A 53-yr-old man from Golpayegan, Isfahan Province, central Iran, with past history of cholecystectomy referred with complaint of vague colicky epigastric pain begun 2 yr from presentation and had fluctuation during the time. The pain became severe and constant gradually, with the peak about 4 months ago, led him to seek medical attention. There was no relationship between food consumption, especially high fat-containing meals, and pain severity. At the beginning of the disease course, the pain had been relieved by anti-acids but eventually, none of the outpatient medications made him free of pain. He did not mention any urticarial reaction, jaundice, nausea, vomiting, night sweats or pruritus during these two years, but he had history of occasional fever without any specific pattern accompanied by chills within this period. He did not have anorexia, but had increased appetite instead; constipation was a cardinal symptom along with malaise. Significant weight loss (about 10 kg) occurred late in the course of his disease (i.e. the last 2 months).\nThe patient agreed to be presented in this report and a written consent was signed by him. He was formerly a farmer and husband-man and from one year before the onset of disease (i.e. 3 yr from now), he was a trucker and had history of traveling around the country and taking unsafe and insanitary food and water. He denied consumption of any illicit drugs, alcohol, and opium at all, but he used to smoke cigarettes. No special medication he was taking.\nOn physical examination, he was afebrile and moderately ill, with stable vital signs and normal sclera without icterus. There was no rash or signs of excoriation, no conjunctivitis, no lymphadenopathy, no gynecomastia and abdominal distention. There was not any abnormality in cardiovascular and lung examination. Right upper quadrant tenderness existed on abdominal palpation, without rebound tenderness and organomegaly. Musculoskeletal and neurologic examinations were normal. The results of initial laboratory investigations are presented in . The first colonoscopy survey was normal and initial evaluation by upper gastrointestinal endoscopy revealed mild antral gastritis. Abdominal ultrasonography revealed dilated CBD without any visible lesion at its end. A hypo-echo mass lesion suggesting pathologic lymph node was seen lateral to aortic bifurcation, at left side. Abdominal CT-scan suggested dilated intra- and extrahepatic biliary ducts and CBD with 10 mm diameter and also some large intestinal lymph nodes with compressive effect on adjacent structures.\nThe second upper gastrointestinal endoscopic survey had the same result as the first.\nDuring Endoscopic retrograde cholangiopancreatography (ERCP), dilated common bile duct (CBD) about 12 millimeter and large ampulla were seen. After sphincterotomy, multiple flat whitish parasites were incarcerated behind Oddi’s sphincter and within common bile duct, which extracted. There was no stone in CBD and ampulla did not contain any mass. Serologic exam, using ELISA method was performed by somatic antigen of Fasciola and yielded positive according to the reference laboratory cut-off.\nThe patient was treated with triclabendazole 250 mg, three tablets daily, for two executive days (six tablets totally) successfully and he pains relieved after ERCP and full course of treatment. He advised not to use unsanitary food and water. On follow up, he was well and did not mention any similar abdominal pain as before.
A 73-year-old man, farmer from Gorgan, a city in the north of Iran, who came because of fever and icterus since 1 week before presentation. He had no obvious symptoms since 1 week before admission when he developed progressive jaundice and episodic right upper quadrant pain especially after meal but unrelated to position or respiration. He also reported mild fever, anorexia, and generalized body pain during this period. To analyze his problem, abdominal sonography was performed in outpatient setting, which showed an increased liver echogenesity without the dilation of bile ducts and gall stone. Based oh the abovementioned symptoms, his primary care physician made a diagnosis of viral hepatitis, but the patient eventually developed constant high-grade fever and right upper quadrant pain. Therefore, he was referred to our hospital and was admitted. At the time of hospitalization, the temperature was 39.5°C, the pulse was 90 beats/min, and the respiratory rate was 18 breaths/min. The blood pressure was 110/65 mm Hg. On physical examination, the patient did not appear to be in severe pain, and there was mild jaundice. The lungs and heart sounds were normal. The abdomen was flat, and the bowel sounds were present. There was tenderness in the right upper and quadrant, with mild guarding but without rebound tenderness. No mass or hernia was detected. The arms and legs were well perfused. No abnormalities were found on rectal examination. His sonography at admission revealed minimal intrahepatic and mild extrahepatic biliary dilation, while other organs were normal and no stones were observed. Blood tests revealed mild normocytic normochromic anemia, while white blood cell and absolute eosinophil count were normal in the patient. The erythrocyte sedimentation rates were high (90 mm/h) and serum chemical analysis revealed the following values: albumin, 3.4 g/dl; alkaline phosphatase, 170 U/l (normal range, 53–128); alanine aminotransferase, 73 U/l (normal range, 10–35); aspartate aminotransferase, 54 U/l (normal range, 14–50); and total bilirubin, 8.9 mg/dl (normal range 0.3–1.2), with a direct bilirubin level of 5.7 mg/dl (normal,< 0.2). The white-cell count was 11 400/mm3, with 84% neutrophils and 1% eosinophils. The urine was orange and was positive for bile (++), protein (+), and urobilinogen (+). Because of the endemicity of leptospirosis, serologic test (indirect hemagglutination test) was done, which revealed negative result. A urine culture and multiple blood cultures were negative. Assays for the presence of hepatitis B antigen and antibody, hepatitis C antibody, and antimitochondrial antibodies were negative. Chest radiographs showed no abnormalities. Endoscopic retrograde cholangiopancreatography (ERCP) demonstrated extrahepatic biliary dilatation; the common bile ducts (CBDs) were about 12–15 mm in diameter, with a small filling defect in the distal part [].\nSerologic test for showed high titer against that (positive titer 1/80), and the detection of ova in stool documented infestation with this liver fluke. After diagnosis, triclabendazole was administered at a dose of 10–12 mg/kg for 1 or 2 days, after which the symptoms disappeared and biochemical values soon returned to normal, and the patient was discharged with good condition. During the follow-up, her jaundice subsided, and ultrasonography revealed an almost normal CBD in our patient.