Shugo Fujibayashi, MD, from the Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University in Asahikawa, Hokkaido, Japan shares this video case “Intraductal cholangioscopic visualization of moving Fasciola hepatica.”
A 75-year-old Japanese male visited a private hospital with abdominal pain and jaundice in October 2013. Because magnetic resonance cholangiopancreatography showed a filling defect in the common bile duct, he was referred to our institute. Endoscopic ultrasonography showed diffuse irregular wall thickening of the common bile duct associated with filling linear hyperechoic structures without an acoustic shadow. Endoscopic retrograde cholangiopancreatography demonstrated linear defects in the common bile duct, while intraductal ultrasonography demonstrated the presence of hyperechoic linear structures, which were separated from the thick bile duct wall. Based on the characteristic features of these images, we suspected the presence of parasites, rather than stones, in his bile duct. Per-oral cholangioscopy was carried out using CHF-B260 (Olympus, Tokyo, Japan) after sphincterotomy. Wriggling ocher leaf-shaped flat worms, which occasionally stuck to the biliary wall, were identified. Two live worms were then caught with a basket and completely removed from the biliary tree. They were ultimately identified as Fasciola hepatica by a DNA sequence analysis of cox1.
Our case is the second report of the visualization of living Fasciola using electronic cholangioscopy. Because the image was dramatically improved by introducing high-resolution endoscopy, specific motions of living Fasciola hepatica, such as the oral sucker stuck to the biliary wall, could be clearly observed. We believe our video will have a strong impact on endoscopists.
Our case suggests that per-oral cholangioscopy is a useful examination tool for the visualization of the characteristic wriggling ocher leaf shape, which led us to the diagnosis of Fasciola hepatica. In addition, the worms could be caught with a basket and used for a DNA sequence analysis. Because the worms were completely removed, the patient’s condition was good without requiring treatment with triclabendazole, suggesting that complete removal of the worms is important for successful treatment.
An infection with Fasciola hepatica induces chronic biliary inflammation, which may cause biliary carcinogenesis. From our video, which clearly demonstrated Fasciola hepatica stuck to the biliary wall, we can easily understand how Fasciola hepatica induces chronic biliary inflammation.
We hope that our findings will help to determine the characteristic findings of Fasciola hepatica infection on cholangioscopy and thereby establish the proper diagnostic procedure according to the findings.
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