| Abstract|| |
Human fascioliasis is well documented throughout the world, both the acute and chronic phases of the disease have been well described. Cholelithiasis with obstructive jaundice and discovery of fasciola hepatica worms during surgical exploration is a frequent mode of first diagnosis of chronic fascioliasis. Here the presentation of six proven cases are described, all were diagnosed and treated by endoscopic retrograde cholangiopancreatography with details of the almost characteristic cholangiographic picture that can be hardly be confused with anything else, the clinical picture of the cases and their follow up together with a review of the disease is discussed.
|How to cite this article:|
Al Teimi IN. Biliary fascioliasis clinical spectrum and endoscopic management. Saudi J Gastroenterol 1995;1:47-51
| Introduction|| |
Fascioliasis caused by sheep liver fluke fasciola hepatica, is found in sheep and cattle raising countries throughout the world. The adult worm measuring by 3 by 1 cm inhabits the biliary tract of the definitive host like sheep, cattle and occasionally humans. Although clinically evident human fascioliasis has not been reported in Saudi Arabia. The clinicians here need to be aware about the intriguing manifestations of this entity because of increased movements of people here for the reason of employment. Whereas acute and chronic forms of human fascioliasis are well described, the literature about biliary fascioliasis is scanty. Moreover, the role of endoscopic retrograde cholangio-pancreatography (ERCP) in its management has been reported recently in a few case reports. ,
The present paper describes the clinical features, the course and the role of ERCP in the management of six proven cases of biliary fascioliasis.
| Material and Methods|| |
The diagnosis of biliary fascioliasis was made on the following basis: 1- recurrent biliary colic or cholangitis (6 cases). 2- bile samples collected at ERCP positive for ova of Fasciola hepatica (6 cases). 3- recovery of live or dead worms of Fasciola hepatica from bile ducts (6 cases). 4- soft brown stones or sludge in the biliary tree recovered at endoscopic sphincterotomy (ES) (3 cases). [Table - 1],[Table - 2] summarizes the clinical features and cholangiographic appearances of these patients, respectively. The duration of symptoms was 6.8 ± 6.1 yr. with a range of 5 months to 20 years. All patients in addition to endoscopic therapy were given praziquantel and symptomatic treatment for biliary symptoms. Praziquantel was given in the dosage of 75 mg/kg thrice a day for 7 days.
A 25 years old laborer was referred for the evaluation of recurrent cholangitis. He underwent cholecystectomy and exploration of common bile duct (CBD) with recovery of soft brown stones 5 months back. Ova of Fasciola hepatica were not seen in the feces. The cholangiogram obtained at ERCP [Figure - 1]; multiple crescentic shaped worms and soft brown stones and sludge were removed from CBD and left hepatic duct. The patient recovered with symptomatic treatment and praziquantel. A repeat ERCP 8 months later showed no filling defects; however, bile duct showed dilatation with excessive branchings and irregularity of intrahepatic ducts.
A 27-years-old women was referred to us for evaluation of recurrent episodes of biliary colic of 8 years duration. Physical examination was normal. The CBD and right hepatic duct showed numerous crescent-shaped filling defects and following ES multiple grayish-white and reddishbrown worms of Fasciola hepatica were removed.
A 40-years old man who suffered from recurrent attacks of biliary colic for 7 years, was referred for evaluation of progressive jaundice of 2 weeks duration. Physical examination showed jaundice and mild hepatomegaly. Ultrasonography revealed dilated biliary tree. At ERCP [Figure - 2], papillitis and multiple crescent-like filling defects were seen in CBD. Following ES 6 worms confirmed to be Fasciola hepatica were removed. He recovered with treatment. A repeat ERCP obtained after asymptomatic period of 2 years showed mild dilatation of the biliary tree with excessive branchings devoid of any filling defects. The bile sampled at ERCP tested negative for ova of Fasciola hepatica.
A 60-years old male who suffered from recurrent episodes of biliary colic and cholangitis for 20 years, presented with cholangitis of one week duration. Ova of Fasciola hepatica were not detected in the stools. At ES, multiple soft brown stones sludge and leaf-like worms of Fasciola hepatica were recovered. The patient remained asymptomatic in the follow up.
