C Parsak, S Koltas, G Sakman, O Alabaz, A Uguz, R Tuncer, M Inal
f.hepatica, surgical treatment, unnecessary surgery
C Parsak, S Koltas, G Sakman, O Alabaz, A Uguz, R Tuncer, M Inal. Fascioliasis In Cukurova Region, Turkey: Unnecessary Surgery In Endemic Areas. The Internet Journal of Gastroenterology. 2006 Volume 5 Number 2.
Fasciola hepatica is a trematoda, which is rarely hosted in humans. The treatment is medical. In complicated cases, surgical and invasive attempts can be administered. It can be diagnosed through serologic and radiological tests. In this study, we investigated cases, half of which were exposed to invasive attempts due to lack of diagnosis though we were in the endemic region. In Çukurova University Hospital, 10 diagnosed F. hepatica cases were examined in retrospective. Invasive attempts were performed to 5 cases (50%) during pre-operative period, as serological examination was not made. Two cases were administered mass excision from the liver, segmentectomy to one case, cholesisteyctomy to 1 case, and T tube drainage, and percutan transhepatic cholangiogram and percutaneous transhepatic biliary drainage were applied to another case. The results suggest that serological methods must be used for diagnosis to avoid unnecessary invasive attempts in suspected cases, particularly in endemic areas.
Turkey is an endemic country in terms of
Cases consisted of 6 female and 4 males with an age average of 47 (11-65), 8 of whom (80%) resided in the rural parts in Cukurova and 2 acute stage patients (20%) resided in the city. Cases were classified according to the durations of symptoms and radiological findings. Those with symptom duration less than 4 months and whose radiological findings indicated no active suspicious images in the gal bladder or main bile ducts were classified as acute stage whereas symptom duration exceeding 4 months and whose radiological findings indicated no active suspicious images in the gal bladder or main bile ducts were classified as chronic 5. 8 patients (80%) were in the acute, 2 patients were (20%) in chronic stages. Most frequently seen clinical symptoms, abdominal pain (7 patients 70%), fever (4 patients 40%), pruritus (4 patients 40%), nausea (2 patients 20%), right upper quadrant pain (2 patients 20%), jaundice (1 patient 10%), epigastria pain (1 patient 10%) and fatigue (1 patient 10%). The only case with jaundice was at the chronic stage. In terms of other symptoms, there was no significant difference between the groups. The demographic data from the cases, symptoms and duration classifications are summarized in Table I.
In laboratory findings analysis, eosinophilia was seen in all cases. The average eosinophilia level was 30.5 % (18.2- 65%) (with reference 0.9-6%), ALT 3 (30%), Ig E 6 (60%) was high levels at cases. As the average ALT level was 35.8 (21- 85) U/L (reference<41), the average Ig E level was 354.5 (120- 579) IU/ml (reference 10-180). In serology; IHA gave three false negative results but ELISA and WB serology gave positive results in all samples. Diagnostic data and laboratory findings are shown in Table II.
Five (62.5%) acute cases diagnosed with serological tests by ELISA and WB. Out of these 5 cases 2 were found out to exhibit lesions in the right lobe of the liver and the liver was tested serologically as well as under ultrasound. The remaining 3 of the acute stage cases were operated following pre-diagnosis of mass in the liver and in 2 cases mass excision was performed from the liver, and 1 case was applied segmentectomy. With the suspicion of
The operation was terminated by placement of T-tube in ductus choledochus. Parasite eggs were detected in the bile samples taken from T-Tube. Pathological and parasitological analysis of the parasites showed
The average follow-up period of cases was 2 and a half years (1- 5 years). No recurrence was detected in the follow-ups. Other family members who lived in the same household with the patients were tested serologically; however no
Fascioliasis might result in significant complications. These are, sub capsular hematoma, hemoperitoneum, hemobilia, cholangitis, obstructive jaundice and liver fibrosis 3,8. Pancreatitis formation due to obstruction in the pancreatic channel is rarely seen in the literature9. Pancreatic obstruction was seen in 1 case and obstructive jaundice complications were seen in 2 cases in our study.
Diagnosis can be made over duodenal liquid, bile and stool examinations and presence of parasite eggs1., Eosinophilia (%95), elevated Ig E and elevated ALT level are helpful in diagnosis at laboratory examinations. In histopathological examinations, Charcot Leyden cyrstals, eosinofillia, necrotic areas and eggs were rarely seen1,8. In all of our cases we have come across eosinophilia, elevated Ig E 6 (60%) and elevated ALT 3 (%30).
Serological methods are especially very significant in diagnosis of
Radiographic techniques have been used to aid in the diagnosis of fascioliasis. US examination is not specific in the acute (hepatic) stage while it is more helpful than CT in showing diffuse ductal dilation and/or thickening in the chronic biliary stage of the disease. CT shows hypo dense hepatic nodules in the acute (hepatic) stage simulating liver abscesses or metastases while bile duct wall thickening is the main finding in the chronic (biliary) stage of fascioliasis9. PTC and ERCP findings are bile duct dilation, tubular filling defects due to parasite itself, and jagged mucosal contour due to hyperplasia of the bile duct epithelium in chronic (biliary) stage of the disease10,11.
Human fascioliasis, however, could be just as well cured naturally by itself. However in order to avoid complications, treatment is advised in asymptomatic cases12,13. Treatment of the disease is medical. Triclabendazol, nitazoxanid, albendazol, bithionol and praziquantel have been used in the treatment of the disease12. Latest literature suggests triclabendazol due to its efficiency and minimum side effects. The disease can be cured by 10 mg/kg single dose postprandial triclabendazol successfully13. Apt et al14 79.2% in the 24 case study and El-Morshedy et al15 in the 134 case study 79.4% success have been observed in order to research the efficiency of single dose triclabendazol. Single dose triclabendazol was used in treatment in all our cases. In the chronic stage case where we performed T Tube, although the patient was given two equal doses 20 mg/kg in 24 hours, eggs had to be isolated in the bile. Response was received to the same treatment administered after one month. In our other case in the chronic stage11 on the other hand, bile ducts were irrigated with povidone iodine by 2.5% with the aid of PDC and thus death of the parasite and drainage of the eggs was made easier. In cases where bile channel was tried and in cases which ERCP and PTC have been performed, external catheter usage might be useful in the analysis of the performance of the drug. There is a need for such serious and more controlled research.