• A 28 year old female presented with pain in abdomen over RHC, fever and jaundice since 1 month
  • EUS- dilated CBD with a sludge and hydatid daughter cysts within
  • ERC- Duodenoscopy revealed bulging ampulla with hydatid daughter cyst at the opening
  • Cholangiogram- sludge and hydatid daughter cysts within CBD with massively dilated right ductal system
  • Biliary Sphincterotomy was performed. Hydatid daughter cyst extraction was carried out with balloon catheter. Sudden gush of infected bile and hydatid daughter cysts were seen
  • A 7 Fr double pigtail stent was placed in to the right ductal system to ensure free flow of bile
  • Follow up after 6 weeks- patient was asymptomatic. Duodenoscopy revealed biliary stent in situ.
  • Previously placed double pig tail stent was removed.
  • Cholangiogram showed the hydatid cyst cavity in the right lobe and right ductal system with daughter cyst membranes. Hydatid daughter cyst membrane extraction was carried out with balloon catheter.
  • In view of residual hydatid cyst membranes in to the right ductal system and right lobe of liver a 7 Fr double pigtail stent was placed in to the right ductal system and a 7 Fr Teflon stent was placed in to the left ductal system to ensure free flow of bile.
  • Patient underwent laparoscopic marsupialization procedure for residual cavity and stent removal was performed after 4 weeks. Patient was asymptomatic on further clinical follow ups.

Expert comments-

  • Early diagnosis and proper management are mandatory in these patients, since serious clinical complications with an increased mortality may ensue
  • ERC proved to be a choice offering excellent immediate and short-term post procedure results. The success rate of endoscopic treatment appears to be satisfactory at 90 – 100%

Take home message-

  • Endoscopic treatment is one of the therapeutic options of a ruptured hepatic hydatid cyst into the biliary tract9 and it is both safe and effective
  • Percutaneous approach with PAIR (Percutaneous aspiration instillation and re aspiration) should not be performed in patients with cyst-biliary communication
Dilated CBD with daughter cysts within

Dilated CBD with daughter cysts within

Massively dilated right ductal system

Massively dilated right ductal system

 

 

 

 

 

 

 

 

 

Hydatid cyst extraction with balloon catheter

Hydatid cyst extraction with balloon catheter

A 7 Fr double pigtail stent in situ

A 7 Fr double pigtail stent in situ

 

 

 

 

 

 

 

 

 

Residual hydatid cavity in right lobe and ductal system

Residual hydatid cavity in right lobe and ductal system

A 7 Fr double pigtail and a 7 Fr Teflon stent was placed in to the right  and left ductal system

A 7 Fr double pigtail and a 7 Fr Teflon stent was placed in to the right and left ductal system

 

 

 

 

 

 

 

 

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