Fasciola hepatica causing acute pancreatitis complicated by biliary sepsis

At the Focal Point

the capsule away from the wall of the esophagus and cut the mucosa adherent to the capsule (B, C). The dislodged capsule then was pushed down into the stomach. There was minor, self-limited bleeding from the site of capsule attachment (D). After removal of the Bravo capsule, the patient noted rapid resolution of chest pain. There were no complications associated with the procedure.

DISCLOSURE All authors disclosed no financial relationships relevant to this publication. Deepak Agrawal, MD, Paul A. Akerman, MD, Harlan Rich, MD, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA doi:10.1016/j.gie.2009.04.001

Commentary The Bravo pH-monitoring system is used to evaluate patients with refractory or atypical GERD. The pH capsule is attached by deploying a locking pin that is passed through the esophageal mucosa and pulled by suction into a small cup in the side of the capsule. Typically, the capsule sloughs spontaneously from the mucosa within 2 weeks and passes uneventfully through the GI tract. Most patients have no or mild symptoms while the capsule is attached, but more severe chest pain, odynophagia, or dysphagia occurs in about 10% of patients. Interestingly, discomfort is more common in patients with functional dyspepsia. Symptoms severe enough to require endoscopic removal of the capsule occur in up to 3% of patients, and methods for its removal are as many as the imagination can dream of; these include, among others, stripping the capsule off the mucosa by direct pressure using a biopsy forceps; cold snare or Roth net removal; and now, scissors. As for scissors, its etymology can be traced from Late Latin (cisorium) to Vulgar Latin (cisoria) to Old French (cisores) to Middle English (sisours), with roots of cutting, tailoring, and carving. Its origin is traced to ancient Egypt, but it is likely that the current cross-bladed pivoted scissors were invented by the Romans about 100 C.E. ‘‘Oh scissors!’’ was a nineteenth century exclamation of impatience or disgust, but in this case, it was a call for an instrument that served its purpose well, and afterwards, an exclamation of joy that the task at hand was accomplished. Lawrence J. Brandt, MD Associate Editor for Focal Points

Fasciola hepatica causing acute pancreatitis complicated by biliary sepsis

386 GASTROINTESTINAL ENDOSCOPY Volume 70, No. 2 : 2009

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At the Focal Point

A 33-year-old recent immigrant from Uzbekistan with no medical history presented with a 2-day history of nausea, vomiting, fever, and right upper quadrant abdominal pain. On admission, he was febrile and had sinus tachycardia, conjunctival icterus, and right upper quadrant tenderness. Laboratory findings included a white blood cell count of 16,000/mm3 with 11% eosinophilia. Liver biochemical tests revealed increased aspartate aminotransferase (282 U/L [normal 1-37 U/L]), alanine aminotransferase (319 U/L [1-40 U/L]), total bilirubin (5.4 mg/dL [0-1.0 mg/dL]), direct bilirubin (3.8 mg/dL [0-0.3 mg/dL]), and alkaline phosphatase (319 U/L [39-120 U/L]). Serum amylase and lipase were increased at 636 U/L (0-131 U/L) and 155 U/L (1-52 U/L), respectively. US revealed a normal common bile duct (CBD) with no gallstones or sludge. Diagnoses of biliary sepsis and acute biliary pancreatitis were made, and the patient was managed with antibiotics and fluids administered intravenously. The patient remained febrile with persistently abnormal liver tests prompting ERCP. ERCP revealed a filling defect in the distal CBD (A). Sphincterot-

omy was performed followed by balloon sweep of the CBD. A flat, brown, leaf-shaped motile organism (B) was retrieved and identified as Fasciola hepatica. Triclabendazole therapy was initiated. The patient rapidly improved and remains well.

DISCLOSURE All authors disclosed no financial relationships relevant to this publication. Nison L. Badalov, MD, Ava Anklesaria, MD, Anita Torok, MD, Ian M. Wall, DO, Jack Braha, DO, Jianjun Li, MD, FACG, Kadirawel Iswara, MD, FACG, Scott Tenner, MD, MPH, FACG, Division of Gastroenterology, Department Of Internal Medicine, Maimonides Medical Center, Brooklyn, New York, USA doi:10.1016/j.gie.2009.04.010

Commentary F hepatica is a trematode with a worldwide distribution that infects sheep, goats, and cattle as their normal hosts; it has been described on all continents but Antarctica. Humans acquire these parasites by ingesting metacercariae encysted on fresh water plants such as watercress, after which the ingested metacercariae excyst in the small intestine, penetrate the bowel wall, enter the peritoneal cavity, migrate to the liver, penetrate the capsule, and travel through the hepatic parenchyma in search of a bile duct. They reside within the bile ducts for many years, laying eggs that pass with the bile and are excreted with the stool. Fasciola were first documented in soil samples from a cemetery dating back to late Neolithic–Roman Iron Age periods, but their earliest mention is in the French literature by Jean de Grie in 1379 who described the consequences of sheep liver rot in his treatise on sheep management and wool production. Fasciola is derived from the Latin word fascia, for fillet or small bandage; hepatica of course refers to its location in the host. Fasciola infections usually are asymptomatic. In the acute phase, patients can have abdominal pain and hepatomegaly as the parasites penetrate the intestinal wall and hepatic capsule; acute symptoms wane as the parasites enter the bile ducts. During the chronic phase of disease, patients may develop intermittent biliary obstruction and cholangitis, and, rarely, pancreatitis. Diagnosis usually is by finding eggs in the stool, although Fasciola release low numbers of eggs, making this test insensitive; most sensitive is an enzyme-linked immunosorbent assay for antibodies against the worms. Duodenal or biliary aspirates also can demonstrate eggs or, as in this case, the trematode itself, which resembles a mobile leaf. John Burroughs, the American essayist and naturalist (1837-1921), however, would not have thought this leaf to be one that grows beautiful with age and whose last days are full of light and color. Lawrence J. Brandt, MD Associate Editor for Focal Points

Spontaneous migration of a prosthetic mesocaval shunt to the duodenum: endoscopic diagnosis of an unusual complication of shunt surgery A 21-year-old woman presented with acute severe cholangitis that was treated with intravenous antibiotics and nasobiliary drainage followed by biliary stenting. Subsequent investigation revealed features of extrahepatic portal vein obstruction with a thrombosed splenoportal axis and portal biliopathy as evidenced by dilated intrahepatic biliary ducts, multiple strictures of the extrahepatic bile duct with

no filling defects, and venous collaterals around the gallbladder and the common bile duct. EGD did not reveal esophagogastric varices. The patient was counseled about various therapeutic options including repeated endoscopic interventions or surgery; she chose surgery and a sideto-side mesocaval shunt with interpositioning of a 13-mm polytetrafluoroethylene graft was performed. Nine months

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