A case report on enormous haemangioma of liver.

Introduction: Hemangiomas are the most common benign liver tumour. These tumours arise from the proliferation of vascular endothelial cells and increase in size owing to dilation. If their diameter exceeds 5 cm, they are classified as giant hemangiomas, while those surpassing 15 cm are considered enormous hemangiomas. Case presentation: A 38-year-old female patient presented with complaints of abdominal fullness for 18 months. Contrast-enhanced computed tomography was performed and two hemangiomas were diagnosed; the , larger one was an enormous hemangioma of size 20 × 16 cm. Non-anatomical hepatic resection was performed to remove the hemangiomas. The patient recovered well, without any complications. Clinical discussion: Hepatic hemangiomas are common, but hemangiomas greater than 15 cm in size are rare. They usually require no treatment unless the patient is symptomatic. Hepatectomy and enucleation of hemangioma are the most common surgical procedure for such hemangioma. Conclusions: Rarely, large hepatic hemangioma can be the cause of abdominal fullness lasting for months. Often, surgical intervention is required.

Castleman disease of the pancreas mimicking pancreatic neuroendocrine tumor: A rare case report.

INTRODUCTION: Castleman's disease (CD) of the pancreas is a rare benign disease which can sometime resemble a pancreatic neuroendocrine tumor. PRESENTATION OF THE CASE: We report a case of a 46-years-old lady with an incidental pancreatic lesion. Preoperative diagnosis was a neuroendocrine tumor of the pancreas, for which anterior Radical Antegrade Modular Pancreatosplenectomy surgery (RAMPs) was performed. The postoperative histopathology showed features consistent with hyaline vascular type Castleman's disease. She had an uneventful surgical procedure and no serious postoperative complications. DISCUSSION: Pancreatic Castleman's disease is usually difficult to diagnose and there is no specific clinical manifestation to distinguish it from a neuroendocrine tumor. Even with radiological imaging it is very difficult to distinguish Castleman's disease from neuroendocrine tumors, and the preoperative imaging diagnosis may not match with the postoperative histopathological diagnosis. Treatment of CD is surgical resection and has a good prognosis. Partial resection and radiation therapy or observation alone is an alternative to complete surgical resection. CONCLUSION: Castleman disease of the pancreas sometimes mimics neuroendocrine tumors of the pancreas. Clinicians should consider Castleman's disease of the pancreas as a differential diagnosis for neuroendocrine like lesions of the pancreas.

Early Outcomes of Extended Hepatectomy: An Experience from the University Hospital of Nepal.

Background Extended hepatectomy (≥ 5 liver segments resection) may be required to have a complete surgical resection and provide the best chance of cure of hepatobiliary tumors. It is associated with high morbidity and mortality but with good perioperative care, its outcomes can be improved. This study was conducted to evaluate the early outcomes of extended hepatectomy at a university hospital in Nepal. Methods For this study, prospectively collected data from all patients who underwent extended hepatectomy from October 2012 to April 2022 were reviewed and analyzed retrospectively. Demographic data, liver volume augmentation methods used, intraoperative variables, and postoperative complications were analyzed. Results Seventeen patients underwent extended hepatectomy from October 2012 to April 2022. Among them 11 (64.7%) were female and the mean age was 53.9 ±16.3 years (18-72 years). Right extended hepatectomy was the most commonly performed procedure (n = 15, 88.2%), and left extended hepatectomy was performed in the remaining (n = 2, 11.8%). Six patients underwent liver volume augmentation procedures (35.3%) with portal vein embolization (PVE) in three, portal vein ligation (PVL) in one, and partial associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) in two patients. Overall complications were 70% with major complications (Clavien Dindo ≥ IIIa) constituting 35.3%. The most common hepatectomy-specific complication was post-hepatectomy liver failure (PHLF) in six cases. The 30-day mortality was 17.6% (three patients). Conclusion Extended hepatectomy can be performed with acceptable major complications and mortality rates in selected patients.

Final analysis of the phase 3 randomized clinical trial comparing HD201 vs. referent trastuzumab in patients with ERBB2-positive breast cancer treated in the neoadjuvant setting.

