithiasis

›Acoustic shadowing posterior to calculus

›Round or faceted echogenic foci

›Biliary worm

›No acoustic shadowing

›Linear tubular morphology

›Active movement may be seen on real-time scanning

›ERCP — diagnostic and therapeutic gold standard for refractory cases

›Both diagnostic and therapeutic in a single procedure

›Visualizes worm in CBD and intrahepatic ducts

›Basket or balloon extraction under direct vision

›Indications for ERCP

›Symptoms persisting or worms remaining at 3 weeks of medical therapy

›Cholangitis requiring biliary decompression

›Nasobiliary catheter drainage when drainage needed

07Disposition/dispo43

Admission indications

›Inpatient admission criteria

›Cholangitis

›Any grade of Tokyo Guidelines cholangitis

›IV antibiotics and biliary decompression required

›Sepsis or hemodynamic instability

›SBP < 90 mmHg or MAP < 65 mmHg

›Lactate >= 2 mmol/l

›Acute pancreatitis

›NPO, IV fluids, monitoring required

›Severity assessment with Ranson or BISAP

›Hepatic abscess

›Drainage planning

›IV antibiotics

›Inability to tolerate oral medications or fluids

›Persistent vomiting

›Dehydration requiring IV hydration

›ICU-level criteria

›Septic shock requiring vasopressors

›Norepinephrine initiation

›Multiorgan dysfunction

›Respiratory compromise

›Aspiration or pleuropulmonary involvement

›Hepatopulmonary syndrome

›Peritoneal signs or perforation

›Emergent surgical intervention

Discharge criteria

›Safe discharge parameters

08Treatment/t107

Initial stabilization

›Supportive measures

›IV fluids

›Crystalloid resuscitation for dehydration or sepsis

›NPO during acute biliary colic, cholangitis, or pancreatitis

›Analgesia

›IV morphine 2 to 4 mg IV every 4 hours PRN for biliary colic

›Titrate to pain relief

›Monitor for respiratory depression

›IV ketorolac 15 to 30 mg IV every 6 hours if no contraindication

›Avoid in renal impairment or GI bleeding risk

›Maximum 5 days

›Antispasmodic

›Hyoscine butylbromide 20 mg IV every 8 hours for ductal spasm

›Reduces Oddi sphincter tone

›May facilitate spontaneous worm exit

›Antiemetics

›Ondansetron 4 mg IV every 6 to 8 hours

›Safe in most clinical contexts

›QT prolongation monitoring if high-risk

Antibiotics for biliary sepsis

›Empirical coverage — cholangitis or sepsis

›Piperacillin-tazobactam IV — first-line

›4.5 g IV every 6 hours

›Extended infusion over 4 hours per local protocol for severe sepsis

›Renal dose adjustment when GFR < 40 ml/min

›Ciprofloxacin plus metronidazole — alternative

›Ciprofloxacin 400 mg IV every 12 hours

›Biliary penetration adequate

›QT prolongation and tendinopathy risk

›Metronidazole 500 mg IV every 8 hours

›Anaerobic coverage

›CNS penetration beneficial if abscess

›Meropenem for severe illness or resistant organisms

›1 g IV every 8 hours

›Broad spectrum including ESBL producers

›De-escalate once cultures known

›Duration of antibiotics

›Uncomplicated cholangitis

›5 to 7 days total course

›IV to oral switch when clinically improving and tolerating oral intake

›Hepatic abscess

›4 to 6 weeks total course

›Guided by drainage culture and clinical response

Anthelmintic therapy

›Timing of anthelmintics

›Administer after acute symptoms subside

›Avoid during active colic — risk of worm agitation and further migration

›Typically initiated when tolerating oral medications

›First-line anthelmintic agents

›Albendazole — most commonly used

›Standard dose 400 mg PO single dose

›High cure rate for intestinal ascariasis

›Take with food to improve absorption

›Higher dose for biliary ascariasis 800 mg PO single dose

›Used specifically for biliary involvement in some series

›Benzimidazole mechanism — tubulin polymerization inhibition

›Mebendazole — alternative

›100 mg PO twice daily for 3 days

›Or 500 mg PO single dose

›Poorly absorbed systemically — primarily luminal action

›Pyrantel pamoate — alternative, especially in pregnancy

›11 mg per kg PO single dose

›Maximum 1 g per dose

›Depolarizing neuromuscular blocking agent

›Cautions

›Benzimidazoles — teratogenic in animal models

›Avoid albendazole and mebendazole in first trimester

›Pyrantel pamoate preferred option in early pregnancy

›Avoid piperazine

›Withdrawn from many markets due to toxicity

›Not recommended

Endoscopic intervention

›ERCP with worm extraction — second-line when medical therapy fails

›Indications

›Symptoms persist or worms remain in ducts after 3 weeks of medical therapy

›Cholangitis requiring biliary decompression

›Worm visible at ampulla on upper endoscopy

›Technique

›Basket extraction preferred for worm retrieval

›Dormia basket engagement of worm body

›Balloon sweep of duct after extraction

›Endoscopic extraction at ampulla without sphincterotomy preferred when worm visible

