Hydatid Cyst in the Liver Communicating with the Biliary System: A Rare Cause of Acute Pancreatitis

Abstract

Purpose: A 23-year-old man with no other medical problems presented to the emergency room with sudden onset abdominal pain associated with nausea for 1 day. Patient had a temperature of 101.5 F and tachycardia. On physical exam, patient had right upper quadrant tenderness. Patient had abnormal liver function tests and lipase of 2865 u/L. Patient had an ultrasound that showed complex cystic mass in the liver and sludge in the gall bladder and common bile duct. Patient was admitted to the hospital and treated conservatively with intravenous fluids, bowel rest, and pain control. Further history was obtained from the patient; patient was born and brought up on a farm in Argentina. Patient moved to United States at the age of 8 years. Patient had an MRI done that showed a complex cystic mass consistent with hydatid cyst that communicated with biliary radicles (Figure 1). Patient had a negative MRI of the head. Patient was treated with two courses of mebendazole without any result. Patient was referred to a surgeon. He had an exploratory laparotomy with cyst excision and imbrication. Patient did well post-surgery and did not have a recurrence. Hydatid cyst is caused by Echinococcus granulosus. It is common in sheep-rearing countries in Asia, South America, and Europe. Most common presentation in this condition is abdominal pain. Other presentations include jaundice, nausea, and abdominal pain. Rare cases of acute pancreatitis due to hydatid cyst have been reported, mostly secondary to primary cysts in the pancreatic head. Other causes for acute pancreatitis (<1%) could be secondary to rupture of the cyst into the biliary duct or due to development of communicating radicles between the cyst and biliary tree. Patients are usually treated with benzoimidazole carbonates. Most patients are treated with external drainage and cystectomy. Few studies have demonstrated safety and efficacy of modern techniques such as laparoscopy and transcutaneous puncture under US guidance (PAIR technique).Figure