A 41-year-old man presented with right-upper-quadrant abdominal pain and a febrile sensation for 3 days. He had no specific medical history. He was employed as a butcher and used to eat raw liver. Physical examination revealed diffuse abdominal tenderness. Laboratory findings demonstrated a white blood cell count of 12,370/mm3 (normal range, 4,500 to 11,000) with an eosinophil count of 2,860/µL (<450/µL), total bilirubin level of 4.2 mg/dL (normal range, 0.2 to 1.2), aspartate aminotransferase of 213 IU/L (normal range, 5 to 40), alanine aminotransferase level of 192 IU/L (normal range, 0 to 40), alkaline phosphatase level of 298 IU/L (normal range, 44 to 119), and gamma glutamyl transpeptidase level of 473 IU/L (normal range, 12 to 73). Transabdominal ultrasonography and computed tomography revealed mild bile duct dilation with no definite cause. Magnetic resonance cholangiopancreatography (MRCP) also revealed no specific findings for acute cholangitis (). ERCP was performed for the diagnosis and treatment of the highly suspected choledocholithiasis. A cholangiogram did not reveal any findings specific for acute cholangitis (). IDUS was performed to evaluate occult bile duct diseases, such as small stones or sludge. A 2.0-mm-diameter IDUS probe with a frequency of 20 MHz (UM-G20-29R; Olympus, Tokyo, Japan) was inserted into the bile duct over a guidewire. The bile duct was examined while withdrawing the probe from the right intrahepatic duct into the papilla. At the beginning of the IDUS scan, crescent-layered wall thickening was apparent in the right main hepatic duct (). However, after a while, the thickened wall-like tubular structure detached from the ductal wall, and was then noted as an actively motile, hyperechoic tubular structure in the bile duct (, Supplementary Video 1 [available online at ]). We performed an endoscopic extraction of this “lesion.” A flat, leaf-shaped motile parasite was extracted from the bile duct using a balloon catheter after endoscopic biliary sphincterotomy. The worm was gently removed from the patient after capturing with grasping forceps (Olympus) (, Supplementary Video 2 [available online at ]). The leaf-shaped worm was identified macroscopically as F. hepatica (). The patient’s symptoms resolved rapidly following the extraction of the parasitic worm.
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.