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 64-year-old female with epigastric and right upper quadrant pain was referred to Taleghani Hospital in Tehran, Iran. She complained of intermittent pain attacks radiating to the back, exacerbated after eating. There had been 3–4 episodes of pain on most days, lasting about 1 h and then decreasing gradually for at least 6 month before presentation.\nShe also stated weight loss of about 3 kg (from 66 to 63 kg) within 6 months without fever, icterus or any change in bowel habit. In her past medical history, there were no important medical problems.\nHer previous laboratory evaluation revealed an increased erythrocyte sedimentation rate (64 mm/h), while total bilirubin was 3.2 mg/dl (normal <2 mg/dl), aspartate aminotransferase 31 IU/l (normal <30 IU/l), alanine aminotransferase 37 IU/l (normal <30 IU/l), alkaline phosphatase 473 IU/l (normal <306 IU/l) and γ-glutamyltranspeptidase 82 IU/l (normal <60 IU/l). Complete blood count showed hemoglobin 12.1 g/dl, platelets 190,000/mm3 (normal 100,000–450,000/mm3) and white blood cells 4,030/mm3 (normal 4,000–10,000/mm3) with 12% eosinophils (484/mm3) on peripheral smear. Blood chemistry tests were in the normal range. Hydatid antibody titer was requested and was within normal limits. The results of stool examinations at three different times for detecting ova and parasites as well as occult blood were normal.\nAfter admission, ultrasonography and abdominopelvic computed tomography (CT) scan showed normal intrahepatic bile ducts, but an ill-defined large heterogeneous mass lesion which contained multiple hypodense portions in the right and caudate lobes of the liver was noted (fig. ). There were no other remarkable findings on ultrasonography and CT imaging. After that, the patient underwent evaluation to rule out possible malignant and non-malignant etiologies as follows: Endoscopy and colonoscopy were performed to rule out probable sources of liver metastasis, which were both unremarkable. The patient also underwent CT-guided core needle biopsy for pathologic and microbiological evaluation, which showed predominant eosinophil infiltration of liver sections with microabscess (eosinophilic abscess) formation without neoplastic or granulomatous process. Microbiological cultures of aspiration fluid of the liver mass showed no growth after 72 h.\nEmpirically, initial treatment with intravenous ceftriaxone and metronidazole was initiated, followed by oral ciprofloxacin and metronidazole. Following antibiotic therapy, the patient's symptoms alleviated gradually, and erythrocyte sedimentation rate decreased to 10 mm/h within 3 weeks. The patient was discharged from hospital and on follow-up visits mentioned improvement in her general condition. Ultrasonography performed 2 months after discharge showed resolution of the liver mass with normal intra- and extrahepatic biliary ducts, but second follow-up ultrasonography revealed a small (8 × 10 mm) cystic lesion in the right lobe of the liver with dilation of the common bile duct (CBD) (9 mm) that was confirmed by magnetic resonance imaging (fig. ). Magnetic resonance cholangiopancreatography showed a slightly dilated CBD (9.5 mm) and normal intrahepatic bile ducts, with irregularity of the wall of the distal third of the CBD with suspicious filling defect (fig. ). Finally, EUS with a linear echoendoscope showed a 10 mm CBD with long, linear, hyperechogenic structures, moving freely in the lower third of the CBD, in favor of F. hepatica (fig. ). After diagnosis of F. hepatica by EUS, ERCP was performed, and after sphincterotomy, an extraction balloon was passed and removed a live Fasciola (fig. ).