Clinical Case Summary

18 years male presented with fever, abdominal pain and obstructive jaundice for one month. Examination showed icterus and diffuse hepatomegaly. Liver function showed conjugated hyperbilirubinemia, ultrasonography showed 9 cm size single cystic lesion in liver with floating membranes and dilated CBD (14 mm). Hydatid serology was suggestive. MRI abdomen with MRCP confirmed the same. ERCP showed grossly dilated bile duct with irregular filling defects and one large cavity opacified in liver. Endoscopic sphincterotomy was performed and CBD was cleared of membranes. Cystobiliary communication was dilated with biliary balloon (8mm). 10 F double pigtail biliary stent was placed in CBD which was removed after 4 weeks. He was treated with Piperacillin+Tazobactum for 10 days and Albendazole 400mg twice daily for 20 days (repeated twice at interval of 3 weeks). Patient improved rapidly. Follow up ultrasonography at 6 months showed resolution of liver lesion and normal CBD.
Discussion
Hepatic hydatid cyst with biliary rupture is traditionally treated surgically. Role of ERCP is limited to biliary drainage and treatment of cholangitis. Parasite dies on coming in direct contact with bile, thus hydatid cyst rarely if ever occur in biliary system. In the index patient, the cystobiliary communication was dilated to increase bile entry into the hepatic hydatid cyst. Cyst resolved without any surgery. Although this strategy was successful in the index patient, it may not be useful in patients with multiple cysts in liver.
Conclusion
Solitary hepatic hydatid with biliary rupture can be treated with ERCP and dilation of cystobiliary communication.

References

Dew, H., 1930. Some complications of hydatid disease. British Journal of Surgery, 18(70), pp.275-293.
El Malki, H., El Mejdoubi, Y., Souadka, A., Mohsine, R., Ifrine, L., Abouqal, R. and Belkouchi, A., 2010. Predictive model of biliocystic communication in liver hydatid cysts using classification and regression tree analysis. BMC Surgery, 10(1).

Introduction

Hepatic hydatid cyst (HHC) is a parasitic disease caused by the development of the tapeworm Echinococcus granulosus. Fistulization into the biliary tract is one of its most common complications. Endoscopic treatment is preferred due to the risks associated with surgery. This study aims to evaluate the role of endoscopic retrograde cholangiopancreatography (ERCP) in the diagnostic and therapeutic management of HHC ruptured into the biliary tract.

Aims & Methods

This is a retrospective, descriptive, and analytical study conducted from January 2002 to August 2021, including 50 patients with HHC fistulized into the biliary tract. All patients underwent ERCP combined with endoscopic biliary sphincterotomy. Overall success was defined as complete clearance of the main bile duct. Statistical analysis was performed using SPSS version 24.0.

Results

Among all ERCPs performed during the study period, 4.6% (n=50) were for a hepatic hydatid cyst communicating with the biliary tract. The mean age of patients was 46.1 ± 14.8 years, with a male predominance (66%; male-to-female ratio = 1.94).
ERCP was performed preoperatively in 52.2% of cases and postoperatively in 47.8%.
The main indications were acute cholangitis (44.9%) and persistent external biliary fistula (34%).
The median diameter of the common bile duct was 10 mm [7–14], and the median cyst diameter was 35 mm [27–47].
Sphincterotomy was performed in 96% of cases, allowing hydatid material extraction using a balloon or Dormia basket in 87.8% of cases. A nasobiliary drain was required in 24% of patients, and biliary stent placement was performed in 8%.
The overall success rate was 96% (n=46). Immediate complications occurred in 8% (n=4): one case of hemobilia and three cases of marginal bleeding.
Clinical improvement included jaundice resolution within 5 to 10 days and closure of the external biliary fistula within 10 days.

Conclusion

Our study confirms that endoscopic management of ruptured hepatic hydatid cysts into the biliary tract is an effective therapeutic alternative, with a low rate of immediate complications (8%) and favorable long-term outcomes.

Introduction

Endoscopic papillary large balloon dilatation (EPLBD) is an established technique for managing difficult common bile duct (CBD) stones. This study evaluates the efficacy and safety of EPLBD in a large cohort from a tertiary care centre.

Aims & Methods

Patients with difficult CBD stones (N = 559) who underwent EPLBD between January 2015 and December 2024 were retrospectively analysed from a prospectively maintained database. The primary outcome was complete CBD clearance. Secondary outcomes included complication rates, number of sessions required, and need for mechanical lithotripsy or surgical intervention. We also identified predictive factors for failed clearance and complications.

