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Excerpt
Hydatid cysts are caused by tapeworms with Echinococcus granulosus infection being the most common etiologic agent. Most patients are asymptomatic; however, many complications can arise from cyst rupture. We describe a case of a 63-year-old Greek man with cyst rupture into the biliary system and resultant obstructive jaundice and pancreatitis. Emergent endoscopic retrograde cholangio-pancreatography decompression was necessary and the patient did well with medical management. This case describes an infrequent complication of hydatid cyst—relevant management issues are discussed.
A 63-year-old healthy Greek male was referred for evaluation of a large hepatic cyst found during the investigation of mild right upper quadrant abdominal pain. A computed tomography (CT) scan showed a 14×7.4 cm multiseptated cyst with an ill-defined cyst wall located within the dome of the liver, 2 (2.6 cm, 4.5 cm) calcified masses in the right hepatic lobe, splenic granulomata, and a normal biliary tree.
Because of his symptoms and serology (an Echinococcal IgG level was strongly positive), a 4-week treatment regimen of Albendazole 400 mg twice daily was initiated. Before a repeat CT could be obtained, the patient experienced abdominal pain, nausea, emesis, subjective fever, and chills. On admission, a CT showed that the largest cyst had become organized and decreased in size to 12×5.6 cm and the 2 calcified masses were unchanged. New findings of perihepatic free fluid, peripancreatic edema and infiltrative changes, and biliary ductal dilatation [common bile duct (CBD) 1.1 cm] were appreciated on CT. Laboratory investigation was notable for direct bilirubin 5.9, aspartate aminotransferase 270, alanine aminotransferase 382, alkaline phosphatase 414, amylase 984, and lipase 628.
Emergent endoscopic retrograde cholangio-pancreatography was performed for presumed cholangitis. The stomach contained a large amount of white linear castlike debris suggestive of cyst contents and solid white debris was seen protruding from the ampulla. A cholangiogram of the CBD revealed multiple filling defects and marked intra and extrahepatic dilatation. A large sphincterotomy was performed and pearly white solid and gelatinous hydatid membranes were seen extruding from the ampulla followed by the evacuation of pus. After multiple balloon sweeps, the CBD was flushed with saline until clear return was seen and no further filling defects were seen on a final cholangiogram.
Microscopic examination of the collected debris revealed tapeworms with hooklets suggestive of E. granulosus. The patient has remained asymptomatic on continued Albendazole therapy. Liver and pancreatic enzymes have normalized and repeat CT imaging shows regression of the large hepatic cyst.
Hydatid cysts are caused by tapeworms. E. granulosus infections are the most common and discovered worldwide, whereas E. multilocularis and E. vogeli are less common. Most patients may remain asymptomatic for many years and the cysts may be discovered incidentally. Although uncommon, both pancreatitis and cyst rupture into the biliary system with resultant obstructive jaundice has been described in literature1; if viable cysts rupture into the peritoneal cavity anaphylactic shock can occur.
Diagnosis of hepatic echinococcus is largely based on CT or ultrasonography in combination with an exposure history and positive serology. Treatment for uncomplicated E. granulosus is Albendazole whereas E. multilocularis or complicated Echinococcal infections require surgery. Recent literature suggests that cautious percutaneous drainage with concurrent administration of antihelminthic therapy may be an effective alternative to surgical intervention in selected cases.2,3
This case demonstrates that pancreatitis and cholangitis can arise from cyst rupture as infrequent complications of hydatid cysts; emergent biliary decompression is essential if this occurs. Furthermore, surgery can be averted in cases of E. granulosus if cyst regression is achieved with medical therapy.
