An Unusual Case of Bile Duct Obstruction: Hydatid Daughter Cyst

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Case Report: A 57-year-old sheep farmer from Uruguay presented with severe intermittent rightsided abdominal pain for 1 week not associated with fever, jaundice, or pruritus. Imaging revealed a 9.3 x 8.0 x 10.6 cm thick-walled septated cystic mass with calcifications in the right lobe of the liver. It consisted of a 1.2 x 0.6 cm septated cystic component anteriorly and a 1.9 x 0.9 cm septated cystic component posteriorly. The extrahepatic biliary duct was dilated at 1.2 cm. Evaluation showed elevated liver chemistries: total bilirubin 1.3 mg/dL, AST 412 U/L, ALT 360 U/L, and alkaline phosphatase 249 U/L. Endoscopic retrograde cholangiography (ERC) revealed a filling defect of the common bile duct (CBD). The biliary tree did not communicate with the septated cyst. A sphincterotomy was performed and a daughter cyst was extracted using a balloon catheter. Subsequently, Echinococcus Ab was positive. The patient was discharged on albendazole prior to surgical management. Discussion: Hepatic hydatid cysts are usually asymptomatic. Symptoms occur due to the size of the cyst causing pressure on the liver parenchyma or from possible intrabiliary rupture. Intrabiliary rupture can occur occultly when the cystic fluid only drains into the biliary tree or as a frank rupture with intracystic material and/or daughter cysts draining into the biliary tract. ERC performed preoperatively in a patient with hydatid cyst with or without biliary dilation may avoid an unnecessary CBD exploration. It can be used for definition of biliary anatomy providing a roadmap of cystobiliary fistulas prior to cystectomy. Additionally, daughter cysts may be extracted from the biliary tract, relieving obstruction and/or cholangitis. Lastly, ERC can prevent abscess formation from the colonization of a ruptured cavity by intra-abdominal pathogens entering through the external cystobiliary fistula.Figure: Extracted daughter cyst wall.Conclusion: Although hepatic hydatid cysts are rarely encountered in the developed world, when suspected, ERC should be performed to relieve obstruction and to avoid CBD exploration. This may decrease morbidity post-operatively from external fistulas and abscess formation.