Endoscopic-Ultrasound Guided Ethanol Ablation of a Giant Hepatic Cyst Causing Biliary Obstruction

Abstract

Introduction: Simple hepatic cysts have a prevalence of 2.5 to 4.25 percent and are more common in women and in patients older than forty years. They usually have a benign course, with a minority causing outlet or biliary obstruction-related complications that require therapeutic intervention. Percutaneous sclerotherapy and surgery appear effective, however are limited by procedure-related morbidity. Alternative methods of cyst drainage that prevent recurrence with minimal risks would be optimal. Here we describe a case of EUS-guided simple hepatic cyst drainage and ethanol sclerotherapy. Case Report: A 72-year-old African American man presented with nausea, abdominal distension, jaundice, anorexia and pruritus for one week with abnormal liver tests. MRI demonstrated a simple hepatic cyst in the right lobe, measuring 12.2 × 10.2 × 15 cm (average radius: 6.233 cm, giving a volume of 1014.33 cm3) causing a mass effect on the porta hepatis and intrahepatic biliary ductal dilatation. The patient desired a minimally invasive approach without percutaneous drains. As a first step, ERCP was performed to evaluate cyst-biliary communication and rule out the presence of cholangiocarcinoma, followed by cyst drainage and sclerotherapy with a 98 percent alcohol solution in the second step. After treatment, EUS demonstrated a collapsed cyst, resulting in complete resolution of the biliary obstruction. The patient tolerated the procedure well and his symptoms resolved immediately. At our patient's follow up visit in one year, he continues to be doing well with none of the symptoms recurring and laboratory examination showing normal values. The repeat MRI done at this point shows that the cyst is now 7.9 × 4.8 × 7.5 cm (average radius: 3.367 cm, giving a volume of 159.89 cm3) showing an 84.2 percent decrease in volume. Discussion: We recommend endoscopic-ultrasound guided ethanol sclerotherapy, without the need of further sessions from the time of ERCP, as a one session therapeutic intervention. We have described to our knowledge, the first case of EUS-guided ethanol ablation of a simple hepatic cyst causing biliary obstruction and have shown it to be feasible, safe and effective (durable) without need for further sessions. This report supports the need for further prospective studies.