A 26-years old male was admitted with cholestasis of 12 days duration. He had recurrent episodes of cholangitis following cholecystectomy 3 years back. His findings at ERCP and ES were similar to the case 4. At 15-months asymptomatic period, at repeat ERCP a few dead worms were removed from the CBD. Ova of Fasciola hepatica were absent in the bile collected at ERCP.
A 25-years old male farmer referred for assessment of upper abdominal pain and jaundice of 10 months duration. Stool tested negative for ova of Fasciola hepatica. Ultrasonography showed mild dilatation of the CBD and mild periportal fibrosis. At ERCP, CBD showed a crescentic-like filling defect [Figure - 3] which changed its shape on serial cholangiogram. After ES, the worm of Fasciola hepatica was recovered [Figure - 4],[Figure - 5].
| Discussion|| |
Fascioliasis is geographically more prevalent than the other liver flukes and has been reported from Asia, Africa, United Kingdom, Russia, Germany, the Crescentic islands and South America. Man is accidentally infected by eating watercress or other aquatic plants contaminated with the encysted metacercaria of the worm; the latter develop into larvae which eventually gain entry into the biliary tree after penetrating through the intestinal wall, peritoneum and Glisson's capsule. 
Biliary fascioliasis has been shown to cause recurrent biliary colic, cholangitis, calculous cholecystitis, pancreatitis and liver abscess. , There may be formation of biliary calculus and secondary sclerosing cholangitis. Despite longstanding destructive obstructive cholangiopathy, unlike clonorchiasis, cirrhosis and cholangiocarcinoma have not been reported in fascioliasis. ,, The diagnosis of biliary fascioliasis is suspected in an endemic area if any adult person presents with symptoms and signs of biliary disease. A history of ingestion of watercress and presence of eosinophilia will support the diagnosis. The examination of the bile obtained at ERCP for ova of Fasciola hepatica was found valuable in our cases. The failure to demonstrate ova of Fasciola hepatica in the stool in our cases possibly because stools were not examined by concentration method. A number of serologic methods have been used for the diagnosis but are not totally reliable.  The biliary symptoms are because of hyperplasia and hypertrophy of the bile duct epithelium due to irritating effects of proline secreted by flukes, worm infestation and/or formation of biliary calculi. Biliary parasites, Ascaris lumbricoides and Clonorchis cinesis are well known to cause biliary lithiasis. The biliary calculi in 3 of our patients were of pigment type, localized in the CBD and intrahepatic ducts. Impaired biliary drainage due to parasite invasion with bacterial colonization with Escherichia More Details coli or other betaglucornidase producing bacteria seem to be necessary for the formation of biliary calculi and destructive changes of chronic cholangitis. The beta-glucornidase causes deconjugation of bilirubin resulting in the formation of calcium biliribinate stones and parasites can act as nidus for stone formation. Intrahepatic stones are found in South America and the Orient, where there is a high incidence of parasitic infections. Endoscopic retrograde cholangiopancreatography is not only an excellent tool for the diagnosis but also for its treatment.  It offers a potential for the radiographic demonstration of worms in the biliary tree; the worms are seen as crescentic-like filling defects which can be easily differentiated from stones. The changing shape of the worms on serial cholangiograms aids further to differentiate them from calculi. The endoscopic removal of worms and stones from the biliary tree at ERCP with ES offers simple and safe method of treatment. Our results showed that ES had significant effect on the course of the disease. All patients remained free of symptoms for an extended period of time without biliary symptoms. The repeat cholangiogram in the follow up period showed significant reduction in the destructive cholangiographic abnormalities.
The conservative treatment of biliary fascioliasis consists of intravenous fluids, antibiotics and analgesics. For treatment of worms, bithionol in the dosage of 30-50 mg/kg of body weight on alternate days has been recommended as treatment of choice. However, praziquantel,  emetine hydrochloride, and chloroquine have been successfully used. We found praziquantel is an effective agent in our patients. Surgery is occasionally required in event of failure of endoscopic treatment.
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Ibrahim N Al Teimi
Department of Medicine, Riyadh Medical Complex, P.O. Box 52493, Riyadh 11563
Source of Support: None, Conflict of Interest: None
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5]
[Table - 1], [Table - 2]