BACKGROUND: The TROIKA trial established that HD201 and trastuzumab were equivalent in terms of primary endpoints (total pathological complete response) following neoadjuvant treatment. The objective of the present analysis was to compare survival outcomes and final safety. METHODS: In the TROIKA trial, patients with ERBB2-positive early breast cancer were randomized and treated with either HD201 or the referent trastuzumab. Eligible patients received 8 cycles of either HD201 or referent trastuzumab (loading dose, 8 mg/kg; maintenance dose, 6 mg/kg) every 3 weeks in combination with 8 cycles of chemotherapy (4 cycles of docetaxel, 75 mg/m2, followed by 4 cycles of epirubicin, 75 mg/m2, and cyclophosphamide, 500 mg/m2) in the neoadjuvant setting. The patients then underwent surgery followed by 10 cycles of adjuvant HD201 or referent trastuzumab according to their initial randomization to complete one year of trastuzumab-directed therapy. Event-free and overall survival rates were calculated using Kaplan-Meier analysis. The hazard ratio for event-free survival was estimated by Cox proportional hazards regression. RESULTS: The final analysis was performed after all patients completed the study at a median follow-up of 37.7 months (Q1-Q3, 37.3-38.1 months). A total of 502 randomized patients received either HD201 or the referent trastuzumab, and 474 (94.2%) were eligible for inclusion in the per-protocol set. In this population, the 3-year event-free survival rates were 85.6% (95% CI: 80.28-89.52) and 84.9% (95% CI: 79.54-88.88) in the HD201 and referent trastuzumab groups, respectively (log rank p = 0.938) (HR 1.02, 95% CI: 0.63-1.63; p = 0.945). The 3-year overall survival rates were comparable between the HD201 (95.6%; 95% CI: 91.90-97.59) and referent trastuzumab treatment groups (96.0%, 95% CI: 92.45-97.90) (log rank p = 0.606). During the posttreatment follow-up period, adverse events were reported for 64 (27.4%) and 72 (29.8%) patients in the HD201 and the reference trastuzumab groups, respectively. Serious adverse events were rare and none of which were related to the study treatment. CONCLUSIONS: This final analysis of the TROIKA trial further confirms the comparable efficacy and safety of HD201 and trastuzumab. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT03013504.

Hepatic mass caused by Fasciola hepatica: A case report.

INTRODUCTION: Fascioliasis is a zoonotic infestation which presents with a wide spectrum of clinical pictures. However, it may often be overlooked, especially in the acute phase, because of uncertain symptoms. Fasciola hepatica can have an initial presentation similar to malignant liver mass or complex hepatic cyst. Here, we report a case of a hepatic mass caused by fasciola hepatica. CASE PRESENTATION: A 48-year-old woman came with chief complaints of epigastric and right hypochondrial discomfort associated with nausea and vomiting. Ultrasonography (USG) showed a heterochronic lesion in the segment VIII of the liver with few cystic lesions. CECT abdomen and pelvic gave impression of ill-defined irregular hypodense lesions in the right lobe of the liver with progressive enhancing peripheral and central cystic areas suggestive parasitic liver infestation likely echinococcus alveolaris. Right hepatectomy was done and the patient was discharged without any complications. DISCUSSION: Fascioliasis is uncommon in developed countries but more commonly seen in developing countries. The identification of fasciola hepatica eggs in the stool is a standard method for the diagnosis of fascioliasis. Fascioliasis may cause a wide variety of clinical signs ranging from asymptomatic infection to severe liver cirrhosis. Surgery for complex hydatid cysts of the liver is potentially burdened by serious complications. Technique of choice for surgical management remains inconclusive. CONCLUSION: Fasciola hepatica infection can mimic a malignant liver mass or a complex hepatic cyst because of its uncertain presentation. The disease can be prevented with public education and environmental precautions.

Duodenal perforation due to migrated biliary stent: Case report.

INTRODUCTION: Biliary stents are frequently associated with various complications; however biliary stent migration causing duodenal perforation is rare and has only been reported in few cases. PRESENTATION OF CASE: We present a case of 33 years old male with pain abdomen and fever for 2 days came to Emergency department. He had undergone open common bile duct exploration (CBD), clearance of stone and placement of CBD stent. In X-ray abdomen, biliary stent migration was suspected. CECT abdomen was done for the confirmation of diagnosis which showed migrated stent with duodenal perforation. Patient underwent exploratory laparotomy and Thal patch repair, pyloric exclusion, retrograde duodenostomy and feeding jejunostomy. Post-operative period was uneventful. DISCUSSION: Biliary stents are used to relieve biliary obstruction. There is increasing use of endoscopic retrograde drainage via plastic endoprosthesis and so the related morbidities. One of the rare but serious complications is intestinal perforation and duodenal perforation is seen in most of the cases, explanation being the relative fixed position of the duodenum. CONCLUSION: Although intestinal perforation is an uncommon complication following CBD stenting, we should suspect it in patients presenting with pain and fever.

