Br. J. Surg. Vol. 65 (1978) 107-108
Endoscopic retrograde cholangiography in hepatic hydatid disease M . C O T T O N E , M . A M U S O A N D P. B . C O T T O N * SUMMARY
Endoscopic retrograde cholangiography provides safe preoperative documentation of the relationship of hepatic hydatid cysts to the biliary ductal system and accurate distinction from coincident calculus disease. RUPTURE of hepatic hydatid cysts into the biliary tree may occur in 5-10 per cent of cases with hepatic involvement (Macris and Galanis, 1966; Levy, 1970; Lofti and Hashemian, 1973; Lewis et al., 1975). Until recently, diagnosis of such a complication was made only at laparotomy. Endoscopic cannulation of the papilla of Vater allows retrograde cholangiography and pancreatography (ERCP), a technique which distinguishes important indications in patients with biliary tract problems (Cotton, 1977). This report illustrates the effectiveness of ERCP in patients with involvement of the biliary tract by hydatid cyst disease. Case reports Case 1 : A 61-year-old Sicilian man was admitted to hospital with recurrent episodes of pain, jaundice and fever. A plain abdominal radiograph demonstrated a calcified cyst in the right hypochondrium. An isotopic liver Scan was normal. The Serum alkaline phosphatase level was raised and a Casoni intradermal reaction was positive. ERCP demonstrated a normal common bile duct but considerable dilatation of both the right and left intrahepatic ducts, with radiolucent filling defects. Further injection of contrast medium demonstrated the cyst directly (Fig. 1). These findings were confirmed at surgery. Case 2: A 45-year-old Greek man was investigated for episodes of right hypochondria1 pain occurring 5 years after cholecystectomy and removal of a subhepatic hydatid cyst. Intravenous cholangiography gave normal results, but retrograde cholangiography demonstrated a daughter cyst within the cystic duct remnant (Fig. 2). These appearances were confirmed at subsequent laparotomy. Case 3: A 30-year-old Libyan man was investigated after suffering right-sided abdominal pains and intermittent jaundice for 4 years. Three years previously a hydatid cyst had been removed from the right side of the liver. An isotopic liver scan showed distortion of both hepatic lobes, but no focal cyst. At endoscopic cholangiography (Fig. 3 ) contrast medium entering the left intrahepatic duct system filled directly into a cavity. Further injection and posturing outlined its full extent (Fig. 4). The patient underwent left hemihepatectomy with a good result. Case 4: A 62-year-old Sicilian man presented with recurrent pain and jaundice. A plain abdominal radiograph was negative, an isotopic liver scan showed a filling defect at the hilum of the liver and a Casoni intradermal reaction was negative. Retrograde cholangiography demonstrated the common bile duct and gallbladder and a complete obstruction of the common hepatic duct. At laparotomy there was a hydatid cyst at the hilum of the liver, opening into the common bile duct. The common hepatic duct was obstructed by daughter cysts.
Discussion Rupture of hepatic hydatid cysts into the biliarY tract provides a clinical picture identical to that of choledocholithiasis (Atlas and Kamenerr, 1952). In areas
Fig. 1. ERCP in Case 1. The right intrahepatic ducts are dilated and contain filling defects. The cyst (arrowed) communicates directly with the left intrahepatic duct.
Fig. 2. ERCP in Case 2. A daughter cyst in the cystic duct remnant (arrowed) following previous cholecystectomy.
* M. Cottone and M. Amuso, Ospedale V. Cervello, Division of Medicine, Palermo, Sicily. P. B. Cotton, Middlesex Hospital, London. Correspondence to: P. B. Cotton.
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Fig. 4. Case 3 . Th e full extent of the cyst is now outlined following further injection of contrast medium and posturing of the patient after removal of the endoscope. Fig. 3. ERCP in Case 3 . A cyst cavity beginning to fill from the left intrahepatic duct.
References and KAMENERR H. (1952) Rupture of echinococcal cysts into the bile duct simulating stones in common duct. Am. J . Med. 13, 384-386. COTTON P. B. (1977) Progress report: ERCP. Gut 18, 3 16-341. ELIAS E. (1976) Progress report: cholangiography in the jaundiced patient. Gut 17, 801-811. LEVY M. (1970) Recurrent cholangitis caused by echinococcosis of the biliary passages. Israel J . Med. 6, 388-394. LEWIS J. w . , KOSS N. and KERSTEIN M. D. (1975) A review of echinococcal disease. Surgery 181, 390-396. LOFTI M. and HASHEMIAN H. (1973) Hydatid cyst disease of the liver and its treatment. Znt. Surg. 58, 166-169. MACRIS G. J. and GALANIS N . N. (1966) Rupture of the echinococcus cyst of the liver into the hiliary ducts. Am. Surg. 32, 36-44. ATLAS D. H .
where hydatid disease is endemic, preoperative differential diagnosis from calculus disease is important, because of the differing surgical approach. Plain radiology, Casoni tests, eosinophilia and hepatic scanning may all help in making a diagnosis of a hydatid cyst, but demonstration of its relationship to the duct system requires high quality cholangiography. Intravenous studies rarely provide adequate definition, even in the absence of jaundice (Case 2), and transhepatic cholangiography (Elias, 1976) is contraindicated when hydatid disease is suspected, ERCP provides a safe and accurate preoperative assessment.
