Endoscopic and surgical management of intrabiliary rupture of hydatid liver cyst

A man with hydatid disease complicated by intraabdominal cyst rupture 15 years earlier, presented with cholestatic jaundice. There was intrabiliary rupture of a hydatid liver cyst on endoscopic retrograde cholangiography. Sphincterotomy was performed allow clearance of hydatid material obstructing the bile ducts and insertion of a nasobiliary catheter for irrigation and drainage. Definitive surgery was performed. While endoscopic management is gaining recognition for relieving biliary obstruction in hydatid cystobiliary rupture, surgery is still required for patients who continue to pass hydatid debris obstructing the biliary tree and increasing the risk of cholangitis.


CASE REPORT
A 37-year-old man (if lt ,1 lian descent presemcd with jaundice assoc iated \\'I th ahdommal disu1mf,1rt for two days.I le had emigrated to Cannda at 12 yean, of age.During his childhood he liwd with hi:, parent, who were fa rmers, rcnd111g cattle, shl•ep, pigs a nd dog~. At 22 years, he expc rienct•d severe ahdommal pain ,1fter hem g hit h) a ba ll in the ,1hdrnnen.Emerge ncy laparntomy revealeJ a ruptured h ydat id cyst 111 the Live r.Pan ial left he pm ic lobecto m) was performed and he made an uncventfu l i-ccnvl'ry.On abdominal examinati on , upper and lower midline surgical scars and a tender, enlarged liver were noted.The li ver function tests were consistent with cholc~taric jaundice and coagulati()n profi le was normal.Ultrasound of the abdomen revealed a distended gall bladder and a cystic le~ion in the remnant left lobe, measuring 3.9 by 4.5 cm.The common hile duct was dilated to l.6 cm.The intrahepatic ducts were also dilated.Endoscopic retrograde cholangil1graphy sh owed a dilated hiliary tree with a cystic dilation in a hranch of the left hepatic duct conrnming hydatid m ateria l (Figure 2).Endoscopic sphincterotomy was performed ,md yellowish gelatinous membrane~ were seen extruding from the ampullary \lrifice.A Donnia basket was passed w evacuatl.'h ydarid dehris from the bi le ducts.There was dramatic recovery wi th relief of biliary obstructi on.
Two weeks later the jaundice recurred, assoc iated with fover ,Hld chills, suggesting chol angitis due tn hiliary obstruction from continuing dischnrgc of daughter cysts.At urgent endoscopic retrograde cholangiography, ycl lowish jelly-like hydatid material and pus were seen protruding out of the ampulla of Yater (Figure 3).There was hydatid debris in the d ilated common hile duct and lefc hepatic radical, which was communicating with the cyst ic cavity (Figure 4).After evacuation nf the debris with a basket, a nasnhiliary catheter was inserted into the cyst crwity to improve drainage and allow irrigation with sali ne.The biliary fluid and sediments did not contain any hooklcts or prntoscolices on microscopy.H en ce there was no evidence for Cyst rupt ure m,1y be due to externa l traum:1 (direct ruptu re) as in the in itia l prcsen ta t i11n of th is case, or degene rati on of t he parasit ic me mbranes (communicating rupture) resulting in the rcle<1sc of hyd atid da ughte r cysts .ind J e hris in to the common h ilc duc t.H yd ar iJ cyst rup ture into the b ili ary tree is a ~eri11us complication occurring in 5 10 15% of pat ien ts with hepat ic involveme n t ( 7 ,8).Diagnosis was made only at laparmom y un t il srn1<igraphy heca mc ava ilable (7)(8)(9).Sonogrn p hi c v isualizau o n of ru p tured cyst material in to the h ili ary t ree and communicat io n be tween a cy~t a nd the hil iary t rnct indicate intrnhi li ary rupture ,if a CAN J GAsrn, lFNTrR()t V()L 6 N o 3 M AY/JUNE 1992 I 37 h epatic h ydatiJ cyst ( 10-12).Toge ther with compute ri:cd axia l tomography, w hic h can de monstrate the cyst-bile duc t communication sometimes difficult to visua li ze with ultrasound, the diagnostic accuracy can reach 96% for intrabi lia ry hydatid cyst rupture (13,14).
