Successful Trans-Papillary Drainage of a Hepatic Hydatid Cyst

Abstract

Purpose: Hydatid cystic disease, caused by the larval form of Echinococcus, commonly affects the liver. When symptomatic, these cysts rupture and cause intraperitoneal leakage, infection, or biliary obstruction and when enlarged, produce mass effect. Definitive treatment of obstructive jaundice due to rupture is Endoscopic Retrograde Cholangiopancreatography (ERCP) and sphincterotomy. We would like to report a case of a trans-papillary drainage of a hydatid cyst. Methods: An 82 year old male with chronic hydatid liver cysts treated with ERCP and sphincterotomy, presented with fever, generalized pruritis, and dark urine for one week. Laboratory work revealed elevated liver enzymes and bilirubin. A CT scan showed a septated cyst in the right lobe and intrahepatic dilatation. ERCP revealed a cyst causing external compression of the intrahepatic ducts. We selectively cannulated and irrigated the cyst using hypertonic saline to kill off remaining scolicides to avoid anaphylactic reaction. After clearance of the fluid with an occlusion balloon, gentamycin was used for irrigation. Results: A repeat CT scan showed a decrease in the size of the cyst with improving intrahepatic dilatation. Irrigation and drainage of the cyst were performed without complication Conclusion: Among the complications of hydatid disease, cyst rupture into the biliary tract occurs in 5–25%. ERCP with sphincterotomy is needed to treat obstructive jaundice caused by debris after a cyst rupture. A study reports an 86% success rate with endocsopic treatment for hydatid cysts. Treatment with anti-hydatid agents is without endoscopic intervention. Literature review reveals that our approach is one of the few reported cases for a trans-papillary drainage of a hydatid liver cyst without the need for stenting or nasobiliary drainage. By managing cystic rupture with ERCP and sphincterotomy along with medical therapy, we avoid the need for surgical or percutaneous approaches. ERCP with sphincterotomy and medical therapy is a safe and effective approach to treat complications of hydatid cystic disease. Our case is unique in that we successfully drained a hepatic hydatid cyst using a trans-papillary approach via ERCP.Figure