LAUSR

An 82-year-old woman presented with 3 days of epigastric and right upper quadrant abdominal pain, nausea, and vomiting. She was afebrile and had a bilirubin level of 2.9 mg/dL without leukocytosis or eosinophilia. Peak aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, and lipase levels were 675, 708, 236, and 7366 U/L, respectively. CT with contrast showed mild gallbladder wall thickening and no stones or pericholecystic fluid. Bile ducts and pancreas appeared normal. EUS of the distal common bile duct revealed a 5-mm thin hyperechoic lesion without shadowing and no pancreatic abnormalities (Fig. 1). ERCP revealed poor contrast drainage but showed no filling defects. Sphincterotomy and sweeping with a balloon retrieved a live 331mm fluke (Video 1, available online at www.VideoGIE. org), which pathology results from the Centers for Disease Control identified as Dicrocoelium dendriticum. By this time, the patient had already been discharged after symptomatic improvement and downtrending liver enzymes while on empiric nitazoxanide and 2 doses of triclabendazole for suspected Fasciola hepatica. Notably, the patient emigrated from China 20 years earlier after working in the fields and construction; she had last visited 4 years earlier and might have been infected during one of those trips. The case illustrates an unusual presentation of biliary obstruction with pancreatitis and a challenging interpretation of EUS findings.