›Preserve sphincter integrity when possible

›Reduces risk of future worm entry

›Nasobiliary catheter drainage

›Indicated for cholangitis requiring ongoing decompression

›Allows repeat cholangiography to confirm duct clearance

›Success rate

›ERCP extraction successful in majority of patients

›Failure rate low with experienced operator

Surgical intervention

›Surgical indications — last resort

›Trapped dead worms with stone formation

›Hepatolithiasis around worm nidus

›Biliary stricture from dead worm

›Biliary perforation

›Free air or bile peritonitis

›Emergency laparotomy

›Hepatic abscess not amenable to percutaneous drainage

›Multiloculated or deep abscesses

›Open or laparoscopic drainage

›Failed endotherapy

›Worm inaccessible to ERCP

›Intrahepatic ductal involvement

›Surgical approach

›Laparoscopic CBD exploration with worm extraction

›T-tube placement for ongoing biliary drainage

›Choledochoscopy to confirm duct clearance

›Open laparotomy reserved for perforation or failed laparoscopic approach

›Peritoneal lavage if bile spillage

›ICU post-operative monitoring

09Special Populations/sp91

Pregnancy

›Pregnancy-specific considerations

›Increased physiologic biliary stasis

›Progesterone reduces gallbladder motility

›Increased lithogenicity of bile

›Higher susceptibility to biliary complications

›Anthelmintic safety

›First trimester — avoid benzimidazoles

›Albendazole and mebendazole teratogenic in animal models

›WHO advises avoidance in first trimester

›Pyrantel pamoate 11 mg per kg PO single dose preferred in first trimester

›Minimal systemic absorption

›No known teratogenicity

›Second and third trimester — albendazole may be considered

›Risk-benefit assessment

›WHO mass drug administration programs use albendazole in second trimester

›Imaging

›Ultrasound — first-line, no radiation risk

›Safe at all gestational ages

›MRCP preferred over CT if further imaging needed

›CT reserved for emergencies only

›Minimize fetal radiation exposure

›Fetal radiation risk greatest in first trimester

›Antibiotics in pregnancy

›Piperacillin-tazobactam — generally safe in pregnancy

›Use for cholangitis with standard dosing

›Metronidazole — avoid high-dose IV in first trimester

›Low-dose oral considered acceptable after first trimester

›Ciprofloxacin — avoid unless benefits outweigh risk

›Quinolone class concerns in growing cartilage

›ERCP considerations

›Perform with lead shielding and fluoroscopy minimization

›Experienced operator essential

›Shortest fluoroscopy time achievable

Geriatric

›Older adult features

›Atypical presentation common

›Absent fever in bacteremic cholangitis

›Immunosenescence reduces febrile response

›Delirium may be the presenting sign

›Blunted pain response

›Peritoneal signs may be minimal despite significant pathology

›Low threshold for imaging

›Polypharmacy and drug interaction risks

›Albendazole metabolism via CYP3A4

›Interactions with warfarin — monitor INR closely

›Phenytoin and carbamazepine induce CYP3A4 — reduce albendazole levels

›Renal dosing adjustments for antibiotics

›GFR-based piperacillin-tazobactam adjustment

›Ciprofloxacin dose reduction when GFR < 30 ml/min

›Frailty and comorbidity considerations

›Higher procedural risk for ERCP and surgery

›Anesthesia risk assessment

›Cardiopulmonary reserve evaluation

›Biliary anatomy more commonly altered

›Previous cholecystectomy more prevalent

›Papillary stenosis from prior stone passage

›Disposition bias toward admission

›Limited home supports

›Higher risk of rapid deterioration

Pediatrics

›Pediatric-specific features

›Age-related presentation differences

›Intestinal obstruction from worm mass more common in children

›Small intestinal caliber more vulnerable to bolus obstruction

›Palpable abdominal mass — worm bolus

›Biliary ascariasis less common in children than adults

›Pediatric CBD smaller and less accommodating

›When it occurs — often with high worm burden

›Severe bacterial outcomes in pediatric biliary ascariasis

›Case series from Brazil reports significant morbidity

›Sepsis, hepatic abscess, cholangitis in children

›Aggressive early management required

›Anthelmintic dosing in children

›Albendazole 400 mg PO single dose for children over 2 years

›Same adult dose used for children over 2 years per WHO guidelines

›Under 2 years — 200 mg PO single dose

›Mebendazole 100 mg PO twice daily for 3 days

›Same dose regardless of age above 2 years

›Pyrantel pamoate 11 mg per kg PO single dose

›Maximum 1 g

›Weight-based dosing preferred in young children

›Antibiotic dosing

›Piperacillin-tazobactam 100 mg per kg IV every 6 hours of piperacillin component

›Maximum adult dose

›Metronidazole 7.5 mg per kg IV every 8 hours

›Maximum 500 mg per dose

›Nutritional considerations

›Ascariasis-associated malnutrition

›Iron deficiency anemia from protein malabsorption

›Zinc and vitamin A deficiency common in endemic settings

›Nutritional rehabilitation after acute treatment

›Growth monitoring

›Micronutrient supplementation

10Background/b92

Epidemiology

›Global burden

›Ascaris lumbricoides — most prevalent human intestinal nematode worldwide

›Estimated 804 million to 1.2 billion people infected globally

›Highest burden in tropical and subtropical regions with poor sanitation

›Biliary ascariasis prevalence in endemic regions

›Accounts for up to 37% of all biliary disease in endemic areas

›Kashmir Valley and sub-Saharan Africa historically highest reported rates

›Sex distribution

›Female sex carries 11.3 times higher odds of hepatobiliary-pancreatic ascariasis

›Prior biliary surgery present in 77 to 80% of adult cases in large series

›Clinical syndrome distribution

›Biliary colic — most common syndrome

›Accounts for 56% of biliary ascariasis presentations in large case series

›Most resolve with conservative therapy

›Acute cholangitis — second most common

›Fever, jaundice, and RUQ pain

›Acute pancreatitis — worm in pancreatic duct

›Less common but clinically significant

›Hepatic abscess — less common, higher mortality

›Dead worm as nidus for bacterial seeding

›Outcomes

›90 to 97% of cases resolve with conservative medical therapy alone

›Worms typically migrate out of biliary tree spontaneously within days to weeks

›Most patients improve within 48 to 72 hours

›Recurrence rate

›76 of 500 patients — 15.2% — had recurrent biliary invasion during 4-year follow-up

