Hepatobiliary Fascioliasis: An Uncommon Cause of Biliary Obstruction in the United States

A 43-year-old woman presented with recurring upper abdominal pain. She had a 5-year history of symptomatic cholelithiasis without improvement following cholecystectomy. She had no prior history of elevated liver tests or jaundice. Her travel history was pertinent for annual trips to the Bahamas. On admission, the patient had a bilirubin of 4.7 mg/dL and liver enzymes more than 5 times the upper limit of normal. Abdominal computed tomography (CT) scan demonstrated a wedge-shaped area of decreased attenuation in liver segment III (Figure 1). Endoscopic retrograde cholangiopancreatography (ERCP) revealed a curvilinear filling defect within the distal common bile duct (Figure 2). Following papillary sphincterotomy, a living parasite was removed from the common bile duct (Video 1) and confirmed by pathology as Fasciola hepatica (Figure 3). Nitazoxanide was prescribed. Her liver enzymes normalized after 1 week of therapy, and symptoms resolved completely. Magnetic resonance imaging (MRI) 4 months later demonstrated resolution of all imaging abnormalities.