Although Fascioliasis is endemic in our neighboring countries (Turkey and Iran), but it seems to be an emerging health problem in our locality and also in whole Iraq. We retrospectively reviewed and analyzed all the cases that had been diagnosed with Fascioliasis in our hospital during the past 15 years. Abdominal pain was the most common presentation and the predominant cause of admission, mostly at Rt. Hypochondrial region in 16 cases (88.8%) and association with tenderness in 12 cases (66.6%). Malaise was recorded in (61.1%) of patients. More than half of our patients (55.5%, n=10) described attacks of fever and rigor, which may be either due to hepatic abscess formation during the 1^st hepatic phase of the disease or due to cholangitis at the 2^nd ; biliary phase. Dyspepsia, which usually present during the acute phase was present in 50 %. Six patients (33.3%) got nausea and infrequent vomiting. Long-standing anemia (Hg level is less than 9g/dl) was recorded in 2 cases.

The laboratory diagnosis was requested to evaluate the cases with hepatobiliary problems, although Fascioliasis was not the suspected cause at the time of admission. Almost three quarters of our patients had elevated serum Alkaline phosphatase (72.2%, n=13) and similar findings were reported [16]. It is known that elevated liver enzymes especially alkaline phosphatase is one sign of liver invasion by the parasite [2].

In our study leukocytosis was detected in 10 patients, but only 5 patients had differential WBC, which showed eosinophilia in all of them. This observation should alert our physicians to ask for differential WBC counts rather than the total count, which may highlight a parasitic infestation in the differential diagnosis of hepatobiliary problems. Stool examination for egg detection was done for 4 patients; only 1 patient had positive results. The presence of the Fasciola eggs in the stool early in the course of the disease is one useful way to confirm the diagnosis, but repeated stool collections are recommended [17].

In Cosme et al. study [16], egg detected in feces was only found positive in 6 cases out of 37, but in Sierra et al. study [18], 221 patients were found positive for eggs out of 278 patients. On the other hand, duodenal sondage (fluid aspirate) was performed in 90 patients, yielding egg detection in 67. Interestingly, nine of them appeared negative in a stool examination, while positive in duodenal sondage [19]. This reveals that stool examination as non-reliable test.

Imaging studies of the hepatobiliary system with ultrasonography and CT scan can sometimes be useful in establishing a diagnosis with variable sensitivity for detecting hepatic abnormalities, like parenchymal heterogeneity and/or multiple small cystic hepatic lesions or tortuous structures. In chronic phase can show motile flukes inside the gallbladder. Ultrasound guided gallbladder aspiration is a new diagnostic method for biliary Fascioliasis and it is safe, less invasive, and also can show the presence of eggs in the bile [2,10].

In our study, abdominal ultrasonography was the imaging modality most commonly used for all of the 18 patients and dilated CBD was detected in 16 of them (88.8%). However, 9 cases were in association with stone or a shadow inside the CBD. This observation was also present in Cosme et al. [16] patients indicating chronicity of the infestation. Gallstones, Liver abscess and liver cysts were also detected in our patients, who were also recorded in other reports [2,9,16,18].

In many human case reports, serology was the sole diagnostic method [20], but unfortunately, none of our cases was sent for serology testing for Fascioliasis because it was not available in our province at time of cases presentations. Other used techniques that aid the diagnosis are, (1) liver scan using ^99mTc uptake, which may show irregular radio colloid and/or lacunar areas. (2) Laparoscopy allows viewing features of diseased liver with tunnel like lesions on its surface and especially yellow-white nodules with a halo hyper-vascularized of different sizes and shapes. (3) Other injuries to the Glisson capsule, peritoneum and liver biopsy can be taken for diagnosis at the same time [16]. Histological features of Fascioliasis demonstrate granulomas, which should be differentiated from other well-recognized diseases including tuberculosis, sarcoidosis, toxoplasmosis, and non-Hodgkin’s lymphoma. The most typical histological finding is central necrosis, cellular debris, and Charcot-Leyden crystals encompassed by eosinophil and inflammatory infiltrate.

In 4 patients, CBD exploration was done for prominent dilatation associated with jaundice. Live Fasciola worms were found to cause this dilatation and obstructing the bile flow. Removal of the flukes performed followed by Choledochoduodenostomy and Cholecystectomy.