Efficacy of HD201 vs Referent Trastuzumab in Patients With ERBB2-Positive Breast Cancer Treated in the Neoadjuvant Setting: A Multicenter Phase 3 Randomized Clinical Trial.

Importance: The drug HD201 is a biosimilar candidate for breast cancer treatment as the reference trastuzumab. Objective: To compare the efficacy of HD201 with referent trastuzumab. Design, Setting, and Participants: This randomized clinical trial (TROIKA) included 502 women with ERBB2-positive early breast cancer treated with either HD201 or referent trastuzumab. It was conducted across 70 centers in 12 countries, including Western and Eastern Europe and Asian countries. Randomization was stratified by tumor hormone receptor status, clinical stage, and geographic region of recruitment. This analysis was conducted on February 12, 2021, after the completion of the adjuvant phase at a median of 31 months (IQR, 28-33 months) of follow-up. Interventions: Patients with ERBB2-positive early breast cancer were randomly assigned to receive HD201 or referent trastuzumab in the neoadjuvant setting for 8 cycles, concurrently with 4 cycles of docetaxel, which was followed by 4 cycles of epirubicin and cyclophosphamide. Patients then underwent surgery, which was followed by treatment with 10 cycles of adjuvant HD201 or referent trastuzumab. Main Outcome and Measures: The primary end point was the total pathological complete response (tpCR) assessed after neoadjuvant treatment. Equivalence was concluded if the 95% CI of the absolute difference in tpCR between arms in the per-protocol set was within the margin of more or less than 15%. Other objectives included the breast pathological complete response, overall response, event-free and overall survival, safety, pharmacokinetics, and immunogenicity. Results: A total of 502 female patients (mean [range] age, 53 [26-82] years) were randomized to receive either HD201 or referent trastuzumab, and 474 (94.2%) were eligible for inclusion in the per-protocol set. The baseline characteristics were well balanced between the 2 arms; 195 tumors (38.8%) were hormone receptor-negative , and 213 patients (42.4%) had clinical stage III disease. The tpCR rates were 45% and 48.7% for HD201 and referent trastuzumab, respectively. The difference between the 2 groups was not significant at -3.8% (95% CI, -12.8% to 5.4%) and fell within the predefined equivalence margins. The ratio of the tpCR rates between the 2 arms was 0.92 (95% CI, 0.76 to 1.12). A total of 433 patients (86.1%) presented with 2232 treatment-emergent adverse events of special interest for trastuzumab during the entire treatment period, with 220 (88.0%) and 213 (84.5%) patients in the HD201 and referent trastuzumab groups, respectively. Conclusions and Relevance: The results of this randomized clinical trial found that HD201 demonstrated equivalence to referent trastuzumab in terms of efficacy for the end point of tpCR, with a similar safety profile. Trial Registration: ClinicalTrials.gov Identifier: NCT03013504.

Chylous leak following pylorus-preserving gastrectomy with D1 lymphadenectomy for carcinoma stomach: A case report.

INTRODUCTION AND IMPORTANCE: Chyle leak is the leakage of milk-like triglyceride-rich lymphatic fluid from the lymphatic system to the peritoneal cavity. The incidence of chyle leak after radical gastrectomy is very low. CASE PRESENTATION: A 77-year-old female presented with complaints of decreased appetite and weight loss for six months. Upper gastrointestinal endoscopy showed a polypoidal growth along the greater curvature and the histopathological report of the biopsy taken showed high-grade tubular adenoma with high-grade dysplasia. The patient underwent pylorus-preserving gastrectomy with D1 lymphadenectomy. Postoperatively, after initiation of the oral diet, the abdominal drain started draining milky white fluid, which was rich in triglyceride. The patient was managed conservatively with nil per oral, total parenteral nutrition, and somatostatin analogue. CLINICAL DISCUSSION: The appearance of milky, nonpurulent fluid in abdominal drain concurrent with the initiation of oral feeding is characteristic of postoperative chyle leak. In our case, we managed the case successfully over a few days with total parenteral nutrition, nil per oral status, and somatostatin analogue. CONCLUSION: The incidence of chyle leak after gastrectomy is low, if it occurs it prolongs the hospital stay. Higher age, female gender, and early enteral feeding have been seen as the risk factors for chyle leak. Conservative treatment is effective and is the treatment of choice.

