fasciola hepatica ( f. hepatica ) is a foodborne trematode , which is occasionally observed in general practice . 

f. hepatica was described as the first foodborne trematode that can occur worldwide in the areas where sheep and cattle are raised .
humans are its accidental hosts . after ingestion of contaminated water or aquatic plants containing metacercariae ,
juveniles penetrate the intestinal wall and migrate through the peritoneal cavity to the liver and then enter the bile ducts , and rarely to the gallbladder , where they mature and release eggs .
f. hepatica in acute phase can cause dyspepsia , fever , right upper quadrant pain , anorexia , urticaria , respiratory symptoms , jaundice , eosinophilia , and abnormal liver biochemical tests . in chronic phase
, f. hepatica can cause biliary colic , intermittent jaundice , fatty food intolerance , cholangitis , and cholecystitis .
the diagnosis of f. hepatica is based on the combination of the clinical and radiologic findings , supported by serology . for f. hepatica infection treatment , a single dose of 10 mg / kg triclabendazole is recommended .
human s behavioral change can prevent the f. hepatica infection transmission . although the number of reports on humans infected with f. hepatica has increased significantly in recent decades ; the removal of living f. hepatica from biliary tract is rare . here
we report a case of a 67-year - old woman who presented with acute cholangitis and three living f. hepatica removed with basket via endoscopic retrograde cholangiopancreatography ( ercp ) .
a 67-year - old woman was presented to our center at namazi hospital ( shiraz university of medical sciences , iran ) with abdominal pain , icter , nausea , and anorexia beginning two weeks prior to evaluation .
she lived in the zagros mountain area ( southern iran ) consuming unsafe water and contaminated vegetables .
her past medical history was unremarkable except for a controlled hypertension with captopril . on physical examination , she was ill and icteric with right upper quadrant tenderness . according to the laboratory values upon admission , she had mild leukocytosis with prominent neutrophil without any evidence of eosinophilia .
her work up for virology markers ( hav , hbv and hcv ) was negative .
laboratory values on admission in abdominal ultrasonography , three small cysts and a dilated common bile duct were seen .
abdominal computed tomography scan showed three small cysts ( < 1 cm ) and a dilated common bile duct , but liver parenchyma and intrahepatic bile ducts were normal ( figure 1 ) .
abdominal computed tomography scan showed three small cysts ( white arrows ) and dilated common bile duct ( black arrow ) .
dilatation of common bile duct with multiple filling defects was seen , but gallbladder and intrahepatic bile ducts were normal ( figure 2 ) .
ercp has showed dilatation of common bile duct ( white arrow ) with multiple linear filling defects ( black arrow ) .
therefore , after sphincterotomy , we used a basket for removing the suspected stones , but surprisingly three living f. hepatica were removed by 3 times use of the basket .
in addition to antibiotics for acute cholangitis ( metronidazole 500 mg / iv / q6h and ceftazidim 200 mg / iv / q8h ) , triclabendazole ( 10 mg / kg single dose ) was started for therapy .
after the first week , oral ciprofloxacin was replaced for iv antibiotics and continued for another week .
clinical and laboratory condition of the patient improved after 4 weeks ; leukocytosis and liver biochemical tests were completely normalized ( table 2 ) .
the patient showed no clinical and laboratory problems in favor of the liver disease after 12 months follow up .
although the number of reports on human infected with the flukes has increased significantly in the recent decades , only a few published reports exist about removal of living flukes ( e.g. f. hepatica ) from biliary tract . as far as we know , there is only one published report on the removal of living f. hepatica in iran .
in contrast to the patient presented by aminian et al . , our case did not show eosinophilia and instead she had symptoms in favor of cholangitis .
although eosinophilia is the most laboratory abnormality during the hepatic phase of f. hepatica infection , this finding might be absent in some patients ; especially during biliary phase .
similar to some others published articles , our primary impression of filling defects in ercp was common bile duct stones or sludge .
however , after sphincterotomy for removing the suspected stones and sludge , surprisingly living flukes was removed that belonged to the genus fasciola .
some published articles have reported the cases of biliary fascioliasis in which the symptoms and management of patients were similar to our case .
there is only one report from iran regarding f. hepatica since a food - borne trematode can occasionally cause hepatobiliary diseases in general practice .
humans , as accidental hosts , are contaminated after ingestion of unsafe water or raw aquatic plants . 

on cholangiography , f. hepatica can cause biliary dilatation with single or multiple small filling defects .
domestic herbivorous animals can be contaminated by liver flukes via the ingestion of grass and vegetables containing metacercariae . in acute ( hepatic ) phase that begins one to three months after ingestion of metacercariae , fascioliasis can cause dyspepsia , fever , right upper quadrant pain , anorexia , hepatomegaly , splenomegaly , ascites , urticaria , respiratory symptoms , jaundice , subcapsular liver hematoma , hemobilia , eosinophilia , and abnormal liver biochemical tests . in chronic ( biliary ) phase
, fascioliasis can cause biliary colic , intermittent jaundice , epigastric pain , nausea , fatty food intolerance , cholangitis , and cholecystitis .
diagnosis of fascioliasis can be difficult in non - endemic areas because the symptoms may be similar to other hepatic or biliary diseases .
although the presence of eggs in fecal samples is used for the diagnosis of f. hepatica infection , but this method is unreliable and complex . in the hepatic and biliary phase of fascioliasis , computerized tomographic
although in the chronic stage , detection of the eggs in the stool can be used for the diagnosis , in acute phase , stool examination can not be used for the diagnosis because of the natural history of f. hepatica infection .
therefore , the diagnosis of chronic phase is based on the combination of clinical and radiologic findings supported by serology .
a single dose of 10 mg / kg triclabendazole is recommended for f. hepatica infection treatment .
the dose can be repeated after 12 - 24 h for major infections . in case of treatment failure , a double dose is recommended .
triclabendazole is registered in a few countries , therefore bithionol can be used when triclabendazole is not available .
it is recommended that f. hepatica infection should be considered as a possible , but not a common cause of acute cholangitis , especially in the endemic areas .
 fasciola hepatica ( f. hepatica ) as a foodborne trematode can occasionally cause hepatobiliary diseases . 
 we report a 67-year - old woman who was referred to our center because of the diagnosis of cholangitis . 
 she was a resident of mountainous area with the history of unsafe water and contaminated vegetables . 
 endoscopic retrograde cholangiopancreatography ( ercp ) was performed as a diagnostic and therapeutic modality for her . 
 three living f. hepatica was removed from biliary tract with a basket via ercp . 
 clinical and laboratory condition of the patient improved after therapy of antibiotics and triclabendazole . 
Introduction
Case Report
Discussion
Conclusion