CardioVascular and Interventional Radiology
© Springer-Verlag New York, Inc. 2002 Published Online: 25 July 2002
Cardiovasc Intervent Radiol (2002) 25:437– 439 DOI: 10.1007/s00270-001-0091-x
CASE REPORTS
Percutaneous Transhepatic Endobiliary Drainage of Hepatic Hydatid Cyst with Rupture into the Biliary System: An Unusual Route for Drainage Mehmet Inal,1 Süreyya Soyupak,1 Erol Akgül,1 Hüseyin Ezici2 1 2
Çukurova University, Faculty of Medicine, Department of Radiology, Balcali Hospital 01330, Adana, Turkey Department of General Surgery, Çukurova University Faculty of Medicine, Balcali Hospital 01330, Adana, Turkey
Abstract
Case Report
The most common and serious complication of hydatid cyst of the liver is rupture into the biliary tract causing obstructive jaundice, cholangitis and abscess. The traditional treatment of biliary-cystic fistula is surgery and recently endoscopic sphincterotomy. We report a case of complex heterogeneous cyst rupture into the biliary tract causing biliary obstruction in which the obstruction and cyst were treated successfully by percutaneous transhepatic endobiliary drainage. Our case is the second report of percutaneous transbiliary internal drainage of hydatid cyst with rupture into the biliary duct in which the puncture and drainage were not performed through the cyst cavity.
A 50-year-old woman with complaints of right upper quadrant pain, fever and jaundice was admitted with a clinical and laboratory diagnosis of obstructive cholangitis. Positive laboratory tests were: total bilirubin level 7.2 mg/dl, direct bilirubin level 4.4 mg/dl and leukocyte count 9800/mm3. Abdominal US examination showed a 5 ⫻ 4 cm heterogeneous mass containing cystic and solid components and adjacent dilated intrahepatic biliary ducts on the medial segment of the left lobe of the liver. US examination was suggestive of intrabiliary rupture of hydatid cyst. The cyst was classified as type IV according to the Gharbi classification [11]. Abdominal CT was performed to rule out intrahepatic cholangiocarcinoma. CT showed an ovoid, well-circumscribed, heterogeneous, lowattenuation mass neighboring the dilated left hepatic ductal system (Fig. 1). Serologic test for echinoccal-antibody was positive (titer: 1/320), confirming the diagnosis of hydatid cyst. Albendazole therapy was started. Endoscopic sphincterotomy could not be performed because of failed cannulation; therefore the patient was referred for percutaneous treatment. Because of the complicated nature of the cyst, percutaneous cyst aspiration or drainage would not have been effective and probably the solid contents of the cyst obstructing the bile ducts would not have been removed with direct puncture of the cyst itself. Percutaneous left hepatic duct puncture with internal-external biliary drainage was planned. Prophylactic therapy against a probable anaphylactic reaction was initiated 2 days prior to the intervention. With the patient supine on the angiography table, percutaneous transhepatic puncture of the dilated left hepatic duct was done successfully with a Chiba needle via an epigastric approach under US guidance. PTC showed band-like filling defects causing obstruction in the distal common bile duct (Fig. 2). An 8 Fr internal-external biliary drainage catheter was inserted over a guidewire reaching into the duodenum (Fig. 3). After 2 days of catheter drainage, transcatheter cholangiography demonstrated the communication between the left hepatic duct and the cyst (Fig. 4). In the following days, transcatheter drainage of membrane particles, debris and the cyst contents was observed. Repeated flushing of the catheter with saline solution was effective in clearing the cyst contents. After 7 days of catheter drainage, the cyst content was almost totally discharged and the cyst eventually disappeared. US, transcatheter cholangiography and CT following transcatheter contrast injection (CT-cholangiography) demonstrated that both the cyst and bile ducts were free of the particles seen previously. Bilirubinemia, leukocytosis and the patient’s complaints were resolved. After removal of the catheter on the seventh day, the patient was discharged from the hospital. Albendazole was continued at a dosage of 10 mg/kg body weight per day for 8 weeks. After 2, 6, 12, 18, 24 and 30 months, serologic tests and imaging with US and/or CT were done. The cyst
