Biliary fascioliasis: Management in a child using endoscopic retrograde cholangio pancreatography
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 []. Sphincterotomy was performed, and multiple worms of FH were extracted using basket and balloon catheter []. 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.