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There are two families of liver flukes that cause disease in humans: Opisthorchiidae (which includes species of Clonorchis and Opisthorchis) and Fasciolidae (which includes species of Fasciola). These two families of liver flukes differ in their geographic distribution, life cycle, and long-term outcome after clinical infection. ‘Fascioliasis’ is a parasitic infestation typically caused by trematode  Fasciola hepatica,  also known as “the common liver fluke”.¹  In humans, the infection begins with the ingestion of watercress or contaminated water containing  encysted larva.² The young worms move through the intestinal wall, the abdominal cavity, and the liver tissue, into the bile ducts, where they develop into mature adult flukes that produce eggs.³ Symptoms are due to acute- intestinal / hepatic  phase and  chronic  biliary phase but hematemesis and severe anemia has not been described in literature. Fasciola infection is both treatable and preventable. We describe a rare novel case of young adult diagnosed as hematemesis due to liver fluke infestation. Live liver flukes were retrievedfrom duodenum endoscopically.

A 18 year old adultpresented with upper abdominal pain, massive hematemesis and hemodynamic instability in the emergency. On examination, he was alert, had pallor with normal systemic examination. History of ingestion of poorly cooked meat, fish, and vegetables was present besides bathing in a pond frequented by cattle. His hemoglobin was 7.4 g/dl with normal mean corpuscular volume (MCV) and no eosinophilia. No abnormality detected in biochemical parameters. USG abdomenand stool examination were normal.Gastroscopy revealed 200 cc fresh blood in the fundus with a large erythematous area of 3x2 cm in the fundus without active bleeding. (Figure 1). Two small erosions in D1 and a live liver fluke in D2 noted which was removed  endoscopically (Figure 2 and 3). This patient was resuscitated, transfused two PCV and treated with albendazole and praziquantel. Endoscopy was repeated after two days, there was no active bleeding, but two more live liver flukes were seen in the second part of duodenum which were removed endoscopically. At follow up after 3 months, he was asymptomatic,there was no history of hematemesis or drop in hemoglobin.

Fascioliasis is a waterborne and foodborne zoonotic disease caused by Fasciola hepatica. Abdominal pain, fever, eosinophilia and abnormal liver function tests were the most commonly encountered symptoms and laboratory abnormality in Fasciola hepatica infection.¹ From all available case series of Fasciola hepatica infection, most patients had symptoms in hepatic or biliary phase but hematemesis was not described in literature.² Diagnosis is usually done by finding Fasciola eggs in stool (fecal) specimens examined under a microscope or from duodenal aspirates. Antibody detection by enzyme immunoassays (EIA) and PCR assay for rapid diagnosis have been developed.⁴

In our case this young boy had no eosinophilia, had normal liver function tests and we found three live liver flukes in duodenum with 200 ml of fresh blood and erythematous patch in fundus, hematemesis causedlikely byliver fluke puncturing one of the small vessels in the fundus. Adult liver flukes are known to migrate from liver into bile duct and duodenum. Massive internal hemorrhage causing death has been reported in animals due to Fasciola hepatica infection but not in human being.

The drug of choice is triclabendazole. It is given as a 2-dose regimen of 10 mg/kg/dose separated by 12 hours. Nitazoxanide is a good alternative to triclabendazole, especially in the chronic stage of infection.⁵ We treated with albendazole and praziquantel and blood transfusion with good results.

For prevention,people can protect themselves by not eating raw watercress and other water plants, especially from Fasciola-endemic grazing areas. Vegetables grown in fields that might have been irrigated with polluted water should be thoroughly washed,cooked, as should viscera from potentially infected animals.

In conclusion, though hepatic and biliary symptoms and signs are common in fascioliasis, Fasciola hepatica infection should also be considered in differential diagnosis in patients with severe anemia of unknown etiology, hematemesis in patients with history of eating raw watercress or vegetables and exposure to water bodies frequented by cattle.