Key words: Bile ducts—Percutaneous drainage—Hydatid cyst— Rupture—Treatment Intrabiliary rupture of hepatic hydatid cyst is a common complication in patients with echinococcal cysts of the liver. Rupture into the biliary tract is reported at a rate of 5–76% [1–3]. It can give rise to jaundice due to cholangitis, and common bile duct obstruction caused by hydatid membranes and daughter cysts. Ultrasonography (US), computed tomography (CT) and direct cholangiography performed through either endoscopic (ERC) or percutaneous (PTC) route are methods used in radiologic diagnosis [1, 3–5]. Surgery [1–3] and endoscopic sphincterotomy [6] are traditional treatment methods of cysto-biliary fistulas. However, surgical therapy is associated with considerable mortality, morbidity and recurrence rates and a longer hospital stay [1–3, 7]. Recent studies showed that endoscopic sphincterotomy is a safe, useful and effective therapy in cystobiliary fistulas [6]. Percutaneous catheter drainage of uncomplicated/unruptured hydatid cysts of the liver is well established [7–9]; however, there is only one case of percutaneous transbiliary internal drainage of ruptured cysts in the literature [10]. Here, we report a case of percutaneous transhepatic endobiliary drainage of hepatic hydatid cyst communicating with the neighboring dilated left hepatic ductal system. Instead of puncturing the cyst itself, we punctured the left hepatic duct and inserted an internal– external drainage catheter reaching the duodenum.
Correspondence to: M. Inal; email:
[email protected]
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M. Inal et al.: Percutaneous Drainage of Biliary Hydatid Cyst
Fig. 1. Contrast-enhanced CT scan of the liver shows a hydatid cyst adjacent to the dilated left hepatic duct, suggesting rupture into the biliary system. Fig. 2. Percutaneous transhepatic cholangiography performed through the left lobe shows dilation of the left hepatic duct and extrahepatic bile ducts. Band-like filling defects leading to obstruction in the distal part of the common bile duct are seen. Fig. 3. Percutaneous biliary internal-external drainage through the left hepatic duct. Fig. 4. seen.
Communication of the cyst with the left hepatic duct is
Fig. 5. Follow-up CT scan 1 year after the percutaneous drainage is completely normal.
had completely disappeared and the bile ducts were completely normal on CT done at 12 months (Fig. 5) and US examination done at 18, 24 and 30 months.
Discussion Hydatid disease caused by Echinococcus granulosus is endemic and a common problem in Mediterranean countries, the Middle East, New Zealand, Australia and South America [7, 9]. Although
it is usually asymptomatic, the most common and serious complication is rupture into the biliary tract causing a hydatid cyst– biliary fistula [1, 3, 4]. When rupture into the biliary tract occurs, the cyst fluid escapes into the biliary tract with daughter cysts discharged into the common bile duct, causing biliary colic, obstructive jaundice and possibly liver abscess [1, 3, 4]. Although the diagnosis of hepatic hydatid disease is easily made with US, CT or MRI, PTC and ERC prove to be the most informative diagnostic methods in
M. Inal et al.: Percutaneous Drainage of Biliary Hydatid Cyst
cases of rupture of the hydatid cyst into the biliary tract (biliary hydatid disease) with the development of obstructive jaundice [1, 3–5]. For acute obstructive and suppurative cholangitis, drainage of purulent bile and daughter cysts and management of the infected hydatid cyst are indicated. The conventional treatment of hydatid disease, whether hepatic or biliary, is surgery [1–3]. Various surgical procedures have been used in the treatment of hepatic and biliary hydatid disease [2, 3]. Surgical therapy is associated with considerable mortality, morbidity and recurrence rates [1–3, 7]. The results of medical treatment are still controversial [9]. Percutaneous catheter drainage of uncomplicated/unruptured hydatid cysts of the liver is well established in recent studies [7–9]; however we found only one case of percutaneous transbiliary internal drainage of ruptured cysts in the literature [10] in which hilar obstruction was relieved with bilateral percutaneous biliary drainage. Reported studies show that