Ezzat et al. Journal of Medical Case Reports 2010, 4:83 http://www.jmedicalcasereports.com/content/4/1/83 Page 3 of 4 Figure 4 Fasciola swimming in the duodenum. Figure 5 Fasciola hepatica in vitro. capsule of the liver and mature in the biliary tree and begin to pass their eggs. In the acute phase of the dis- ease, our patient may have prolonged fever, right upper quadrant pain, liver enlargement and eosinophilia that can be easily misdiagnosed. These symptoms abate when the chronic phase is reached. Once the flukes enter the bile ducts, they may cause symptoms due to cholestasis and cholangitis. Although the definitive diagnosis for fascioliasis can be made by detecting the eggs of the parasite in the stool or duodenal aspirates, egg detection rate is not high because of the low egg production rate of the parasite. Immunoserological tests thus become the basis for the diagnosis of fascioliasis, especially during its early stages or in ectopic infections, but an enzyme-linked immuno- sorbent assay (ELISA) test provides more rapid and reli- able results. Although some parts of Iraq are endemic areas for human fascioliasis, we did not immediately arrive at this diagnosis in the case of our patient. We did not come up with a diagnosis before the parasite reached a full term (ERCP) because Fasciola hepatica is still considered as a very rare cause of biliary obstruc- tion. As expected, sphincterotomy and balloon extrac- tion rapidly alleviated our patient’s symptoms. Unlike patients with other liver flukes, therapeutic fail- ure is common in patients with Fasciola hepatica trea- ted with praziquantel. Bithionol or triclabendazole remains the treatment of choice for this parasitic infec- tion. The use of bithionol, with a recommended dose of 30 to 50 mg/kg every other day for 10 to 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 eradi- cate the parasite with a single oral dose of 10 mg/kg [4]. Our patient was treated with a single 10 mg/kg oral dose of triclabendazole. We report this case because fascioliasis should be kept in mind in the treatment of patients with cholestasis and preceding vague gastrointestinal symptoms, espe- cially in endemic areas of the world. Conclusion Chronic biliary fascioliasis may be asymptomatic or it may present with biliary obstruction, cholangitis, or por- tal fibrosis [5]. Our patient presented with cholangitis, and FH was not suggested during the investigations prior to ERCP when her condition was being diagnosed and treated. However, serological tests can help in arriv- ing at the correct diagnosis [2], although such tests are not available in Kurdistan. The technique of endoscopic sphincterotomy was initially introduced to treat common bile duct stones. The indica- tions have been expanded to include other biliary disorders. Currently, this method is considered as the optimal approach in treating biliary parasitosis including biliary fas- cioliasis, biliary ascariasis, and biliary hydatid disease [6-8]. Previous reports have noted success with the combination of ERCP and sphincterotomy for extracting FH from the biliary tree [6,9,10]. This case report emphasizes the inclu- sion of FH in the differential diagnosis for symptoms of right upper quadrant pain and common bile duct dilata- tion, particularly when ERCP management is amenable.