Biliary fascioliasis: Management in a child using endoscopic retrograde cholangio pancreatography.

A 9-year-old boy presented with right upper abdominal pain and fever. The radiologic investigations revealed multiple cholangitic abscesses with cholangitis and worms in common bile duct. Endoscopic retrograde cholangio pancreatographic (ERCP) sphincterotomy, basketing, ballooning and extraction of Fasciola hepatica worms from the common bile duct were done.

INTRODUCTION

Fascioliasis is a helminthic disease caused by Fasciola hepatica (FH), the common liver fluke and Fasciola gigantica. Fascioliasis occurs worldwide; however, human infections with FH are found in areas where sheep and cattle are raised. Here we report an unusual case of biliary fascioliasis in a child. On review of literature, we found few adult cases of biliary FH managed by endoscopy, but no pediatric case has been reported; ours is the first case managed successfully by Endoscopic retrograde cholangio pancreatography (ERCP).

CASE REPORT

A 9-year-old boy, from Nepal, presented with history of mild pain in right upper abdomen and recurrent low-grade fever since five months. He also complained of mild facial puffiness since four months. There was no history of jaundice or itching. At presentation, he was mildly febrile with tender hepatomegaly but no icterus. The hematologic investigations showed anemia with eosinophilia and raised ESR. The liver function tests were within normal limits. An ultrasonography (USG) of the abdomen revealed multiple small cholangitic abscesses, cholangitis, mild intrahepatic biliary radical (IHBR) dilatation and appearance suggestive of “round worms” in the common bile duct. Magnetic resonance cholangio pancreatography (MRCP) revealed multiple cholangitic abscesses right lobe of the liver and impacted debris in the dilated common bile duct, common hepatic duct and right hepatic duct causing IHBR dilatation. Multiple hypointense linear structures were seen on T2 weighted images in common bile duct representing worms. ERCP was performed wherein CBD was selectively cannulated, and the cholangiogram revealed irregular filling defects in CBD [Figure 1]. Sphincterotomy was performed, and multiple worms of FH were extracted using basket and balloon catheter [Figure 2]. After CBD clearance, 7 Fr stent was placed for free bile drainage. The child required repeated doses (10mg/kg) of triclabendazole for FH infection and praziquantel 25 mg/kg three times a day for two days for H. nana infection were administered. Presently, the child is under follow up without any complaints. A repeat USG abdomen and stool microscopy was normal.

Figure 1

Endoscopic retrograde cholangiogram showing irregular filling defect

Figure 2

Endoscopic extraction of multiple biliary Fasciola hepatica

DISCUSSION

FH is a leaf-like trematode that usually infects cattle, goat and sheep. Humans can become infected by ingesting metacercariae present on freshwater plants, especially watercress.[1-3] The diagnosis is based on identification of FH eggs in the stool, duodenal or biliary aspirate and immunologic tests. Imaging studies, including ultrasonography, MRCP and ERCP have been utilized in the diagnosis. On USG, hepatic lesions produced by migration of the trematodes are hypoechoic nodules and cystic lesions.[4-6] ERCP may be normal in early biliary fascioliasis or may closely mimic primary sclerosing cholangitis in the chronic phase.[7] A short sphincterotomy is often adequate to achieve removal of these soft parasites.[8-10] Treatment of this condition can be divided into pharmacologic and non-pharmacologic therapy. Bithionol or triclabendazole remains the treatment of choice for this parasitic infection. The use of bithionol, 30-50 mg/kg every other day for 10-15 doses or repeated doses has resulted in the cure of acute and prolonged fascioliasis. Triclabendazole, another effective and safe drug for fascioliasis, has been found to eradicate the parasite with a single oral dose of 10 mg/kg.[1112] Non-pharmacologic therapy involves the use of ERCP with sphincterotomy and removal of the parasites from the biliary tree.[13]