Endoscopic ultrasound in biliary fasciolosis.

A 16-year-old woman presented with recurrent episodes of severe upper abdominal pain and vomiting of 3 years duration. Multiple upper gastrointestinal scopies and ultrasonographies (USG) were normal. CT scan of abdomen had revealed mild intrahepatic biliary radical dilatation up to the lower end of common bile duct (CBD), but no stones or mass lesion. Her amylase and lipase levels during attacks of pain were normal. She was labeled as suffering from depression and was on antidepressants. Her liver function tests were normal except deranged alkaline phosphatase (178 IU/L). Clinical examination was unremarkable. Endoscopic ultrasound (EUS) revealed dilated CBD with a 3–4 cm floating and moving structure in the mid CBD coming down into the lower CBD with appearance like fluke (Fig. 1a). A biliary sphincterotomy was performed and a leaf like live worm was extracted with balloon catheter (Fig. 1b). Microbiological examination revealed diagnosis of Fasciola gigantica. She received a course of antihelminths and is asymptomatic on follow up of 9 months. Conventional USG in biliary fasciolosis usually reveals biliary dilatation, irregular thickened walls and worms are seen as vermiform structures without acoustic shadowing. USG is believed to be helpful in diagnosis of biliary fasciolosis, it may miss distal CBD lesions. EUS is an accurate investigation for imaging the lower biliary tree. Its role in the diagnosis of biliary fasciolosis has been documented earlier [1].