An 82-year-old female patient underwent emergency endoscopic retrograde cholangiopancreatography
(ERCP) with common bile duct (CBD) stenting (7 Fr × 7 cm) 2 years ago for acute severe
cholangitis secondary to cholelithiasis and choledocholithiasis (multiple calculi).
At that time, magnetic resonance cholangiopancreatography also revealed a large hydatid
cyst with defined daughter cysts (∼8.5 × 7.4 × 8.7 cm in size, World Health Organization
[WHO] stage CE3b) in the left lobe and a hemangioma in segment VI of the liver ([Fig. 1A]). Despite being advised to undergo a repeat ERCP for CBD clearance and surgery for
gallstone and hydatid cyst the patient was lost to follow-up.
Fig. 1 (A) Coronal True Fast Imaging with Steady-State Free Precession (TRUFI) magnetic
resonance imaging (MRI) image showing enlarged liver with choledocholithiasis with
large hydatid cyst (arrow) in the left lobe of the liver (Gharbi stage 3), (B) endoscopic
image showing fistulous opening (arrow) along the lesser curvature of the stomach,
and (C and D) axial and coronal computed tomography images showing fistulous communication
(arrow) between the left lobe of the liver and the stomach lumen along the lesser
curvature.
She now presents with a 2-week history of epigastric pain, accompanied by nausea and
occasional vomiting. On examination, her general physical condition and initial laboratory
investigations were unremarkable. Esophagogastroduodenoscopy revealed a small fistulous
opening along the lesser curvature near the gastric cardia ([Fig. 1B]). A computed tomography scan identified a fistulous tract extending from the left
lobe of the liver to the gastric cardia, with evidence of oral contrast leakage into
the tract ([Fig. 1C, D]). Additional findings included calcific foci in segments II and V, indicative of
sequelae from a previous hydatid cyst (WHO stage CE5), as well as portal vein thrombosis
extending into its branches. Cholelithiasis, choledocholithiasis, and a hepatic hemangioma
were also noted, with no evidence of hydatid cyst dissemination into the chest, abdomen,
or pelvis.
ERCP was performed under propofol sedation using a triple-lumen sphincterotome (CleverCut
3V, Olympus) and a guidewire (VisiGlide, Olympus, 0.025 inch), which was successfully
advanced into the left intrahepatic duct. Cholangiography revealed a dilated CBD with
multiple calculi, which were extracted using a triple-lumen extraction balloon (Multi-3V
Plus, Olympus). A 7 Fr × 7 cm double pigtail stent was subsequently placed in the
CBD. The patient was then referred to the surgical department for cholecystectomy.
Fistulization of the hydatid cyst in the gastrointestinal tract is extremely rare
even in highly endemic countries and depends on the cyst location (inferior surface
of the liver), infection (create adhesions), and close contact.[1] The presence of hydatid membranes in the stool (hydatidorrhea) or in the vomit (hydatidemesis)
is highly suggestive of bowel fistulization.[2]
