Biliary obstruction caused by an erupted hepatic hydatid cyst

A 60-year-old woman presented to the emergency room with nausea and upper abdominal pain radiating to the back. Her past medical history was significant for an inactive hepatic hydatid cyst for 30 years. She had presented 4 months earlier with acute pancreatitis. Despite a negative abdominal ultrasound, a laparoscopic cholecystectomy was performed for presumed biliary pancreatitis.

On physical examination, a non-icteric, afebrile patient was seen. No tenderness or pain was observed during abdominal examination. Laboratory results showed elevated liver tests and a normal eosinophil count (AST 557 U/l; ALT 535 U/l; LD 754 U/l; gamma-GT 440 U/l; bilirubin 74 µmol/l (conjugated 30 µmol/l); eosinophils 0.04 x10^9 /l). Endoscopic ultrasound showed a non-dilated common bile duct containing a heterogeneous substance ([Fig. 1]). An endoscopic retrograde cholangiopancreatography (ERCP) was performed showing a protruding papilla ([Fig. 2 a]). Immediately after cannulation, black fluid drained out of the papilla. Cholangiography suggested remaining material within the choledochal duct ([Fig. 3]). After papillotomy, pus and a gelatinous substance of approximately 2 centimeters were extracted using a balloon ([Fig. 2 b, ] [Video 1]). The material was aspirated and the pathology report noted its origin from a hydatid cyst. An abdominal computed tomography (CT) scan showed a multilocular hydatid cyst of 66 by 48 millimeters, consistent with prior imaging ([Fig. 4]). Anthelmintic albendazole therapy was started and the patient was referred for percutaneous evacuation of cyst content [1].

Fig. 1 Endoscopic ultrasound shows a non-dilated common bile duct (CBD) containing a heterogeneous substance.

Fig. 2 a Endoscopic retrograde cholangiopancreatography shows protruding papilla. b After papillotomy, a soft substance was extracted from the common bile duct.

Fig. 3 Cholangiography shows remaining material within the choledochal duct.

Video 1 Endoscopic extraction of hepatic hydatid cyst material. During cannulation black fluid drained out of the papilla. After papillotomy, a soft substance of approximately two centimeters was extracted using a balloon.

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Fig. 4 Abdominal computed tomography scan shows a multilocular hydatid cyst of 66 by 48 millimeters.

Hepatic hydatid cysts are caused by parasitic infection through ingestion of eggs from the echinococcus tapeworm (Echinococcus granulosus) [2]. Biliary obstruction secondary to a frank intrabiliary rupture occurs in up to 17 % of cases [3] [4]. The prior episode of acute pancreatitis in our patient might have been caused by an earlier eruption [5]. Primary treatment of intrabiliary rupture consists of balloon extraction by ERCP followed by percutaneous or surgical treatment and albendazole therapy for 1 to 3 months [1] [2] [3] [4].

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• References

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• 4 Dolay K, Akbulut S. Role of endoscopic retrograde cholangiopancreatography in the management of hepatic hydatid disease. World J Gastroenterol 2014; 20: 15253-15261
• 5 Al-Toma AA, Vermeijden RJ, Van De Wiel A. Acute pancreatitis complicating intrabiliary rupture of liver hydatid cyst. Eur J Intern Med 2004; 15: 65-67