Hemobilia and liver flukes in a patient from Thailand

A patient from Southeast Asia presented with abdominal pain, fever, jaundice, and upper gastrointestinal bleeding of unknown origin. Opisthorchis viverrini eggs were found in the stool and multiple hepatic filling defects were noted on liver scan and sonogram. Endoscopic retrograde cholangiopancreatography revealed cholelithiasis and crescent-like filling defects in the biliary system. At surgery, the gallbladder was filled with clotted blood and pigmented stones. During T-tube drainage of the common bile duct, small elliptical flukes (4 X 3 mm) identified as O. viverrini were recovered. Despite adequate biliary drainage, the patient continued to have high fevers. On the 53rd postoperative day, a larger fluke (2.8 X 0.8 cm) identified as a Fasciola hepatica migrated down the T-tube. Institution of therapy with bithional resulted in complete clinical resolution within 3 wk. Six years later the patient returned with fever, jaundice, and right upper quadrant pain. Two large pigmented stones were found in the common bile duct and were removed after endoscopic sphincterotomy. The stones had developed even though there was no evidence of recurrent helminthic infection.