A 42 year old man presents with pain in the right upper abdomen for 3 days, associated with a swinging fever, nausea and vomiting. No other symptoms are present. His medical and drug histories are unremarkable. His history is otherwise significant only for multiple visits to India during the last one year. The last visit was around a month ago. His full blood count shows a leukocyte count of 14,500/mm3, with 89% neutrophils.
Amylase: 50 U/L (40 - 140) Lipase: 45 U/L (30 - 210)
The common bile duct is 1.5 cm in diameter; a hyperechogenic tubular structure without acoustic shadowing is seen inside. The intrahepatic bile ducts are grossly dilated. The gallbladder is contracted and no gallstones are seen.
AST: 56 U/L (14 - 59) ALT: 50 U/L (10 - 55) ALP: 430 U/L (45 - 150) Total bilirubin: 5.81 mg/dL (0.3 - 1.0) Direct bilirubin: 4.88 mg/dL (0.1 - 0.3)
Roundworms are seen in the 2nd part of the duodenum. The common bile duct and intrahepatic bile ducts are dilated. A motile tubular structure is seen inside the biliary tree.