Right-sided paraduodenal hernia with malrotation - A case report.

INTRODUCTION: Paraduodenal hernia is a rare cause of internal hernia. It is the herniation of small bowel through a peritoneal sac in the duodenum. It occurs due to incomplete rotation and fixation abnormalities of the primitive midgut during fetal development. We report a case of right sided paraduodenal hernia in an adult male. CASE PRESENTATION: This is a case of 36-year-old gentleman who presented with complaints of abdominal fullness and upper abdominal pain for 1.5 months and 7 to 8 episodes of vomiting. CT scan of abdomen gave an impression of right-sided paraduodenal hernia. Exploratory laparotomy with hernia repair was performed and patient was discharged without complications. DISCUSSION: Right sided paraduodenal hernia is the protrusion of viscera through the fossa of Waldeyer. It is frequently associated with malrotation and strangulation. Its diagnosis is frequently delayed. Symptoms are non-specific and may need laparotomy for diagnosis. Technique of choice for surgical management remains inconclusive. CONCLUSION: Paraduodenal hernias are frequently diagnosed late or incidentally because of vague symptoms. They are rarer and carry higher lifetime risk of strangulation and bowel obstruction. Surgical management is necessary after diagnosis.

Ileal perforation as an initial manifestation of systemic lupus erythematosus: A case report.

INTRODUCTION AND IMPORTANCE: Lupus enteritis is uncommon in patients with SLE and usually presents with anorexia, vomiting, and abdominal pain. Intestinal perforation as an initial manifestation of SLE is rare and can have a grave prognosis if not timely diagnosed. CASE HISTORY: We report an unusual case of a 22-year-old regularly menstruating female who presented with features of perforation peritonitis as an initial manifestation of lupus enteritis. Intraoperatively, a gangrenous ileal segment with multiple perforations was present. Thus, with an intraoperative diagnosis of perforation peritonitis, a gangrenous segment of the small bowel was resected and a double-barrel jejuno-ileostomy was created. DISCUSSION: Lupus enteritis manifesting initially as bowel perforation can be an uncommon cause of acute abdomen. A plain chest X-ray can show gas under the diaphragm suggesting bowel perforation. A contrast-enhanced CT scan of the abdomen is the gold standard in diagnosing lupus enteritis with a good prognosis on steroids. CONCLUSION: Primary closure, resection, and anastomosis of small gut or diverting stoma are required for management of perforation. A high degree of clinical suspicion is required for early diagnosis thus preventing the grave prognosis of such an entity.

Multiple Endocrine Neoplasia Type 1 with Concomitant Existence of Malignant Insulinoma: A Rare Finding.

Multiple endocrine neoplasia type 1 (MEN1) is a rare syndrome of autosomal dominant inheritance defined by co-occurrence of two or more tumors originating from the parathyroid gland, pancreatic islet cells, and/or anterior pituitary. Insulinoma which has an incidence of 0.4% is a rare pancreatic neuroendocrine tumor. Malignant insulinoma is extremely rare, while primary hyperparathyroidism is a common occurrence in MEN1. We present a case of MEN1 syndrome with 2.6 cm insulinoma in the pancreatic head and parathyroid adenoma in a 56-year-old female who presented with symptoms suggestive of hypoglycemia like multiple episodes of loss of consciousness for four years. Classical pancreaticoduodenectomy was carried out, and the postoperative period was uneventful. Later, subtotal parathyroidectomy was performed, which showed parathyroid adenoma. Patients presenting with features of hypoglycemia should be vigilantly assessed for the presence of a sinister pathology.

Pancreatic Neuroendocrine Tumor with Benign Serous Cystadenoma: A Rare Entity.

Mixed serous-neuroendocrine neoplasm constitutes pancreatic serous cystic neoplasms and pancreatic neuroendocrine tumor, two tumor components with different underlying pathologies. The differentiation of these tumors is important as the management and prognosis depend on the pancreatic neuroendocrine tumor component. We report a case of mixed serous-neuroendocrine neoplasm in a 47-year-old female who presented with epigastric pain abdomen for two years. Imaging studies, tumor markers, thorough systemic evaluation, surgical resection, histopathological examination, and timely follow-up constituted our management approach. A 4 cm × 4 cm mass in the distal pancreas with multiple cysts in the pancreatic parenchyma containing serous fluid on distal pancreatectomy and splenectomy was found. The histopathological examination revealed combined benign serous cystadenoma and neuroendocrine tumor. She did not have any recurrence or metastasis by four years of follow-up.