almost all cases of cysto-biliary communications are treated either surgically or endoscopically [1–3, 6]. Our case is the second report of percutaneous transbiliary internal drainage of hydatid cyst with rupture into the biliary duct in which the puncture and drainage was not performed through the cyst cavity. Biliary obstruction was successfully relieved, and the cyst was drained as well. Percutaneous intervention was chosen because endoscopic cannulation for sphincterotomy failed. It is well known that cysts with complex morphologic appearances containing undrainable components (type V and some of type IV lesions according to the Gharbi classification) are not suitable for percutaneous treatment [7–9]. The lesion in our patient was classified as type IV containing a minimal fluid component and communicated with the biliary tract, both of which are unsuitable conditions for percutaneous cyst aspiration or drainage. The cyst would not have been drained successfully by direct puncture because of its solid contents; therefore, the transductal route for drainage was preferred. If the cyst had been directly punctured and drained, further ductal puncture and drainage would have been obligatory to relieve the biliary obstruction. It seemed reasonable that a dilated left hepatic duct puncture and insertion of a catheter reaching into the duodenum would drain both the biliary ducts and the communicating cyst cavity. Because the left main hepatic duct was targeted as the entry site, the epigastric approach was obligatory in our case. This procedure was done under US guidance on the angiography table and the
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internal-external catheter was safely inserted with no complications. After catheter insertion, no spillage of contrast material was seen on transcatheter cholangiography. Repeated transcatheter saline injections and aspirations helped remove the solid cyst contents either externally or internally into the duodenum. US, CT-cholangiography and repeated cholangiograms were obtained easily through the initially inserted catheter, which helped us confirm the effectiveness of the procedure. Although large series are needed for making a definitive comment on this treatment route for biliary hydatid cysts, encouraged by the excellent result in our case we believe that percutaneous transhepatic endobiliary drainage (plus albendazole therapy) may be considered as one of the options for biliary hydatid disease treatment, especially in those cases where the endoscopic route is not available. References 1. Kornaros SE, Aboul-Nour TA. (1996) Frank intrabiliary rupture of hydatid hepatic cyst: diagnosis and treatment. J Am Coll Surg 183: 466 – 470 2. Aktan AO, Yalin R, Yegen C, Okboy N (1993) Surgical treatment of hepatic hydatid cysts. Acta Chir Belg 93:151–153 3. Paksoy M, Karahasanoglu T, Carkman S, Giray S, Senturk H, Özcelik F, Ergüney S (1998) Rupture of the hydatid disease of the liver into the biliary tracts. Dig Surg 15:25–29 4. Marti-Bonmati L, Menor F, Ballesta A (1988) Hydatid cyst of the liver: Rupture into the biliary tree. AJR Am J Roentgenol 150:1051–1053 5. Farrely C, Lawrie BW (1982) Diagnosis of intrabiliary rupture of hydatid cyst of the liver by fine-needle percutaneous transhepatic cholangiography. Br J Radiol 55:372–374 6. Rodriguez AN, Sanchez del Rio AL, Alguacil LV, De Dios Vega JF, Fugarolas GM (1998) Effectiveness of endoscopic sphincterotomy in complicated hepatic hydatid disease. Gastrointest Endosc 48:593–597 7. Khuroo MS, Wani NA, Javid G, Khan BA, Yattoo GN, Shah AH, Jeelani SG (1997) Percutaneous drainage compared with surgery for hepatic hydatid cysts. N Engl J Med 337:881– 887 8. Akhan O, Özmen MN (1999) Percutaneous treatment of liver hydatid cysts. Eur J Radiol 32:76 – 85 9. Üstünsöz B, Akhan O, Kamilog˘ lu MA, Somuncu I, Ug˘ urel MS¸ , Çetiner S (1999) Percutaneous treatment of hydatid cysts of the liver: Longterm results. AJR Am J Roentgenol 172:91–96 10. Savader SJ, Trerotola SO, Osterman FA, Lund GB, Venbrux AC (1993) Bilateral percutaneous biliary drainage in a patient with hilar biliary obstruction and multifocal hydatid liver disease. J Vasc Interv Radiol 4:611– 615 11. Gharbi HA, Hassine W, Brauner MW, Dupuch K (1981) Ultrasound examination of the hydatid liver. Radiology 139:459 – 463
