ERCP in the Diagnosis and Treatment of Life-threatining Biliary Obstruction Caused by Fascioliasis: Experience of 5 Cases

Kemal Dolay, MD¹, Engin Hatipoglu, MD², Fatma Umit Malya, MD¹, Adem Akcakaya, MD¹. ¹Bezmialem Vakif University General Surgery Department, ²Cerrahpasa University General Surgery Depatment

Introduction: Fasciola hepatica is one of the endemic parasites in Turkey. Biliary fascioliasis is rarely asymptomatic and in many cases; biliary obstruction and inflammation usually occur in chronic infections.  Because of technical limitations, images obtained by US, CT or MRCP are of lesser significance when compared to the ones taken by ERCP.  For that reason, the gold standard for evaluation of the bile ducts in these patients is still ERCP. Even though the medical treatment seems adequate in the acute period, endoscopic techniques may be necessary in the chronic period for cases with biliary obstruction. Here we report five cases of fascioliasis presented with findings of acute cholangitis and biliary pancreatitis.

Methods and Procedures: Here we present 5 cases of biliary fascioliasis. All of our patients were referrals from other centers, with probable diagnosis of pancreatitis due to choledocholithiasis and they were sent to our hospital for further evaluation with ERCP. Following radiaologic evaluation Endoscopic retrograde cholangiopancreatography (ERCP) was performed as a next step.

Results: ERCP allowed  both diagnosis and treatment in all cases. During the ERCP procedure, linear filling defects in the distal common bile duct were revealed. After sufficient endoscopic sphincterotomy procedure, baloon catheter and Dormia basket catheter was used to extract live parasites. In 3 patients baloon catheter was not enough to extract the parasite, and dormia basket was used in a half open position to capture the parasite. We prescribed Triclabendazol (Egaten 250; Novartis, Switzerland) single dose 10mg/kg to all our patients. In all of our patients, the physical findings and jaundice regressed, 3 days after ERCP procedure. The lab values progressively decreased in 10 days. In one of our cases, during the ERCP procedure the lesion occupying the liver  was thought to be similar to a dead Fasciola hepatica parasite. In this patient, there was a stricture of a short segment in the proximal common bile duct. After endoscopic sphincterotomy and parasite extraction, baloon dilatation was performed and a 6 cm 10F stent was placed. In the control ERCP that was performed three months later, no pathology could be observed, and her stent was extracted. No extra findings were observed in the 6 month and 1-year follow-up controls

Conclusions: Biliary fascioliasis may present with different clinical aspects. The most serious presentations are acute cholangitis or pancreatitis which can threaten life. In those cases ERCP has a crucial role both in diagnosis and treatment.