Transduodenal surgical ampullectomy for intra-ampullary papillary tubular neoplasm (IAPN): A case report.

INTRODUCTION AND IMPORTANCE: Intra-ampullary papillary tubular neoplasms (IAPNs) are relatively rare kind of neoplasms occurring in the region of the papilla which exhibit significant malignant transformation. The patient was concerned about his pain and the possibility of malignancy. CASE PRESENTATION: We report a case of a 47-year-old male who presented with persistent upper abdomen pain. Following detail investigations, he was diagnosed as IAPN and managed by transduonal ampullectomy (TDA). CLINICAL DISCUSSION: The insidious onset of IAPN along with its high risk of malignancy makes it mandatory for its proper treatment. Although, endoscopic approach is advantageous for initial therapy, it has some technical difficulties. Hence TDA forms the cornerstone in the management of IAPN with good prognosis. CONCLUSION: Transduodenal ampullectomy is a safe and feasible option for IAPN. It can be the first choice of treatment in selected cases where endoscopic papillectomy is not available.

Mucormycosis-unusual cause of lower GI bleeding: A rare case report.

INTRODUCTION: Mucormycosis is a rare systemic fungal infection seen in immune-compromised patients. Gastrointestinal tract involvement is not usual. CASE PRESENTATION: A 36 years female presented with fever and progressive bilateral leg swelling for 25 days. She was diagnosed as nephrotic syndrome and started on methylprednisolone and cyclophosphamide. She developed hematochezia during hospital stay. On colonoscopy, ulcero-proliferative lesion was noted in caecum. Histopathology examination has confirmed it as mucormycosis of Caecum. DISCUSSION: Mucormycosis is an opportunistic angioinvasive disease caused by fungus zygomycosis it is a rare disease and often manifests as a life-threatening condition in immune-compromised patient. Invasion by fungal hyphae leads to arterial thrombosis, tissue infarction, hemorrhage and, necrosis. Diagnosis is confirmed by histopathological examination and culture. It is usually treated by the anti-fungal drug- liposomal amphotericin and surgical debridement. CONCLUSION: Mucormycosis is a fatal systemic fungal infection, which can present as lower gastrointestinal bleeding in immunocompromised patients.

Concomitant hilar cholangiocarcinoma with choledochal cyst and cholelithiasis in an asymptomatic patient: A case report.

INTRODUCTION AND IMPORTANCE: Choledochal cyst is an important risk factor for cholangiocarcinoma. Concomitant hilar cholangiocarcinoma with choledochal cyst with cholelithiasis is a rare finding. CASE PRESENTATION: A 52-year-old male presented with non-specific complaints of generalized weakness for 3 months. Transabdominal ultrasound showed dilated common bile duct with hyperechoic mass at hilar region; further evaluation with magnetic resonance cholangiopancreatography and contrast-enhanced computer tomography of abdomen and pelvis revealed concomitant intraductal hilar cholangiocarcinoma (Bismuth Corlette type 1) with Choledochal cyst (type IVa) with cholelithiasis. After optimization patient underwent left hepatectomy with common bile duct excision with cholecystectomy with Roux-en-Y hepaticojejunostomy. Histopathological examination confirmed it to be well-differentiated adenocarcinoma, intestinal type at the hilar confluence. CLINICAL DISCUSSION: An asymptomatic male patient with the concomitant finding of perihilar cholangiocarcinoma (Bismuth Corlette type I) with choledochal cyst type IVa with cholelithiasis is a rare finding. The patient was managed with surgical excision of the common bile duct with Roux-en-Y hepaticojejunostomy and cholecystectomy. Diagnostic evaluation should be proper not to miss or overlook such a synchronous lesion. CONCLUSION: Incidental finding of concomitant perihilar cholangiocarcinoma with the choledochal cyst is rare. Proper evaluation of the patient with CECT abdomen and pelvis and MRCP is necessary for the diagnosis. Proper surgical resection with adequate lymph node removal is important for surgical clearance.

Squamous cell carcinoma arising within choledochal cyst managed by pancreaticoduodenectomy: A case report.

