The Role of Endoscopic Retrograde Cholangiopancreatography (ERCP) in the Management of Intra-Biliary Rupture of Liver Hydatid Cysts (IBRH): Follow-Up of 12 Cases

Abstract

Background: Intra-biliary rupture of hydatid cyst [IBRH] is not a rare complication of hydatid disease of the liver and surgery until recently is the only definitive treatment. With the introduction of ERCP preoperatively or postoperatively there was a great reduction in the operative complications. There were reports in which the ERCP was the sole treatment of this condition. Objective: To evaluate role of ERCP in the management of cases of IBRH. Design: A retrospective study of 7 cases of IBRH and prospective study of 5 cases of IBRH managed by ERCP. Setting: The ERCP Unit of Kurditan Center for Gastroenterology & Hepatology, Asulaimaneyah-Iraqi, Kurdistan, Iraq. Main Outcome Measurements: Improvement in the symptoms, obstructive liver functions pattern and ultrasonic findings in these patients following ERCP management. Methods: This is a study of 12 cases of IBRH managed by ERCP in the Kurdistan Center of Gastroenterology (KCGE) in Asulaimaneyah-Iraq, from 2007-2010. Seven cases of these were studied retrospectively from the available information on the center computers and on follow-up of these patients, while the other five patients were studied prospectively during the study period. We collected the available information: laboratory investigations, trans-abdominal ultrasonography (TAUS), computed tomography (CT) or magnetic resonance images (when available), before and after ERCP. We depended on the liver functions, trans-abdominal ultrasound and the clinical presentation before and after the ERCP; some patients were contacted via mobile phone for follow-up. Results: Cases were more males than females (58% vs 42%); most were from the ages between 30 - 50 years. The clinical presentation was fever, jaundice, itching and right hypochondrial pain in most patients. The liver function tests were obstructive pattern with elevated direct bilirubin and alkhaline phosphates in most patients. The trans-abdominal ultrasound revealed dilated common bile duct and single liver cyst in most patients and 2 or 3 cysts in others. The ERCP management led to improvement in clinical, laboratory and ultrasonic findings in 6 patients and in these 6 patients ERCP was the only procedure needed and proved by follow-up of these patients for 1 year in 4 patients and 2 years in the other 2 patients, especially in those with hydatid mebranes seen at ERCP and those with cholangiographic evidence of communication with the cyst; surgery was needed in 5 cases and one patient died from septic shock. Conclusions: ERCP is an important management strategy for patients with IBRH, which can lead to clinical, laboratory and ultrasonographic improvements, and can be the only required procedure in more than 50% of cases especially in those with hydatid mebranes seen at ERCP and those with cholangiographic evidence of communication with the cyst.