# Sustained abnormal bilirubin and leukocyte levels after ERCP with acute suppurative obstructive cholangitis: a case report with 2 months follow-up observation

## TL;DR

A patient had ongoing high bilirubin and white blood cell levels after ERCP, which were eventually linked to a liver fluke infection.

## Contribution

Highlights the role of eosinophilia in diagnosing parasitic infections after ERCP when standard tests are negative.

## Key findings

- Persistent hyperbilirubinemia and leukocytosis after ERCP were linked to an undiagnosed liver fluke infection.
- Diagnostic treatment with albendazole led to normalization of blood markers.
- Liver fluke detection in ENBD fluid and positive IgG confirmed the diagnosis.

## Abstract

Acute Suppurative Obstructive Cholangitis (AOSC) typically resolves post-ERCP. However, a 53-year-old male had persistent hyperbilirubinemia and leukocytosis (WBC 28.12×109/L) along with marked eosinophilia (20.26×109/L) despite standard antibiotic therapy. Systematic diagnosis ruled out residual calculi, Endoscopic Nasobiliary Drainage (ENBD) dysfunction, biliary neoplasms, and sclerosing cholangitis. A history of undercooked freshwater fish consumption and eosinophilia prompted suspicion of occult liver fluke infection, despite negative initial stool tests. Diagnostic treatment with albendazole resulted in a decrease in WBC and eosinophil counts; subsequent detection of liver flukes in ENBD fluid and positive liver fluke IgG confirmed the diagnosis. At 2-month follow-up, all markers normalized. This case highlights the diagnostic value of eosinophilia in guiding the identification of parasitic infections in refractory post-ERCP inflammation, and the utility of diagnostic therapy when direct evidence is lacking.