›Driven by reinfection in endemic settings

›Mortality

›Severe complications carry 0.8 to 3.8% mortality

›Suppurative cholangitis and hepatic abscess highest risk

Pathophysiology

›Worm life cycle and biliary migration

›Ascaris lumbricoides adult worm habitat

›Adult worms reside in the small intestinal lumen

›Large nematode — 15 to 35 cm in length

›Migrates through the ampulla of Vater into the biliary tract

›Trigger for migration

›Fever or drugs — including anthelmintics given during acute infection

›Disrupted sphincter anatomy from prior biliary surgery

›High worm burden promoting ectopic migration

›Worm entry pathway

›Enters CBD via sphincter of Oddi

›May ascend into intrahepatic ducts

›May enter gallbladder or pancreatic duct

›Consequences of biliary migration

›Mechanical obstruction

›Partial or complete CBD obstruction

›Biliary hypertension and dilatation

›Obstructive jaundice

›Bacterial translocation

›Worm carries intestinal bacteria into sterile biliary tract

›Cholangitis, biliary sepsis

›Worm death in ducts

›Dead worm acts as nidus for stone formation — hepatolithiasis

›Intrahepatic abscess formation

›Biliary stricture from fibrotic reaction

›Inflammatory cascade

›Helminthic antigen stimulation

›Eosinophilic response — may be blunted in acute biliary disease

›IgE-mediated response

›Bacterial superinfection

›Gram-negative enteric organisms dominant

›Anaerobic organisms contribute to abscess formation

Therapeutic Considerations

›Conservative therapy rationale

›Spontaneous worm migration out of biliary tree in most cases

›90 to 97% resolution with supportive care and anthelmintic treatment

›Anthelmintics should be delayed until acute symptoms subside

›Premature anthelmintic use may agitate worms and worsen migration

›Serial ultrasound monitoring

›Confirms worm exit from biliary tree

›Guides decision for escalation to ERCP

›Typically within 1 to 3 weeks of treatment

›Endoscopic vs surgical decision

›ERCP preferred over surgery when available

›Lower morbidity than open CBD exploration

›Diagnostic and therapeutic in single procedure

›Preserving sphincter where possible reduces future worm entry risk

›Surgical intervention for ERCP failure or complications

›Biliary perforation

›Hepatolithiasis from dead worm

›Intrahepatic abscess not amenable to percutaneous drainage

›Prevention and public health dimensions

›Reinfection control in endemic settings

›Treat household contacts — high household clustering of infection

›Sanitation improvement — core prevention strategy

›Food hygiene education — wash vegetables, avoid fecal-contaminated soil

›WHO preventive chemotherapy programs

›Annual or biannual mass drug administration in high-burden communities

›School-age children primary target

›Albendazole or mebendazole as platform drugs

›Post-treatment monitoring

›Stool O&P at 2 weeks post-treatment — up to 3 samples recommended

›Confirm parasitological cure before discharge from follow-up

11Patient Discharge Instructions/pdi51

copy discharge instructions

›Diagnosis and general information

›Biliary ascariasis — roundworm migration into the bile ducts

›Caused by Ascaris lumbricoides — a large intestinal roundworm

›Worms migrate from the intestine into the liver bile ducts

