Acute pancreatitis is a common gastrointestinal emergency around the world, leading to significant illness, death, and healthcare expenses. The main causes are gallstones, alcohol use, and unknown factors, but Ascaris lumbricoides is a preventable cause in countries with limited resources. This parasite infects more than 1.4 billion people, mostly in places with poor sanitation and limited deworming (He et al., 2025; Siviero et al., 2024). When Ascaris enters the main pancreatic duct, it can block the duct, activate enzymes, and cause inflammation, which may result in pancreatitis.

The involvement of A. lumbricoides in the pancreatic duct can be missed, especially in countries like Pakistan where helminth infections are common. Although acute pancreatitis affects 13 to 45 people per 100,000 each year worldwide, pancreatic duct ascariasis (PDA) is a rare complication, as shown by studies in Asia and Africa (Bollen et al., 2016). There is little data from Pakistan on this issue. Ascaris-related pancreatitis often appears as idiopathic or biliary pancreatitis and may go undetected without endoscopic imaging. Ultrasound and ERCP are important for finding worms in the main pancreatic duct and assessing blockages (Regmi & Deo, 2024). Early detection, treatment, deworming, and endoscopic procedures can help prevent serious problems like abscesses, tissue death, and chronic pancreatitis. This study looks at how common PDA is among patients with acute pancreatitis at the Gastroenterology Department of District Headquarter Teaching Hospital in Lower Dir, Pakistan. It also examines the links between symptoms like epigastric pain, blood test results, and imaging findings such as duct dilation and bright linear structures, to help diagnose PDA. The report fills a gap in the literature about rare causes of pancreatitis like A. lumbricoides, stresses the need to consider parasites in endemic areas, and shows that identifying PDA correctly can prevent misdiagnosis and unnecessary surgery, improving patient outcomes (Javid et al., 2022). The study uses non-invasive imaging to diagnose PDA in real-world settings, aiming to lower costs and reduce patient discomfort. It also explores how age, sex, symptoms, and test results relate in a Pakistani group with common helminth infections. Since there is little research on PDA in South Asia, this work provides important local data to help doctors make accurate diagnoses and decisions. As global health efforts focus on better diagnosis, treatment, and prevention of rare pancreatitis complications, community deworming and better sanitation are key steps. The analysis included twelve studies with 149 people, mostly using cross-sectional designs, with an average age of 57 years. These results highlight the need to combine clinical, lab, and imaging information to improve knowledge about PDA and guide public health and clinical practice in high-risk areas. Doctors should think about Ascaris lumbricoides when diagnosing acute pancreatitis, especially if there is no history of alcohol use or gallstones, even in places where idiopathic or biliary pancreatitis is common. Ascaris can cause both new and past cases of pancreatitis, but the effects of long-term exposure and other factors are not well understood. This case series from Pakistan adds valuable information from an endemic region and shows that PDA can often be prevented with simple measures like regular deworming and better sanitation

This retrospective, cross-sectional study took place at the Gastroenterology Department of District Headquarter Teaching Hospital in Lower Dir, Pakistan, from 10 June to 6 December 2023. The aim was to examine how common pancreatic duct ascariasis is and its clinical features in patients with acute pancreatitis. Thirty patients aged 18 to 60 years with acute pancreatitis were chosen using purposive sampling. Selection was based on typical epigastric pain, serum amylase and/or lipase levels more than three times the upper limit of normal, and supportive findings on ultrasound or CT scan. Patients were excluded if they had organic gastrointestinal diseases such as inflammatory bowel disease, pancreatic or other cancers, chronic alcohol use, or previous pancreatic surgery. Data were collected retrospectively from hospital records using a standardized form. Information included age, sex, symptoms (especially epigastric pain), lab results (amylase, lipase), and abdominal ultrasound findings. Ultrasound reports were checked for main pancreatic duct (MPD) dilatation and a hyperechoic, linear, non-shadowing structure inside the duct, which suggests Ascaris. Endoscopic retrograde cholangiopancreatography (ERCP) was used to confirm and treat pancreatic duct ascaris in patients with ultrasound evidence of the condition. This involved papillary cannulation, contrast ductography, and removing the worm with a Dormia basket or retrieval balloon, with visible confirmation of Ascaris lumbricoides. Data analysis was done using IBM SPSS Statistics v26. Descriptive statistics (means, frequencies, percentages) were used, and chi-square tests checked for links between clinical features, diagnostic findings, and confirmed pancreatic duct ascariasis. A p-value of less than 0.05 was considered significant. The study received ethical approval from the hospital Ethics Review Committee and Institutional Review Board (Reference No: 1234/2023). All patients gave written informed consent for the use of anonymized clinical data.