Cottone ct al (15) first reported the use of endoscopic retrograde cholangiograph y in the diagnosis of hepatic h ydatid cyst rupture into the biliary tree.The endoscopic pi c ture o f yellowish gelatinous me mbranes protruding out of the ampu lla suggest hydatiu cystobiliary rupture and this is confirmed by pathological examination of the infected bile whi c h will contain fragmented membranes and daughter cysts.The presence of pus suggests secondary infectio n and requ ires adm in istrntinn o f apprnrriat c ,rnt ibi o t ics.The chola ngingram shows a dilated bilia ry tree with filling defects represen ting daughter c ysts and h ydarid memhranes.The leaf-like radio logical appearance of t hese membranes som etimes c hanges in shape on serial ch o langiogram and it differentiates hydatid materi a l from c holcdocholithias is ( 16,17).Entry of contrast into a cystic space po inrs t0 a communi cating type of ruptu re.Other radiological fca-tu res include extrins ic compres •io n of the biliary tract by a hepatic cyst , complete ohstruc t ion of extrnh cpatic bi le ducts and biliary fistula ( 18).Perc utaneous transbe patic c holang iography has been used ro demo n strate the ruptun.: of a cyst into the bilia ry tree ( 19,20).H owever, the re is the risk of peritoneal seeding or a naphylaxis atho ugh diagnostic and therapeutic percutaneous aspiratio n of an hepatic hyJatid cyst h as a lso been described (21 ).
Before che adve m of therapeutic endoscopy, surgery was the o n ly e ffective mode of trca tm.e nt fo r h yJacid disease (15).When the h ydatid cyst can be complccd y removed, surgical exc isio n, partial hcpaceccomy or hepatic lobectomy is performed (4).ln addition, cysts that h ave ruptured into the bi liary tract must be trea ted as infected and the c,>mmon bile duct must be explored and drained with a large calibre T -tubc whic h would a lso a llow a c ho langiogram to be don e to ensure common bile duc e clearance before its rem oval (22).
Decompression of the biliary tree by e ndoscopic sphincterotomy was fi rst repo rted in 1986 by S h e mesh ct a I ( 23).
Evacuation of h ydacid debris from the obstructed biliary tree was safe and effective in preventing sepsis (23-25 ).Patients with good clearance of the bile duc ts avoided ~urgery (26,27).In posto perative patie nts, rhc cause nf jaundice was quickly found a nd endoscopic sphincterutomy w ith insertion of a nasob i I iary rntheter for irrigation replaced surgery in some patients (26).
Scolic ida l agents such as hypertnnic saline can be used co irrigate a nd kill any viable parasites via the nasohilimy drain (27).
Me nor F, Ballcsrn A.
Th is was not used in the p resent patient as t he patho logist found no v iable parasites.However, frequent irrigatio n via a nasohilimy cat heter helps to clea r the h il c ducts l1f dcbrb a nd this mi gh t have prevented a recurrence of cholangitis a fter the fir~t e ndoscopic retrograde c holangiogrnphy and endoscopic sphinctcrntomy .More likely, it is t h e con tinued d isch a rge of daughter cysts t ha t prevents h ilc drainage.O ther possible causes incl ude incomple te ex tractio n of common hilc duc t debris and inadcquarc sphinc tcru romy.Whil e e ndoscopi c treatment of intrabilia ry rupture of hydacid cyst may tempora ri ly relieve biliary ob truc tion, su rgery shou ld he comidered if th ere 1, persistent discharge of h ydac id debri, obstructi ng the b il e duct,.T hi~ will prevent cholangi tis nnd eradicate hydatid d isease.