*Corresponding author: Swamy P T, Resident doctor, Department of General Surgery, PDU Medical College and Hospital, Rajkot, Gujrat, India
How to cite this article: Swamy P T, Jayendra V, Jatin G B, Shailesh G. Liver Hydatid Cyst with Rupture into Extrahepatic Right Hepatic Duct presenting
as Obstructive Jaundice: A Case Report. Adv Res Gastroentero Hepatol, 2021; 18(2): 555982.
Introduction: Cystic hydatid disease is most commonly seen in liver, and it is associated with its own set of complications. Intrabiliary rupture of hydatid cyst is one of the common complications of liver hydatid disease which usually presents with jaundice. Here we bring to light a case of 62-year-old male patient of liver hydatid cyst disease having cyst rupture into extrahepatic right hepatic duct presenting as obstructive jaundice.
Hydatid disease or echinococcosis is a zoonotic disease caused by tapeworm called echinococcus granuloses, with human being dead end host. It usually effects liver followed by lung, spleen, kidney, bone and the brain . Liver hydatid disease is usually accompanied by complications like disseminated disease, severe anaphylactic disease, rupture into biliary tree or into peritoneum or into thorax depending on the location of the cyst and infection of the cyst lead to liver abscess. Treatment is advised for all the patients who are symptomatic and whose cyst are in risk of rupture or other complication.
A 62-year-old male patient farmer by occupation presented to outpatient department of Department of General Surgery with complaints of abdominal pain for 1 month, weight loss in the last 1 month, fever in the past 10 days and non-bilious vomiting for 2 days. There was no history of breathlessness, changes in bowel habits. Patient is a non-diabetic, non-hypertensive with no positive medical or surgical history. On physical examination icterus (greenish yellow colour) was observed. There was mild
tenderness over right hypochondrium with no palpable lump or organomegaly. Laboratory findings revealed increased total count (16,700 cells/cumm), raised total bilirubin (6.5 mg/dl) and direct bilirubin (5.2 mg/dl) suggesting obstructive type of jaundice, with elevated serum Alkaline phosphatase (631IU/L) and serum Alanine Aminotransferase (78 IU/L). All other blood investigations were normal. The ultrasound of abdomen showed large liver hydatid cyst with dilated Common Hepatic Duct with echogenic material within CBD lumen. CECT Abdomen suggested evidence of peripherally enhancing cystic lesion with internal daughter cysts involving subcapsular location of segment 7 of liver with patchy peripheral calcification and lesion was superiorly indenting into diaphragm and basal lung and compressing IVC & right atrium. Lesion measured 7.7*12.5*8.1 cm (AP*TR*CC) (Figure 1), with Similar lesion of size 4.4*4.4*3.9 cm (AP*TR*CC) located in segment 6 of liver. This lesion was causing compression over confluence of right and left hepatic duct with subsequent dilatation of bilobar IHBR (R>L), with focal defect in inferior wall of cyst with possible communication with right hepatic duct was seen (Figure 2). CHD (11mm) and CBD (15mm) are dilated upto lower end s/o distal CBD stricture. MRCP was done as CECT was inconclusive, it showed Two complex cystic area in right lobe of liver with communication between them as well as
communication between lower cyst and right hepatic duct with
presence of parasitic contains in biliary tree and moderate to
severe asymmetric dilatation of biliary tree with benign distal
CBD stricture with CBD diameter of 16mm. Patient was taken
for open Deroofing of liver hydatid cyst with external drainage
with cholecystectomy with choledochoduodenostomy in Right
lateral decubitus position with right thoracoabdominal incision.
On exploration bulge was seen posterior aspect of liver, hydatid
cyst was confirmed by aspiration, Hydatid cyst deroofing done
with drainage of 700cc fluid with debris. Cholecystectomy was
done followed by location of CBD. A 2cm long longitudinal incision kept over CBD and cystic content were removed (Figure 3). Cystic
wall was opening into Right Hepatic Duct just above confluence
which was closed with PDS 3-0. Infant Feeding Tube passed from
CBD through to hydatid cyst wall (Figure 4), 2 major Cystobiliary
communication in medial wall of cyst were noted and closed with
prolene 2-0. First part of duodenum located 2.5cm longitudinal
incision kept choledochoduodenostomy performed with PDS
3-0. Omentopexy done into cyst cavity and drain was kept in
cyst cavity, Cyst wall approximated with PDS 3-0. Post operative
period was uneventful. Patient started orally on 2nd postoperative
day with removal of Intercoastal drain. Patient discharged on post
operative day 6 with normal laboratory reports.
Liver is the most obvious first site for hydatid cyst
development, after organism enters bloodstream and passes into
portal circulation. Hydatid cyst may present with various signs
and symptoms depending on site of cyst location, most commonly
in right lobe of the liver. Patient may complain from generalized upper abdominal pain or fever, jaundice due to cholangitis or
intrabiliary rupture of cyst. Complications of hydatid cyst of the
liver ranges upto 40%  of cases, most common complications
include superadded infection of hydatid cyst, followed by
intrabiliary rupture of hydatid cyst either in the form of occult
rupture or frank rupture. In case of occult rupture, cyst fluid
drains into biliary tree and in frank rupture there will be a overt passage of intracystic material into biliary tract. Incidence of
intrabiliary rupture ranges from 3 to 17% [3,4]. The intrabiliary
rupture of hydatid cyst leads to biliary complications such as
cholangitis, hydatid biliary lithiasis or even obstructive jaundice.
Diagnosis of intrabiliary rupture can be made with CECT or MRCP.
The presence of dilated CBD, jaundice with cystic lesion of liver.
Other complication of hydatid cyst includes intrathoracic and
intraperitoneal rupture. Some complications of the hydatid cyst
of liver are very rare such as fistulisation of skin , can lead to
portal hypertension either pre-hepatic, hepatic or post-hepatic,
and in some cases may lead to vascular erosions. Diagnosing
hydatid cyst of liver is very tricky, most of the cases goes unnoticed
and some are incidentally noticed during investigation for other
pathologies. Patients in some cases presents with complication
of cyst. Surgery remains gold standard for management of liver
hydatid cyst disease, aim of surgery is to inactivate the parasites in
cyst and completely evacuate it, keeping in mind to avoid spillage,
managing any Cystobiliary communications.
Endoscopic management is used commonly in intrabiliary
rupture in the form of ERCP, it is used to clear out intrabiliary
residual hydatid material . In our case due to presence of large
hydatid cyst an open approach was opted with thoracoabdominal
incision, with clearance of biliary trunk from the residual
hydatid material, Cystobiliary connections were closed with
choledochoduodenostomy as CBD was dilated (15mm).
Intrabiliary rupture of liver hydatid cyst is one of the common
complications, these intrabiliary ruptures occur in intrahepatic
biliary radicles, sometimes cyst may rupture into extrahepatic
biliary radicles. Prompt diagnosis and management is required
for any intrabiliary rupture, but management varies from patient
to patient and final judgment must always be made by taking into
consideration of all imaging studies available.