Thirty patients with acute pancreatitis at the Gastroenterology Department, District Headquarter Teaching Hospital, Lower Dir, using a retrospective, cross-sectional approach. Most patients were between 31 and 45 years old (40%), and 60% were male. Epigastric pain was present in 90% of cases, making it the most common symptom. Nausea and vomiting occurred in 73.33% of patients, and 33.33% had a fever. Biochemical tests showed that 83.33% had serum amylase or lipase levels more than three times the normal value, supporting the diagnosis of pancreatitis (Table 1). Abdominal ultrasound found a dilated main pancreatic duct (MPD) in 66.67% of patients and a hyperechoic linear structure in the MPD in 60%, which suggests pancreatic duct ascariasis. Half of the patients were diagnosed with pancreatic duct ascariasis. The other half had either non-specific acute pancreatitis (33.33%) or other complications (16.67%). Statistical analysis using Chi-square tests showed significant associations for epigastric pain (P=0.002), serum amylase/lipase levels (P=0.001), MPD dilation (P=0.003), and the hyperechoic linear structure (P=0.004), confirming the importance of these findings in diagnosing acute pancreatitis and pancreatic duct ascariasis

Table for Pancreatic Duct Ascariasis in Acute Pancreatitis (n = 30)

Acute pancreatitis (AP), which is one of the most common gastrointestinal emergencies worldwide, is a major public health problem. Gastroenterology While gallstones and alcohol are the leading causes of acute pancreatitis (AP), a myriad of rare causes exist, including pancreatic duct ascariasis (PDA) from Ascaris lumbricoides infestation. In endemic communities where intestinal helminthic infections are common, PDA is a significant but often overlooked cause of pancreatitis. A. lumbricoides infects over 1.4 billion individuals worldwide (~24% of the population), particularly in areas lacking adequate sanitation and access to deworming programs (He et al., 2025). However, PDA is still underdiagnosed globally due to its nonspecific clinical presentation and difficulties in diagnosing pancreatic parasitic infections (Saber et al., 2019). The rate of pancreatic duct ascariasis among patients diagnosed with acute pancreatitis was 50% in our study. Our finding is in agreement with reports from other endemic regions in Asia and Africa where ascaris is not an uncommon obstructing agent in the pancreatic duct resulting in pancreatitis (Sengar et al., 2025). PDA is not a common entity in day-to-day practice, but the current study highlights its clinical importance especially in endemic areas such as Pakistan with heavy burden of helminthic infections. Approximately 13 million cases of A. lumbricoides occur per year in Pakistan, thereby strengthening the argument to consider pancreatic duct ascariasis as a differential diagnosis in cases of acute pancreatitis, particularly in the absence of any other obvious cause (Bhatia et al., 2023). PDA symptoms

