Self-Drainage of Large Hydatid Cyst: Reducing the Necessity for Surgical Intervention

An 82-year-old female patient underwent emergency endoscopic retrograde cholangiopancreatography (ERCP) with common bile duct (CBD) stenting (7 Fr × 7 cm) 2 years ago for acute severe cholangitis secondary to cholelithiasis and choledocholithiasis (multiple calculi). At that time, magnetic resonance cholangiopancreatography also revealed a large hydatid cyst with defined daughter cysts (∼8.5 × 7.4 × 8.7 cm in size, World Health Organization [WHO] stage CE3b) in the left lobe and a hemangioma in segment VI of the liver ([Fig. 1A]). Despite being advised to undergo a repeat ERCP for CBD clearance and surgery for gallstone and hydatid cyst the patient was lost to follow-up.

Fig. 1 (A) Coronal True Fast Imaging with Steady-State Free Precession (TRUFI) magnetic resonance imaging (MRI) image showing enlarged liver with choledocholithiasis with large hydatid cyst (arrow) in the left lobe of the liver (Gharbi stage 3), (B) endoscopic image showing fistulous opening (arrow) along the lesser curvature of the stomach, and (C and D) axial and coronal computed tomography images showing fistulous communication (arrow) between the left lobe of the liver and the stomach lumen along the lesser curvature.

She now presents with a 2-week history of epigastric pain, accompanied by nausea and occasional vomiting. On examination, her general physical condition and initial laboratory investigations were unremarkable. Esophagogastroduodenoscopy revealed a small fistulous opening along the lesser curvature near the gastric cardia ([Fig. 1B]). A computed tomography scan identified a fistulous tract extending from the left lobe of the liver to the gastric cardia, with evidence of oral contrast leakage into the tract ([Fig. 1C, D]). Additional findings included calcific foci in segments II and V, indicative of sequelae from a previous hydatid cyst (WHO stage CE5), as well as portal vein thrombosis extending into its branches. Cholelithiasis, choledocholithiasis, and a hepatic hemangioma were also noted, with no evidence of hydatid cyst dissemination into the chest, abdomen, or pelvis.

ERCP was performed under propofol sedation using a triple-lumen sphincterotome (CleverCut 3V, Olympus) and a guidewire (VisiGlide, Olympus, 0.025 inch), which was successfully advanced into the left intrahepatic duct. Cholangiography revealed a dilated CBD with multiple calculi, which were extracted using a triple-lumen extraction balloon (Multi-3V Plus, Olympus). A 7 Fr × 7 cm double pigtail stent was subsequently placed in the CBD. The patient was then referred to the surgical department for cholecystectomy.

Fistulization of the hydatid cyst in the gastrointestinal tract is extremely rare even in highly endemic countries and depends on the cyst location (inferior surface of the liver), infection (create adhesions), and close contact.[1] The presence of hydatid membranes in the stool (hydatidorrhea) or in the vomit (hydatidemesis) is highly suggestive of bowel fistulization.[2]

 

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Conflict of Interest

None declared.

Acknowledgments

None.

Informed Consent

Patient provided informed consent to publish the included information.

Ethical Statement

Not applicable.

Authors' Contributions

All authors contributed equally to the article.

Data Availability Statement

There is no data associated with this work.

• References

• 1 Onka B, Benmoula FZ, Traore WM. et al. A rare case: Spontaneous gastric fistula from a hydatid cyst of the liver. BJR Case Rep 2022; 7 (06) 20210087
• 2 Pedrosa I, Saíz A, Arrazola J, Ferreirós J, Pedrosa CS. Hydatid disease: radiologic and pathologic features and complications. Radiographics 2000; 20 (03) 795-817

Publication History

Received: 14 October 2024

Accepted: 02 February 2025

Article published online:
25 March 2025