Complicated hepatic hydatid cyst with simultaneous biliary tree and intraperitoneal rupture: can we treat it in a minimally invasive way?
An 87-year-old woman, with senile dementia, diabetes mellitus, hypertensive diastolic heart failure and chronic renal disease presented at the Accident and Emergency Department with jaundice (total bilirubin 15.8 mg/dL, direct 12.4 mg/dL), significant bile duct dilatation at ECHO examination and obstructing cholangitis. Since 1987, when she has had an open cholecystectomy for symptomatic cholecystolithiasis, she was known to have three calcified asymptomatic hydatid cysts. One cyst was located at the spleen and another at the left liver lobe, both heavily calcified. The third one, that was barely calcified radiologically, was at the periphery of the right liver lobe, about 45-50mm in diameter. An ERCP performed the next day visualized at least five round bile duct contents (), which proved to be, after sphincterotomy and debriment of the bile duct, hydatid cyst remnants. A 10F plastic stent was inserted and broad spectrum antibiotics were initiated. Bilirubin level dropped to a total of 5.31 mg/dL (direct 4.95 mg/dL) on day 3 of admission.\nOn the third day of hospitalization, the patient developed dyspnea, tachypnea and clinical signs of right pleural effusion and ascitic fluid. An emergency CT scan of the thorax and abdomen was performed that revealed a large right pleural effusion with atelectasis (which proved to be reactive after laboratory analysis), a small left effusion and a large diffuse peritoneal effusion around the liver and down to the pelvis. Air was present inside the right hepatic lobe hydatid cyst, consistent with a biliary tree communication and the antecedent sphincterotomy (). The CT scan suggested a simultaneous free intraperitoneal cyst rupture. Due to the concomitant biliary tree communication, not only hydatid cysts and remnants, but also bile leak, was probably the cause of patient’s large effusions.\nAfter thorough discussion with the patient’s family and considering her poor general status and possible technical difficulties, a minimal invasive approach was selected. After a second ERCP that removed the plastic stent and another debridement that confirmed an efficient sphincterotomy and a clear duct, a subdiaphragmatic drainage was placed radiologically. Albendazole at a dose of 15 mg/kg/day was initiated.\nPeritoneal fluid drainage gradually fell from 300 cc to about 50 cc/day over a two-week period. X-ray chest film showed a complete resolution of the pleural effusions () and CT scan revealed the absence of ascites (). After 3 months of albendazole, the drainage tube was extracted and patient remained both clinically and radiologically improved at the first monthly scheduled follow-up.