D0037 - Biliary Fascioliasis Presented With Recurrent Pruritus

Introduction: Fascioliasis is a waterborne disease caused by Fasciola Hepatica (FH), mainly involves the hepatobiliary and has two phases of manifestation. The hepatic phase typically occurs 6-12 weeks after ingestion, characterized by right upper quadrant abdominal pain, elevated liver enzyme, and eosinophilia. Adult flukes migrate to biliary tracts during the biliary phase and can be asymptomatic or present with biliary obstruction, cholangitis, and pancreatitis. In the endemic areas, FH should be considered for idiopathic biliary obstruction with atypical symptoms. Here, we report a 36 y/o male from Iron who presented with recurrent pruritus and was found to have FH which was removed by ERCP

Case Description/Methods: A 36-year-old male from Iran was initially admitted due to 2 years history of occasional vague abdominal pain. The patient also had recurrent non-rash pruritus not responding to medication. Past medical history was unremarkable. The laboratory test were all normal except for elevated CRP and eosinophil percentage (3%).

Upper and lower endoscopy were all negative. Abdominal US showed dilated CBD without any significant findings. Follow-up EUS showed dilated CBD of 16mm with some filling defects and two live parasites (Fig. 1). EUS-guided ERCP was done with CBD cannulation and biliary stent placement. 10mg/kg of triclabendazole was administered as a single dose 4 days after the procedure. Another ERCP was performed later for biliary stent removal and live trematode extraction without any complication. During one month follow up, the patient was free of symptoms with back to normal CRP and eosinophil percentage. 1-year EUS follow-up showed normal CBD without any stone, sludge, or lesion.

Discussion: Humans can be accidental hosts for FH with variable symptoms, such as urticaria, cough, dyspnea, cholangitis, biliary obstruction, and cholecystitis. Stool microscopy in addition to imaging studies is always used for diagnosing. The first-line treatment is 10mg/kg triclabendazole every 12 hours for 2 doses. However, due to the high risk of biliary obstruction and related complications, endoscopic clearance is mandatory in cases like this. Biliary sphincterotomy and extraction of flukes by balloon extraction or basket are very effective and safe interventions. In a patient suffering from recurrent pruritus not responding to medications and eosinophilia, abdominal US should be considered for FH, especially in an endemic region of the world.