A Case of Chronic Hepatobiliary Fascioliasis Mimicking Acute Choledocholithiasis: A Case Report and Review of Literature

Abstract

Introduction: Hepatobiliary fascioliasis is a rare trematode-associated zoonotic infection. The disease is caused by Fasciola hepatica and rarely found in the United States. Here we present one such case that mimicked choledocholithiasis and a review of the literature of hepatobiliary fascioliasis cases in the United States. Case: A 28-year-old Hispanic female presented to our hospital 1 week postpartum with a 2-day history of intermittent nausea, vomiting, and abdominal pain. She recently presented to the ER 1 month earlier with nonspecific abdominal pain and was diagnosed with symptomatic cholelithiasis. An elective cholecystectomy was scheduled post-partum. On current physical exam, she was afebrile and appeared icteric with right upper quadrant tenderness. Lab studies showed WBCs of 6.4 K/uL, AST of 117 Units/L, ALT of 182 Units/L, AP of 358 Units/L, total bilirubin of 3.7 mg/dL, and a direct bilirubin of 1.8 mg/dL. An abdominal sonogram revealed cholelithiasis and CBD dilation to 10 mm. To investigate the suspected biliary tract obstruction an ERCP was performed. The initial cholangiogram showed a CBD of 12 mm in diameter with several small filling defects. After a generous sphincterotomy, three liver flukes were extracted from the distal CBD. Repeat cholangiography revealed no filling defects. No stents were placed. Subsequent stool studies for ova and parasites and an ELISA test were sent and returned positive for Fasciola hepatica. The patient was diagnosed with chronic hepatobiliary fascioliasis. She was treated with 750 mg of triclabendazole orally for 2 days1. She improved clinically and was discharged from the hospital. Repeat ova and parasite stool studies were all negative. She subsequently underwent an uncomplicated elective cholecystectomy as an outpatient and no flukes were found in the specimen. We searched PubMed and Medline for Fasciola hepatica in the United States and found 41 cases since the 1930s. Besides the 21 cases on the Hawaiian Islands2, only three cases were local on mainland United States3-5. Like our case, the rest were imported infections from endemic areas. Only four cases were described as being chronic hepatobiliary fascioliasis3,5-7. Conclusion:Fasciola hepatica is an extremely rare cause of biliary tract obstruction in the United States. It is a challenging diagnosis to make but in view of the large number of travelers and immigrants from endemic regions, a high index of suspicion should be maintained in patients with atypical presentations of choledocholithiasis. In addition, as seen in our case it can also be confused for biliary colic in pregnant women. The backbone of treatment remains clearance of bile ducts, classically with ERCP and antiparasitic medications9.