Presentation
Nausea and RUQ pain for 3 months.
Patient Data
Two peripheral somewhat wedge-shaped areas with heterogeneous patchy hypo-enhancing foci are visible in the segment VIII and VI of the liver. A few small minimally dilated bile ducts and a tubular hypodense lesion are present in segment VI. The segment VII heterogeneous enhancement and tubular lesion mimic a tumor with macrovascular extension. However, the normal portal vein branch is visible separate from that, favors the biliary origin of the tubular structure. The two mentioned hypo-enhancing areas become isodense with the liver parenchyma on delayed images.
Minimal dilation of peripheral bile ducts in segment VI of the liver is present. An oval biliary filling defect is seen proximal to the mentioned dilated ducts.
The lab data shows normal liver enzyme tests, absolute eosinophilia of about 736 /mm3, normal tumor marker, ESR, and CRP levels.
The brown arrow shows a heterogenous enhancing area and the white minimally dilated peripheral bile ducts. The yellow arrow depicts the tubular structure visible on MRCP as a filling defect (red arrow) and ultrasound as a faint hyperechoic elongated structure (not shown).
Case Discussion
Fasciola hepatica is a fluke infesting the biliary tree. Two phases are presumed for the disease a parenchymal hepatic phase and a biliary phase.
In the hepatic phase, patchy hypo-enhancing lesions somewhat with tunnel and cave appearance are present. The lesions may be migratory, extending from the subcapsular area toward peribiliary regions and porta hepatis. In the biliary phase, mature flukes live within the extrahepatic bile ducts. Mild biliary dilation or bile duct wall thickening may present at this phase. Abscess formation and impacted fluke in intrahepatic bile ducts are less common features.
Peripheral blood eosinophilia, positive serology, or stool exam for ova are useful for diagnosis. The mature flukes are fairly visible on endoscopic ultrasound.
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