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A 63-year-old woman was admitted to the hospital with vomiting and abdominal pain. Approximately one year earlier, she had undergone a papillotomy and laparoscopic cholecystectomy for biliary colic. Laboratory examination revealed elevated liver enzyme levels (alkaline phosphatase, 560 U per liter;  glutamyltransferase, 230 U per liter; lactate dehydrogenase, 399 U per liter; and bilirubin, 1.2 mg per deciliter [20.5 µmol per liter]). On ultrasonography, the intrahepatic bile ducts were not substantially widened; however, the lumen was filled with sludge-like material. Endoscopic retrograde cholangiopancreatography showed a worm-like structure measuring 10 cm in length at the papilla (Panel A); the worm was extracted endoscopically (Panel B). The patient was discharged from the hospital three days later. The abdominal symptoms had resolved, and the liver-enzyme elevation had markedly improved. Currently, the patient is well, without signs of cholangitis. Biliary obstruction is an important complication of Ascaris lumbricoides infestation.
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