Ezzat et al. Journal of Medical Case Reports 2010, 4:83 http://www.jmedicalcasereports.com/content/4/1/83 C A S E R E P O R T JOURNAL OF MEDICAL CASE REPORTS Open Access Endoscopic management of biliary fascioliasis: a case report Rajan F Ezzat*, Taha A Karboli, Kalandar A Kasnazani, Adnan MH Hamawandi Abstract Introduction: Fasciola hepatica, an endemic parasite common in Iraq and its neighboring countries, is a very rare cause of cholestasis worldwide. Humans can become definitive hosts of this parasite through their ingestion of a contaminated water plant, for example, contaminated watercress. Symptoms of cholestasis may appear suddenly and, in some cases, are preceded by long periods of fever, eosinophilia, and vague gastrointestinal symptoms. Here we report the case of a woman with a sudden onset of symptoms of cholangitis. Her infection was proved by endoscopic retrograde cholangiography to be due to Fasciola hepatica infestation. Case presentation: A 38-year-old Kurdish woman from the northern region of Iraq presented with fever, right upper quadrant abdominal pain, and jaundice. An examination of the patient revealed elevated total serum bilirubin and liver enzymes. An ultrasonography also showed a dilatation of her common bile duct. During endoscopic retrograde cholangiopancreatography, a filling defect was identified in her common bile duct. After sphincterotomy and balloon extraction, one live Fasiola hepatica was extracted and physically removed. Conclusion: Fasciola hepatica should be a part of the differential diagnosis of common bile duct obstruction. When endoscopic retrograde cholangiopancreatography is available, the disease can be easily diagnosed and treated. Introduction Fasciola hepatica (FH) is a leaf-shaped trematode that usually attacks cattle and sheep. Humans can become accidental hosts through drinking contaminated water or ingesting raw green vegetables contaminated with encysted metacercariae. The bacteria’s larva penetrates the intestinal wall to enter the peritoneal cavity. It then usually passes through the liver capsule and hepatic tis- sues where, after it becomes an adult, finally invades the biliary tract [1]. The greatest number of infected people has been reported in Bolivia, China, Ecuador, Egypt, France, Iran, Peru, and Portugal. In Iraq, Lebanon, Mor- occo, Tunisia and Yemen fewer than 100 cases have been documented so far, implying that the problem has probably not yet received enough attention in these countries. Infestation with FH has two distinct clinical phases: one corresponding to the hepatic migratory phase of the life cycle of the flukes, and the other corresponding to * Correspondence: rajanfuad@yahoo.com Kurdistan Gastrointestinal Center, Sulaimanyah Teaching Hospital, Sulaimanyah, Iraq the presence of the parasites in their final location in the bile ducts. FH infestation may be suspected in patients who exhibit tender hepatomegaly, fever, and eosonophilia. Adult flukes can cause obstructive jaun- dice or make a patient vulnerable to cholelithiasis [2]. Here we report a case of FH infestation that was diagnosed endoscopically and treated by endoscopic extraction along with antiparasitic medication. Case presentation A 38-year-old Kurdish woman from the northern region of Iraq presented with fever, right upper quadrant pain, and jaundice for three days. She had two cesarean sec- tions in 1995 and 2003 and an appendicectomy three years prior to presentation. Six months prior to presen- tation, she underwent laproscopic cholecystectomy, in which no parasites were found in her gall bladder. Her physical examination revealed jaundice, scars of previous surgical procedures, and right subcostal tender- ness without hepatomegaly. Her laboratory investigations revealed the following results: hematocrit, 30%; white blood cell count, 6700/cmm;eosonophil, 15%: platelets, © 2010 Ezzat et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.