1291 Pancreatico-Biliary Stricture by Benign Hepatic Cysts

Abstract

INTRODUCTION: Hepatic cysts are frequently identified incidentally, and usually do not require any follow up. We present a case of benign, large hepatic cysts which were extrinsically compressing on biliary ductal system and caused a fusiform-dilitation of the hepatic ducts, distal dilation of the common bile duct (CBD) and a narrowing of the pancreatic duct. CASE DESCRIPTION/METHODS: A 77-year-old male presented to our facility for drainage of a large liver cyst. Initial discovery was incidental, but follow up imaging showed increased solid component in one of the cysts. At the time of presentation he was completely asymptomatic and laboratory studies were all within normal range. Computed Tomography (CT)-guided drainage of the hepatic cyst yielded 250 cc of brown fluid. The cytology was benign. Patient then presented to one-month follow up appointment with painless jaundice, and elevated total bilirubin of 6.7 mg/dL. Magnetic Resonance Cholangiopancreatography (MRCP) was performed and showed filling defects of the CBD and bilateral hepatic ducts. Elective Endoscopic Retrograde Cholangiopancreatography (ERCP) a few days later showed dilated CBD and strictures of biliary duct at the bifurcation and pancreatic duct at the neck. The stricture appeared to be from extrinsic compression. We were concerned about infected cyst, and repeated cyst drainage. Previsouly drained cyst yielded 200 cc for purulent fluid; the adjacent cyst was also drained and it yielded >1 L of clear fluid. At this time, patient had leukocytosis of 13.7 K, total bilirubin 6.2 mg/dL, ALP 433 IU/L. Patient was admitted post-procedure and was placed on broad-spectrum antibiotics. Culture grew Actinomyces species, and patient was discharged to home on long term oral antibiotics. ERCP was repeated two weeks later, and it showed fusiform dilation of intrahepatic duct, though stricture of the biliary tract and pancreatic duct were now resolved. There was no communication between the biliary tract and the hepatic cysts. CT of the abdomen showed persistent fluid collections, the patient ultimately underwent laparoscopic resection of hepatic cyst with partial hepatectomy, cyst fenestration and cholecystectomy. Pathology confirmed that it was indeed a benign cyst. DISCUSSION: It appears that due to close abutment of two large cysts caused compression of the ductal system. This unusual presentation of benign liver cyst leading to stricture of bile and pancreatic duct by extrinsic compression is worth a report.