Paper accepted 17.8.1977.
Endoscopic retrograde cholangiography in hepatic hydatid disease M . C O T T O N E , M . A M U S O A N D P. B . C O T T O N * SUMMARY
Endoscopic retrograde cholangiography provides safe preoperative documentation of the relationship of hepatic hydatid cysts to the biliary ductal system and accurate distinction from coincident calculus disease. RUPTURE of hepatic hydatid cysts into the biliary tree may occur in 5-10 per cent of cases with hepatic involvement (Macris and Galanis, 1966; Levy, 1970; Lofti and Hashemian, 1973; Lewis et al., 1975). Until recently, diagnosis of such a complication was made only at laparotomy. Endoscopic cannulation of the papilla of Vater allows retrograde cholangiography and pancreatography (ERCP), a technique which distinguishes important indications in patients with biliary tract problems (Cotton, 1977). This report illustrates the effectiveness of ERCP in patients with involvement of the biliary tract by hydatid cyst disease. Case reports Case 1 : A 61-year-old Sicilian man was admitted to hospital with recurrent episodes of pain, jaundice and fever. A plain abdominal radiograph demonstrated a calcified cyst in the right hypochondrium. An isotopic liver Scan was normal. The Serum alkaline phosphatase level was raised and a Casoni intradermal reaction was positive. ERCP demonstrated a normal common bile duct but considerable dilatation of both the right and left intrahepatic ducts, with radiolucent filling defects. Further injection of contrast medium demonstrated the cyst directly (Fig. 1). These findings were confirmed at surgery. Case 2: A 45-year-old Greek man was investigated for episodes of right hypochondria1 pain occurring 5 years after cholecystectomy and removal of a subhepatic hydatid cyst. Intravenous cholangiography gave normal results, but retrograde cholangiography demonstrated a daughter cyst within the cystic duct remnant (Fig. 2). These appearances were confirmed at subsequent laparotomy. Case 3: A 30-year-old Libyan man was investigated after suffering right-sided abdominal pains and intermittent jaundice for 4 years. Three years previously a hydatid cyst had been removed from the right side of the liver. An isotopic liver scan showed distortion of both hepatic lobes, but no focal cyst. At endoscopic cholangiography (Fig. 3 ) contrast medium entering the left intrahepatic duct system filled directly into a cavity. Further injection and posturing outlined its full extent (Fig. 4). The patient underwent left hemihepatectomy with a good result. Case 4: A 62-year-old Sicilian man presented with recurrent pain and jaundice. A plain abdominal radiograph was negative, an isotopic liver scan showed a filling defect at the hilum of the liver and a Casoni intradermal reaction was negative. Retrograde cholangiography demonstrated the common bile duct and gallbladder and a complete obstruction of the common hepatic duct. At laparotomy there was a hydatid cyst at the hilum of the liver, opening into the common bile duct. The common hepatic duct was obstructed by daughter cysts.
Discussion Rupture of hepatic hydatid cysts into the biliarY tract provides a clinical picture identical to that of choledocholithiasis (Atlas and Kamenerr, 1952). In areas
Fig. 1. ERCP in Case 1. The right intrahepatic ducts are dilated and contain filling defects. The cyst (arrowed) communicates directly with the left intrahepatic duct.
Fig. 2. ERCP in Case 2. A daughter cyst in the cystic duct remnant (arrowed) following previous cholecystectomy.
* M. Cottone and M. Amuso, Ospedale V. Cervello, Division of Medicine, Palermo, Sicily. P. B. Cotton, Middlesex Hospital, London. Correspondence to: P. B. Cotton.
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Fig. 4. Case 3 . Th e full extent of the cyst is now outlined following further injection of contrast medium and posturing of the patient after removal of the endoscope. Fig. 3. ERCP in Case 3 . A cyst cavity beginning to fill from the left intrahepatic duct.
References and KAMENERR H. (1952) Rupture of echinococcal cysts into the bile duct simulating stones in common duct. Am. J . Med. 13, 384-386. COTTON P. B. (1977) Progress report: ERCP. Gut 18, 3 16-341. ELIAS E. (1976) Progress report: cholangiography in the jaundiced patient. Gut 17, 801-811. LEVY M. (1970) Recurrent cholangitis caused by echinococcosis of the biliary passages. Israel J . Med. 6, 388-394. LEWIS J. w . , KOSS N. and KERSTEIN M. D. (1975) A review of echinococcal disease. Surgery 181, 390-396. LOFTI M. and HASHEMIAN H. (1973) Hydatid cyst disease of the liver and its treatment. Znt. Surg. 58, 166-169. MACRIS G. J. and GALANIS N . N. (1966) Rupture of the echinococcus cyst of the liver into the hiliary ducts. Am. Surg. 32, 36-44. ATLAS D. H .
where hydatid disease is endemic, preoperative differential diagnosis from calculus disease is important, because of the differing surgical approach. Plain radiology, Casoni tests, eosinophilia and hepatic scanning may all help in making a diagnosis of a hydatid cyst, but demonstration of its relationship to the duct system requires high quality cholangiography. Intravenous studies rarely provide adequate definition, even in the absence of jaundice (Case 2), and transhepatic cholangiography (Elias, 1976) is contraindicated when hydatid disease is suspected, ERCP provides a safe and accurate preoperative assessment.
Paper accepted 17.8.1977.
