A 63-year-old Thai man was referred to our hospital from a local government hospital in September 2018. He presented with acute intermittent epigastric pain and high-grade fever (body temperature 39°C) for 5 days. He was diagnosed with acute cholangitis and had initially been treated with intravenous ceftriaxone and metronidazole for 5 days. The symptoms slightly improved, but he still had abdominal pain and persistent fever; he was then referred to our hospital. He had a history of alcoholic chronic pancreatitisand diabetes mellitus type 2 with insulin supplementation. He had a history of heavy alcohol drinking (80 g per day for 20 years) and active smoking (10 packs per year). There was no history intravenous drug use, blood transfusion and unprotected sexual intercourse as well as no family history of viral hepatitis or liver disease.\nOn physical examination, he appeared conscious, slightly pale without icteric sclera, with vital signs body temperature 39.3°C, blood pressure 100/60 mm Hg, and pulse rate 100/min. His abdomen was soft with tenderness at the right upper abdomen. Murphy's sign was negative. The liver size was about 10 cm with a firm consistency smooth surface and blunt edge without any sign of portal hypertension or chronic liver disease.\nThe complete blood count was as follows: WBC 5,650/mm3, PMN 54%, Lymp 23%, Eos 12%; HB 11.1 g/dL, HCT 32.7%, MCV 98.5 fL, Plt 400 × 103/μL.\nThe liver biochemistry test revealed the following: total bilirubin 1.30 mg/dL (normal range 0.2–1.2 mg/dL), direct bilirubin 0.97 mg/dL (normal range 0-0.2 mg/dL), aspartate aminotransferase 185 U/L (normal range 0–32 U/L), alanine aminotransferase 70 U/L (normal range 0–33 U/L), and alkaline phosphatase 1,225 U/L (normal range 39–117 U/L).\nViral hepatitis B and C profiles were negative.\nMagnetic resonance imaging (MRI) with abdominal magnetic resonance cholangiopancreatography (MRCP) were performed; the resulting images showed abrupt change in caliber with a thickened wall of the distal common bile duct 2 cm in length caused by upstream bile duct dilatation with no obvious common bile duct stone or intra-ductal filling defect. Multiple small gallstones were detected without evidence of acute cholecystitis. Atrophic changes of pancreas with multiple pancreatic duct stones and main pancreatic dilatation were also observed (Fig. ). Initially, the diagnosis was suspected to be distal common bile duct stricture and severe cholangitis without response to initial antibiotic. He was later referred to our hospital for endoscopic management.\nEmergency ERCP was performed, which showed a dilated common bile duct 18 mm in diameter consisting of large irregular shape amorphous filling defect in the common bile duct (Fig. ). Sphincterotomy was then performed, and during the procedure a basket and balloon catheter was used to aid the extraction foreign bodies, which were observed as a dead, non-motile, leaf-shaped parasite seen in the duodenum (Fig. ). After bile duct clearance, a biliary double-pigtail plastic stent 7 Fr × 5 cm was inserted for biliary drainage.\nWe investigated the serology test for Fasciola antibody, but the result was negative. The definite diagnosis was confirmed by histopathology of dead parasite (Fig. ). The patient was treated with endoscopic removal of the dead parasite subsequent with single oral dose triclabendazole (10 mg/kg body weight/day). The clinical result was significantly improved without any relapse during the 1-year follow-up.\nThe patient came for the clinical follow-up, and an ERCP for removal of stent with complete occlusion cholangiography was done to confirm that there was no other filling defect in the extrahepatic bile duct and that the distal biliary stricture disappeared.\nLiver biochemistry returned to normal: TB 0.50 mg/dL (normal range 0.2–1.2 mg/dL); DB 0.25 mg/dL (normal range 0-0.2 mg/dl); aspartate aminotransferase 40 U/L (normal range 0–32 U/L); alanine aminotransferase 20 U/L (normal range 0–33 U/L); and alkaline phosphatase 126 U/L (normal range 39–117 U/L).
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.