Rupture of a hepatic echinococcal cyst into the bile ducts and gallbladder: a clinical case

U. O. Abidov; Абидов У. О.; Sh. T. Urakov; Ураков Ш. Т.; M. M. Abdurakhmanov; Абдурахманов М. М.; N. D. Sultonzoda; Султонзода Н. Д.; I. U. Obidov; Обидов И. У.

doi:10.17816/pmj422138-145

Rupture of a hepatic echinococcal cyst into the bile ducts and gallbladder: a clinical case

Authors: Abidov U.O.¹, Urakov S.T.¹, Abdurakhmanov M.M.¹, Sultonzoda N.D.¹, Obidov I.U.¹
Affiliations:
1. Bukhara State Medical Institute named after Abu Ali ibn Sino
Issue: Vol 42, No 2 (2025)
Pages: 138-145
Section: Clinical case
Submitted: 19.03.2025
Published: 27.05.2025
URL: https://permmedjournal.ru/PMJ/article/view/677316
DOI: https://doi.org/10.17816/pmj422138-145
ID: 677316

Cite item

Full Text

Abstract
Full Text
About the authors
References
Supplementary files
Statistics

Abstract

A clinical case of liver echinococcosis complicated by cyst rupture into the bile ducts and gallbladder is presented. It is a rare but serious condition which requires emergency medical care.

Liver echinococcosis is a serious medical problem, especially in endemic regions. Complications of the disease, such as cyst rupture into the bile ducts with the development of obstructive jaundice, aggravate the clinical course of the disease significantly, leading to cholangitis, hepatic abscesses and liver failure. It is a clinical case of a 36-year-old patient with an echinococcal hepatic cyst that ruptured into the biliary tree, which led to the development of obstructive jaundice and cholangitis. Diagnostic methods, including ultrasound, magnetic resonance imaging and endoscopic retrograde cholangiopancreatography are described, as well as the successful use of endoscopic papillosphincterotomy and choledochotomy with the removal of parasite elements and drainage of the biliary tract.

Keywords

Hepatic echinococcosis, cyst rupture, bile ducts, gallbladder, obstructive jaundice, cholangitis, choledochotomy, endoscopic papillosphincterotomy

Full Text

Introduction

The first case of the rapture of a hepatic echinococcal cyst into the bile ducts and gallbladder is found in medical literature from the late 19th – early 20th centuries, when doctors began to pay closer attention to the clinical manifestations of parasitic hepatic diseases. One of the key sources that mentions early descriptions of parasitic diseases is the work of the French surgeon Dominique-Jean Larrey, who was one of the first to study parasitic hepatic diseases.

The 19th century medical treatise Traité de Chirurgie describes cases of hepatic echinococcosis and its complications. That time, the diagnosis of echinococcosis was limited and surgical interventions were the main treatment, often without a clear understanding of the causes of complications. It became possible to identify and describe such cases more accurately only with the development of X-ray methods and, later, ultrasound diagnostics.

Echinococcosis is a natural focal zoonotic disease caused by tapeworms of the genus Echinococcus. The most common forms are cystic echinococcosis, caused by Echinococcus granulosus, which is spread in endemic regions throughout the world, including Central and Middle Asia, Russia, Southern Europe, Turkey, South America, Africa and Australia. The spread of the disease beyond endemic zones is associated with population migration and increased tourist activity. The liver is affected by Echinococcus granulosus invasion in 65–80 % of cases [1–8].

Rapture of elements of a hepatic echinococcal cyst into the bile ducts is one of the most severe complications of the disease, second in frequency only to cyst suppuration; it occurs in 3.7–7.9 % of patients [4; 5; 8–13]. The main problem in treating patients with this pathology is that they are taken into the hospital already at the stage of hepatic failure development caused by mechanical obstruction and hypertension of the bile ducts. This condition significantly worsens the prognosis, increases the likelihood of complications after surgery, the risk of disease recurrence and prolongs the recovery period.

A growing cyst can lead to atrophy and fibrosis of the hepatic tissue [9; 11]. Compression and displacement of the bile ducts can often contribute to spontaneous rupture of the bile ducts. Timely detection and treatment are mandatory in the case of intrabilliary rupture of a hepatic echinococcal cyst, which can lead to obstruction of the bile ducts with a 50 % mortality rate [10; 11; 14–16].

Protoscolexes and microacephalocysts are able to take root after the rupture, entering the tissue after surgery or rupture of the cyst [8; 10].

Imaging tools such as medical ultrasound (U/S), abdominal computed tomography (CT), magnetic resonance cholangiopancreatography (MRCP) and endoscopic retrograde cholangiopancreatography (ERCP) are important diagnostic methods for the disease. U/S and CT are primarily used in such situations [7], ERCP can help in the final diagnosis as well as in the treatment of patients with rupture of the echinococcal cyst into the biliary ducts, and MRCP can determine the site of obstruction of the bile-excreting system [8; 14; 17].

A description of a clinical case of hepatic echinococcosis with a complication in the form of a cyst rapture into the bile ducts and gallbladder is given bellow.

Clinical Case

Patient B., born in 1991, was admitted on 12.02.2024 with complaints of pain in the right half of the abdomen, hyperthermia, vomiting, bile-tinged skin, acholic stool, change in urine color and poor appetite.

Anamnesis morbi: the patient had acute pain in the right hypochondrium three days before hospitalization. The next day, urine became dark and the yellowness of the sclera appeared. The patient turned to the Bukhara Regional Infectious Hospital, from where he was sent to the Bukhara branch of the Republican Scientific Center for Emergency Medical Assistance after the examination.