›Most cases resolve with medication and rest

›Worms usually exit the bile ducts on their own within days to weeks

›Follow-up ultrasound will confirm resolution

›Medications at discharge

›Take your prescribed anthelmintic (anti-worm) medication exactly as directed

›Albendazole or mebendazole — take with food

›Complete the full course even if feeling better

›Pain and anti-spasm medications as prescribed

›Take only as directed

›Avoid NSAIDs if told to avoid them due to kidney or stomach concerns

›Antibiotics if prescribed for infection

›Complete the full course

›Do not stop early even if feeling better

›Diet and activity

›Start with clear fluids and advance to low-fat foods as tolerated

›Avoid fatty or spicy foods until fully recovered

›Stay well hydrated

›Rest for the first 24 to 48 hours after discharge

›Gradually return to normal activities as pain improves

›Food hygiene to prevent reinfection

›Wash all raw vegetables and fruit thoroughly

›Drink only safe treated water

›Avoid contact with fecal-contaminated soil

12References/r36

Guidelines and key sources

›Primary literature

›Khuroo MS, Rather AA, Khuroo NS, Khuroo MS — Hepatobiliary and Pancreatic Ascariasis — World Journal of Gastroenterology 2016 — PMID 27672273

›Comprehensive review of hepatobiliary and pancreatic ascariasis

›Epidemiology, clinical features, management

›Khuroo MS, Zargar SA — Biliary Ascariasis, A Common Cause of Biliary and Pancreatic Disease in an Endemic Area — Gastroenterology 1985 — PMID 3965331

›Landmark case series describing biliary ascariasis clinical syndromes

›56% biliary colic, 15.2% recurrence rate at 4 years

›Sandouk F, Haffar S, Zada MM, Graham DY, Anand BS — Pancreatic-Biliary Ascariasis, Experience of 300 Cases — American Journal of Gastroenterology 1997 — PMID 9399767

›Large case series documenting risk factors and outcomes

›Female sex 11.3 times higher odds ratio

›Khuroo MS, Zargar SA, Mahajan R — Hepatobiliary and Pancreatic Ascariasis in India — Lancet 1990 — PMID 1972440

›Ultrasound diagnostic criteria established

›Sensitivity approximately 86% for biliary worms

›Systematic reviews and guidelines

›Conterno LO, Turchi MD, Correa I, Monteiro de Barros Almeida RA — Anthelmintic Drugs for Treating Ascariasis — Cochrane Database of Systematic Reviews 2020

›Evidence base for albendazole and mebendazole efficacy

›Single dose regimens supported by evidence

›Jourdan PM, Lamberton PHL, Fenwick A, Addiss DG — Soil-Transmitted Helminth Infections — Lancet 2018 — PMID 28882382

›Global epidemiology and preventive chemotherapy strategies

›WHO mass drug administration program evidence

›Miller JM et al — Guide to Utilization of the Microbiology Laboratory for Diagnosis of Infectious Diseases — IDSA and ASM 2024 Update — PMID ciae104

›Stool ova and parasite testing recommendations

›Kato-Katz technique for quantification

›Supporting case series and imaging studies

›González AH, Regalado VC, Van den Ende J — Non-Invasive Management of Ascaris Lumbricoides Biliary Tract Migration — Tropical Medicine and International Health 2001 — PMID 11286203

›97% resolution with conservative management

›Prospective study of 69 patients in Ecuador

Evidence & Review