Comparative study on presentation of biliary ascariasis with dead and living worms

Ascariasis is a common parasitic infestation in Asia and Latin America. The most serious presentation is biliary and pancreatic ascariasis [BPA]. The aim of the present study was to compare the clinical presentation of BPA with dead worms with that with living worms. We included 138 consecutive cases of BPA that occurred during the period January 2005 to July 2009. All the patients had endoscopically proven BPA consisting of living or dead worms. Comparison was done by chi-square and independent t tests. The age [mean +/- SD] of the patients was 36.8 +/- 16.1 years. Prevalence ratio between male and female patients was 1:5. Ninety eight patients contained living worms and 40 had dead worms. Males were more prone to develop dead worm BPA. The commonest presentation was biliary colic [131; 94.9%]; others were acute cholangitis [30; 21.7%], obstructive jaundice [19; 13.8%], choledocholithiasis [20; 14.5%], acute pancreatitis [10; 7.2%], acute cholecystitis [6; 4.3%], liver abscess [2; 1.4%], hepatolithiasis [3; 2.2%], stricture of common bile duct [2; 1.4%], pancreatic abscess [1; 0.7%] and cirrhosis of liver [1; 0.7%]. Choledocholithiasis, hepatolithiasis, liver abscess and cirrhosis were associated only with dead worms. We could successfully remove all the worms with endoscopic interventions, but 5 patients required surgical intervention as there were strictures and stones within the biliary tree or Ascaris were in gallbladder. Recurrences of stone and cholangitis occurred only in those with dead worms. Biliary ascariasis with dead worms is more dangerous than that with living worms. Endoscopic or surgical intervention may be required repeatedly in those with dead worms

Natural course of fulminant hepatic failure: the scenario in Bangladesh and the differences from the west

Fulminant hepatic failure [FHF] is a devastating complication of acute viral hepatitis, leading to death in most cases. The etiology and predictors of outcome differ according to the geographical region. This study was conducted with the aim of evaluating the etiology, complications, and outcome of FHF in Bangladesh. In this prospective study, we included 67 consecutive cases of FHF presenting to the Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, between November 2003 and May 2008. Thirty-nine of the patients were male and 28 were female. Data was analyzed using SPSS, version 13.0. The mean age of the subjects was 31.9 +/- 11 .7 years. Hepatitis E virus [HEV] was the commonest etiological factor for FHF [50 cases, 74.6%]; of the 50 cases with HEV infection, 43 [64.2%] were not coinfected with any other virus, four cases were Hepatitis B virus [HBV] carriers, and three had coinfection with hepatitis A virus [HAV]. HBV was the cause of FHF in nine [13.4%] patients. HCV, paracetamol, and alcohol were not responsible for any of the cases. Most of the patients [57 patients, 85%] developed FHF within 2 weeks of the onset of jaundice. Of the 67 patients, 49 [73.1%] died. Cerebral edema was the single most common cause of death [48 patients, 71.6%]. Other complications were renal failure [23 patients, 34.3%], sepsis [15 patients, 22.4%], electrolyte imbalance [12 patients 17.9%], and bleeding tendency [7 patients, 10.4%]. Occurrence of cerebral edema, longer prothrombin time, higher grade of encephalopathy, and longer jaundice-to-encephalopathy interval had significant negative influence on outcome. The etiology of FHF in Bangladesh is different from that in the West. Prolongation of prothrombin time and occurrence of cerebral edema are predictors of the worst prognosis