BILIARY COMPLICATIONS OF LARGEECHINOCOCCUS GRANULOSUSCYSTS:

Abstract

Hydatid cysts are often incidentally found and remain clinically silent. However complications can occur. We present 2 patients who developed biliary complications due to a large hydatid cyst. In the first patient compression on the intrahepatic bile ducts and cystic duct by the cyst, caused cholangitis and cholecystitis. Moreover the cyst had ruptured into the right intrahepatic bile ducts. A sphincterotomy was performed with extraction of hydatid sand. A pericystectomy was necessary because of infectious deterioration of the patient. Albendazole was continued for 8 weeks after surgery. The second case presented with jaundice and weight-loss since 1 month. A large hydatid cyst caused compression on the bile duct bifurcation with proximal bile duct dilatation. A cystectomy was performed 2 weeks after albendazole therapy initiation, which was continued for 8 weeks after surgery. Follow-up of both surgical interventions was unremarkable. Although Echinococcus granulosus in not prevalent in Belgium, we must be aware of this pathology in patients coming from high endemic regions.

Anatomical patterns of intrahepatic cystic echinococcosis in reference to serological and clinical findings

“…Yet the latter complication was exclusively reported in CE lesions involving segment VII, that harboured the largest cyst with a mean size of 10 cm. Biliary complications are reported with large cysts close to the hepatic hilum, due to bile duct compression or rupture of hydatid cysts into biliary tree [32] . In fact, Atli and colleagues [33] stated that cyst diameters > 10 cm and > 14.5 cm are independent clinical predictors of frank and occult intra-biliary rupture, respectively.…”

Satellite cysts and biliary fistulas in hydatid liver disease. A retrospective study of 17 liver resections

“…It varies accordingly between 3% and 32% [3][4][5]7,9,11,[15][16][17][18][19][20]. The authors often acknowledge that the number of small fistulas was probably underrated and there seems to be general agreement that only a minority of fistulas are wide enough to permit gross evacuation of cyst contents into the biliary tree leading to colicky abdominal pain, acute cholangitis, and eventually to obstructive jaundice [7,[15][16][17]19].…”

“…That this was the case in 30% of our patients is unusual and may reflect the fact that some patients were referred specially for liver surgery. That parts of the parasite can occasionally be removed from larger bile ducts by endoscopy or surgery is well documented [3,[16][17][18] and parasitic material can even be found by stool analysis [17,21].…”

“…Slow drainage of cyst fluid into the biliary system has, however, been held responsible for the occasional observation of chronic sclerosing cholangitis in downstream bile ducts situated between a hydatid cyst and the liver hilus. Dilatation of these bile ducts seen by ultrasound examination has long been recognized as indicating fistulas of longer duration [11,12,16] and has to be distinguished from obstructive dilatation of upstream bile ducts [18]. The unsuspected presence of such fistulas may also explain the so-called caustic cholangitis observed occasionally after injection of scolicidal substances into the cyst [22][23][24].…”

Mechanical and Anatomical Causes of Bile Duct

“…Tuberculosis of bile duct-associated lymph nodes situated in the hepatoduodenal ligament can cause duct compression (Amarapurkar and Agrawal 2006), and periportal tuberculous lymphadenitis may encroach upon the extrahepatic duct system (Stanely et al 1984). Echinococcus cysts caused by E. granulosus exhibit expanding growth and can displace and compress bile ducts (Colle et al 2002), sometimes with effacement of the bile duct confluence (Martin Molinero et al 1989).…”