Anamnesis vitae: he lives in a rural area, has contacts with pets, which could contribute to infection with echinococcosis. The patient did not have hepatic or bile ducts diseases in anamnesis.

The patient’s condition is evaluated as moderately sever. Patient’s orientation in the environment is normal. Yellowing coloring of the skin and sclera is noted. Arterial blood pressure is 120/80 mm HG, body temperature is 38.8°C. Pain in the right half of the abdomen is determined on palpation. Symptoms of peritoneal irritation are negative.

Ultrasound of the abdominal organs: a large solitary cyst with a hyperechogenic wall, 15×10 cm in sizes, is found containing numerous internal partitions and proliferation cyst.

There is an expansion of intrahepatic and extrahepatic bile ducts, which indicates obstruction. The gallbladder is expanded, the thickness of the walls of the gallbladder is 4 mm. Scraps of the chitin coat are visible in the lumen of the gallbladder.

MRI with cholangiography: foreign tissue lesion is revealed in the right lobe of the liver with a size of 15×10 cm with clear contours and even edges, which has a heterogeneous structure due to the presence of many rounded inclusions cysts. The rapture of the hepatic cyst into the bile ducts and the gall bladder with the obstruction of the choledochous duct was revealed.

Blood test: hemoglobin – 127·10⁹/l; red blood cells – 4.15 · 10⁹/l; color indicator – 0.9 · 10⁹/l; white blood cells – 5.2 · 10⁹/l; Eosinophils – 3 %; monocytes – 3 %, fibrinogen – 3.9 g/l; total protein – 60 g/l; glucose – 4.7 mmol/l; urea – 6.0 mmol/l; general bilirubin – 83 mmol/l.

A diagnosis was established on the bases of the given data: echinococcosis of the right liver lobe. Rapture of an echinococcal cyst into the bile ducts and gallbladder.

The Endoscopic Retrograde Pancreatic Cholangiography (ERCP) was made to the patient on February 13, 2024 aimed at establishment of the diagnosis and decompression of the bile ducts. Papillosphincterotomy was performed by endoscopic method; cannulation of the choledochous duct was made using a special catheter, after which a contrasting substance was introduced for conducting cholangiography (Fig. 1).

Fig. 1. ERCP and an intraduodenal picture of the bile ducts after papillotomy with the extraction of the chitin coating

An expansion of the choledochous duct up to 25 mm with the fluid in the lumen of hyperechoic areas in the middle and distal segments was found in the image of the X-Ray TV Unit monitor.

Hydatid sand, fragments of coating and elements of cyst were removed from the choledochous duct using special tools, baskets and cylinders. The bile ducts were thoroughly washed with physiological solution and germicides in order to maximize the removal of fragments and the contents of the echinococcal cyst, as well as the prevention of the development and progression of cholangitis. Then, a catheter was installed in a choledochous duct for ablution through the papillosphincterotomy wound to administrate the necessary antimicrobial agents.

On February 23, 2024 a radical operation was performed after the appropriate preparation of the patient, elimination of liver failure manifestations and obstructive jaundice, loss of the general inflammatory response of the body and after consultation of an anesthesiologist: supramedian laparotomy, echinococcectomy of the right lobe of liver, cholecystectomy from the fundus of gallbladder, choledochotomy. Drainage of the residual cavity of the cyst and the right subhepatic space was made.

The course of the operation: supramedian laparotomy up to 18 cm was performed. A section of the fibrous membrane of the echinococcal cyst spreading to falciform ligament was detected on the visceral surface of the IV liver segment. Partial pericystectomy was made, closure of the section of rupture of the cyst into the gallbladder was made. Partial capitonnage and drainage of the residual cavity was made.

The choledochous duct is dilated to 25 mm. A cholecystectomy is performed from the fundus of the gallbladder, the gallbladder duct is 10 mm in diameter. The choledochous duct is opened with a linear longitudinal incision 10 mm long below the level of the origin of the gallbladder duct. The elements of the echinococcal cyst and turbid bile are removed from the choledochous duct (Fig. 2). External drainage of the choledochous duct according to Kehr, closure of the choledochotomy wound, drainage of the subhepatic space and closure of the laparotomy wound were performed.

Fig. 2. Extracted gallbladder and the cyst fluid, after rapture into the bile ducts and gallbladder (a–c); according to the ultrasound examination in the cavity of the gallbladder, chitin and echinococcal fluid (b); partial precystectomy and bile fistula (d)

The postoperative period was uneventful, obstructive jaundice and inflammatory manifestations gradually regressed, and the patient was discharged for outpatient observation on the 8th day after the operation.

Results and Discussion

Rupture of an echinococcal cyst into the bile ducts and gallbladder at the same time is a rare and serious complication of hepatic echinococcosis. The main diagnostic methods that allow good visualization of the gall bladder and bile ducts are ultrasound, MRI and ERCP, which make it possible to determine accurately the location of the perforation and the functional state of the gallbladder and bile ducts.

Currently, endoscopic treatment methods such as ERCP have significantly changed the approach to the treatment of patients with ruptured hepatic echinococcal cyst into the choledochous duct. The advantages of transpapillary endoscopic intervention are minimal invasiveness and the ability to prepare the patient for the second radical method of echinococcectomy and cholecystectomy, as demonstrated in the presented case. ERCP also allows making more accurate diagnosis of the localization of the echinococcal cyst itself and the site of rapture into the bile ducts and the sanitation of the biliary tree, thereby reducing the manifestations of the inflammatory process and creating conditions for the main stage of the operation. An important aspect of surgical interventions is the use of germicidal agents administered transpapillary through an endoscopically installed catheter into the lumen of the choledochous duct in order to prevent recurrence of the underlying disease.