INTRODUCTION AND IMPORTANCE: Choledochal cysts (CC) are rare cystic dilatation of the biliary trees. Malignancy is one of the important significant findings in CC and its incidence increases with age. Associated squamous cell carcinoma of the choledochal cyst is an uncommon pathological finding. CASE PRESENTATION: We present a 21-year-old male diagnosed with type 1 CC and planned for excision of the cystic dilated extrahepatic biliary tract with hepaticojejunal anastomosis in Roux-en-Y but underwent pancreaticoduodenectomy due to intraoperative palpable mass of CC which was adhered to the duodenum and pancreatic head. Histopathology of the excised specimen revealed squamous cell carcinoma (SCC) of the choledochal cyst. DISCUSSION: CC represents a rare biliary cystic disease. Though infrequent, malignant transformation in CC includes cholangiocarcinoma, adenocarcinoma, and rarely SCC. The post-operative management for SCC in CC is ill-defined and carries a grave prognosis. CONCLUSION: The choledochal cyst should be completely excised wherever possible to avoid the possible malignant transformation in CC including SCC.

Jejunal varices with extra hepatic portal vein obstruction: A case report.

INTRODUCTION AND IMPORTANCE: Extrahepatic portal vein obstruction (EHPVO) with portal hypertension is rare in children. Intestinal varices as new collaterals accompanying portal hypertension are very rare. PRESENTATION OF CASE: We report an unusual case of a 12-year-old boy with EHPVO with gastrointestinal bleeding from ectopic jejunal varices, without any gastroesophageal varices. DISCUSSION: Portal hypertension is the most common cause of EHPVO. Among various ectopic varices, intestinal varices are found distal to the duodenum and present with complaints of hematochezia, melena, or intraperitoneal bleeding. The diagnosis of the EHPVO is aided by imaging investigations like Doppler ultrasound, computed tomography, or magnetic resonance imaging. A multidisciplinary team including gastroenterologists, interventional radiologists, surgeons, and intensivists is crucial in the management of ectopic varices. CONCLUSION: Jejunal varices must be considered in the differential diagnosis of gastrointestinal (GI) hemorrhage in patients with a negative source of bleed on upper and lower GI endoscopy.

Case Report: Cryptococcal meningitis in an apparently immunocompetent patient in Nepal - challenges in diagnosis and treatment.

A 50 year old woman from Nepal had clinical features suggestive of meningitis. Cerebrospinal fluid (CSF) analysis was normal except for the presence of cryptococcal antigen. The inclusion of test for Cryptococcus in the CSF helped in making the diagnosis of cryptococcal meningitis in our patient who was apparently immunocompetent. Treatment with liposomal amphotericin B could not be started on time due financial constraints. The patient had a stroke and further deteriorated. Liposomal amphotericin B is stocked by the government of Nepal for free supply to patients with visceral leishmaniasis, but the policy does not allow the drug to be dispensed for other infections. The family members of our patient acquired the drug within a few days from a government center using their political connections and following administering the treatment the patient improved. This case demonstrates the utility of considering cryptococcal meningitis as a differential diagnosis, and including tests for Cryptococcus when dealing with immunocompetent patients presenting with meningitis. It also demonstrates the effects of the sociopolitical situation on health care delivery in low- and middle-income countries (LMICs) such as Nepal.

Human case of Fasciola gigantica-like infection, review of human fascioliasis reports in Nepal, and epidemiological analysis within the South Central Asia.

The diagnosis of a 22 year-old male patient from Kerabari, Morang District, Nepal led to the review of human fascioliasis cases and analysis of the epidemiological situation in that country not included in the WHO fascioliasis map. Symptom onset one month before egg detection and normal levels of ALT and AST did not agree with the 3-4-month migratory period of fascioliasis. A shorter acute phase may happen when the main biliary duct is reached by the migratory juveniles directly from the intestinal lumen. The causal agent was ascribed to F. gigantica-like worms after considering adult fluke morphology, altitude of the patient's infection area, fasciolid characteristics in the neighbouring Bangladesh, and lymnaeid snail vector species known in Nepal and in the patient's infection area. Previous reports of human infection by Fasciola in Nepal are reviewed. The patient in question proved to be the twelfth case and the first in whom a F. gigantica-like infection is reported. In Nepal, the wide geographical distribution of livestock fascioliasis, with high prevalences in buffaloes, cattle and goats, and the reports of Fasciola-infected schoolchildren close to the capital Kathmandu, give rise to concern on the situation in remote rural areas in a country where most of the population lives in rural areas. Moreover, the climate change impact in Nepal remembers Pakistan, where human fascioliasis emergence has been related to climate change and man-made irrigation. All in all, the present analysis suggests that human infection by Fasciola may be underestimated in Nepal.