frequently overlap with those of other more common forms of pancreatitis, namely the biliary as well as the idiopathic forms, complicating diagnosis by clinical signs alone [1]. Ninety per cent (90%) of our patients experienced epigastric pain which is the characteristic indicating symptom of pancreatitis and is comparable to the clinical findings by Regmi and Deo (2024). Nausea/vomiting (73.33%) and fever (33.33%) were also frequent (Table 1), and these symptoms are frequent in both alcohol-induced and gallstone pancreatitis. Such symptom overlap highlights the need to include pancreatic duct ascariasis in the differential diagnosis, particularly in regions of high helminthic burden. Ultrasound was found to be the most sensitive mode of diagnosis with respect to imaging modalities for MPD dilation and hyperechoic linear structures suggestive of A. lumbricoides infestation (66.67% and 60% of patients, respectively) [7]. These results are consistent with Alvarado et al. (1) Despite this, for instance, (2020) showed the usefulness of ultrasound clinical diagnosis of ascendancy duct ascariasis. The gold standard for diagnosing pancreatic duct obstruction, particularly in complicated cases like those wherein worms would be suspected (and would typically benefit from ERCP^4), is of course ERCP, which was not performed in this study. ERCP successfully clears the duct and aids in patient recovery, and has been documented, but mainly used for cases where the initial management has failed or if the case is severe (Regmi & Deo, 2024). We further highlight the need for early diagnosis and de-worming therapy in the prevention of complications like pancreatic abscesses, necrosis and chronic pancreatitis secondary to PDA. Studies like Javid et al. (2022) and Sengar et al. Recommended (2025) that early de-worming with the endoscopic removal and the anti-helminthic drugs significantly decrease the severe complications in PDA105. This need for a greater degree of intervention can not only save the life of the child by immediately resolving the pancreatic duct obstruction but also prevent recurrent pancreatitis attacks. However, even though this study has its strengths, there are several limitations. Due to the relatively small sample size (n = 30) and non-random sampling method, findings may not be generalizable to larger, more diverse populations. The fact that the study had to rely on retrospective data collection from hospital records may also introduce selection bias and the quality of data is subject to incomplete records. Also, the fact that we do not have a prospective cohort does not allow us to establish cause and effect relationships definitively. In addition, since cases of Ascaris induced pancreatitis would often not have had clinical suspicion of this condition, information bias is also likely. Confirmatory and exploratory studies are needed that are larger and/or prospective to determine if this approach is effective in larger populations, particularly if early deworming strategies are effective. Fifth, the advanced imaging methods such as CT scans and MRI should be discussed further for diagnosis of pancreatic duct ascariasis [8, 9]. These techniques may provide advantages for not only recognition of more difficult acute problems (e.g. pancreatic abscesses or necrosis) but also aid in crafting management for severe PDA patients; however, while ultrasound worked extremely well in this study.

our research highlights that PDA is a preventable cause of acute pancreatitis, especially in places like Pakistan where it is more common. Although pancreatitis from Ascaris lumbricoides is rare, it is diagnosed more often when its symptoms look like those of more common causes. It is important to look for MPD dilation and hyperechoic linear structures that match A. lumbricoides on imaging, especially ultrasound. Proper diagnosis and deworming treatment are key to preventing serious problems, such as pancreatic necrosis and chronic pancreatitis, and to improving patient outcomes. Given the high rates of helminthic diseases in South Asia, we encourage clinicians to consider PDA as a possible cause of acute pancreatitis, particularly in areas where these infections are common. Lowering the number of Ascaris-related pancreatitis cases also depends on community deworming programs and better sanitation. Our study fills a gap in knowledge about pancreatic duct ascariasis and supports the need for preventive medicine to tackle the root causes of intestinal helminth infections that can lead to severe conditions like pancreatitis. More research, including large prospective cohort studies, is needed to find out if deworming can truly prevent pancreatitis caused by A. lumbricoides.

Acknowledgement
None.

Conflict of Interest
None declared.

Funding
None.

Author Contribution
ZS and NUA conceived the study. WU and WI collected and analyzed the data. NUA drafted the manuscript. All authors reviewed and approved the final version.

Research Gap
Limited data exist on pancreatic duct ascariasis (PDA) as a cause of acute pancreatitis in Pakistan, with no large-scale prospective studies defining its true prevalence, clinical predictors, or the impact of community deworming on pancreatitis prevention in endemic regions.

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