One case presented with chronic calculus cholecystitis symptoms and ultrasound showed a single gallstone and normal biliary tree. For this patient, open Cholecystectomy was done and the stone was sent for analysis. Interestingly a calcified Fasciola hepatica worm was forming the nidus for the gallstone. Indeed, gallstone disease has recently proved to be one of the effects of advanced chronic Fascioliasis, since Fasciola hepatica is able to survive up to 9–13.5 years within a human host [18]. Two other cases were diagnosed with Liver abscesses. Eventually, they underwent abdominal exploration for drainage and live worms were found in the abscesses cavities. This indicates that these two patients were in the acute stage of the disease.

In another case, a patient was admitted for recent features of calculus cholecystitis. Hence open cholecystectomy was done and upon opening the gallbladder in vitro a live motile Fasciola was found swimming inside the gallbladder (Figure 1 ). The patient Rt. hepatic lobe also had 2 small cystic lesions that were aspirated and sent for parasitological study. The aspirate was clear and negative for the eggs.

Facing Fascioliasis during surgery or ERCP is a recognized issue worldwide, but it is obscure in our country. It is worthwhile to mention that cases admitted before 2006 were found positive only during conventional hepatobiliary surgery. Since ERCP was introduced to our hospital on 2006, cases afterword was discovered endoscpoically.

When ERCP became available in our province, the first case of biliary tree Fascioliasis was diagnosed and treated. The patient presented 6 months post laparoscopic cholecystectomy with obstructive jaundice. The ERCP with sphinecterotomy managed to retrieve a live fluke from the CBD (Figure 2). Notably, another 4 cases of post cholecystectomy obstructive jaundice were diagnosed within 6–9 months postoperatively and managed similarly. Another case of obstructive jaundice, Rt. hypochondria pain and pruritus (not cholecystectomis) was diagnosed to have biliary Fascioliasis and managed by ERCP. Indeed intraoperative cholangiography would have been helpful in diagnosing CBD infestation with the flukes. On the other hand, these cases could have been in the acute stage, when they underwent the cholecystectomy and the flukes invaded the biliary tree within the 6-9months postoperatively.

A later patient presented with liver abscess, confirmed by CT scan and managed by ultrasound guided percutaneous drainage (using pigtail catheter) with daily aspiration and irrigation of the cavity. It was completely empty of pus in conjugation with ERCP with sphincterotomy and removal of a live Fasciola hepatica from the CBD. Then another case managed by ERCP, was presented 17 years post open cholecystectomy with obstructive jaundice. Ultrasound showed a large CBD stone. Utilizing endoscopic mechanical lithotripsy, stone fragments were collected and sent for analysis. Surprisingly a calcified Fasciola hepatica worm was found with the fragments. Similar situation was reported, Obstructive jaundice due to biliary Fasciola hepatica infestation observed 11 years post-open cholecystectomy and CBD exploration [21]. Another interesting case of biliary fascioliasis was diagnosed by retrieving 14 live adult worms from the CBD (video) the last two cases presented with anemia and abdominal pain and ERCP retrieved Fasciola flukes from CBD. Indeed anemia is recorded in other studies as associated symptom and sign [22].

Fascioliasis could be completely cured using Triclabendazole as first choice anthelminthic. Triclabendazole is a Benzimidazole compound used routinely in veterinary practice since 1983 for treatment of Fascioliasis, but it was not used in humans until the 1989, when the Iranian authorities approved the use of the veterinary formulation to treat human epidemic of Fascioliasis near the Caspian Sea. The recommended dose is 10-mg/kg body weights as single dose administered with food containing fat to increase the absorption. A second dose can be given 12 hrs. intervals for severe cases [2]. Only three of our cases received a single dose of triclabendazole, obtained from outside Iraq. The other eight patients received Albendazole 400 mg t.d.s. for 7 days postoperatively. The remaining patients denied any drug administration. Still, we are facing difficulty in obtaining Triclabendazole and the same situation is true for Cosme et al. [16] and Sierra et al. [18]. For decades; Emetine and dehydroemetine were used successfully to treat Fascioliasis with a cure rate reaching 90%, but it has toxic side effect on heart, liver and digestive tract.