Results

The cohort had a mean age of 47.8 ± 14.6 years; 75% were female. The mean diameter of the largest CBD stone was 15.1 ± 4.2 mm, with an average of 2.16 ± 1.7 stones per patient. Mean CBD diameter was 15.1 ± 3.1 mm, and the average balloon size used was 14.8 ± 1.7 mm. Complete clearance was achieved in 84.9% (475/559) of the patients in a single session and in 89.9% (503/559) of the patients overall. Mechanical lithotripsy achieved additional clearance in only 11(2.5%) patients. Complications occurred in 34(6.1%) patients: perforation (n=18,3.2%), bleeding (n=15,2.7%), and pancreatitis (n=1,0.2%). Procedure-related mortality was observed in three (0.5%) patients (perforation, n=2; bleeding, n=1). Regression analysis identified larger stone size as a predictor of clearance failure (OR: 1.10; 95% CI: 1.03–1.17; p = 0.004) and need for repeat intervention as a predictor of complications (OR: 4.49; 95% CI: 1.68–11.99; p = 0.003).

Conclusion

EPLBD is a safe and effective approach for the management of difficult CBD stones. It offers high success rates with acceptable complication rates, making it a valuable one-stop management for difficult CBD stones, particularly in resource-constrained settings.

Introduction

Hydatid cyst of the liver is a parasitic disease caused by the development of the taenia Echinococcus Granulosus. Fistulization in the bile duct is one of the most frequent complications. Endoscopic treatment is necessary because of the risks associated with surgery.

Aims & Methods

Aims: To evaluate the impact of endoscopic ERCP in the diagnosis and Therapeutic management of ruptured liver hydatid cysts in the bile ducts.
Methods: 60 patients with a hydatid cyst fistulized in the bile ducts were included retrospectively over a period of 20 years, from January 2002 to September 2022. Overall success was defined by definitive vacuity of the main bile duct.
The results were analysed by JAMOVI 2.0

Results

Among the ERCPs performed in our department during the study period, 4.6%(n=60) were for a hepatic hydatid cyst communicating with the bile ducts.
Median age of our patients was 46.1±14.8 with a sex ratio of 2.
ERCP was indicated for acute cholangitis in 44.9% and persistent external biliary fistula in 34%. Median bile duct diameter was 10[7-14]mm and median cyst diameter was 35[27-47].Sphincterotomy was performed in 96% of patients allowing extraction of hydatid fluid by balloon or Dormia in 87.8%.
Nevertheless, 24% required naso-biliary drainage and 8% benefited from biliary prosthesis placement. Overall success rate was 93,3% (n=56) while 4 patients (6,7%) developed some complications.
This technique helped with the disappearance of jaundice after 5 to 10 days.

Conclusion

Our study confirms that endoscopic treatment of ruptured hydatid cyst in the bile ducts is an effective therapeutic alternative, with a low rate of immediate complications and a good long-term evolution.

Introduction

Difficult bile stones (DBS) accounts for 10 to 15% of choledocholithiasis cases. In this setting different endoscopic techniques are available to obtain bile duct clearance. Of them endoscopic papillary large balloon dilation (EPLBD) demonstrated high rate of efficacy and is usually performed as a first step when DBS are encountered. However, EPLBD alters the anatomy and the functional role of major papilla potentially exposing patients to cholangitis. To date, few data are available in literature on the long-term consequence of EPLBD.

Aims & Methods

Aim of the study is to explore the long-term complications of EPLBD in terms of cholangitis and biliary recurrence. This is a multicenter retrospective study conducted within 33 centers. Adult patients who underwent to EPLBD (balloon diameter ≥12 mm) and obtained complete bile duct clearance in one or more endoscopic sessions were included in the study. Patients with surgical altered anatomy and those with orthotopic liver transplantation were excluded from the study. Primary outcome of the study was the rate of cholangitis; secondary outcome was endoscopic reintervention after EPLBD.

Results

1221 patients (654 female) with a median age of 77 yo (IQR 68-84) were included in the study. EPLBD was performed after previous failed ERCP standard treatments in 43.7% of cases. Indication for EPLBD was a single or double large stone in 51.8% of patients or multiple stones in 48.2% of patients with a median common bile duct (CBD) diameter of 15 mm (IQR 12-18). Large balloon dilation was performed at a median diameter of 13 mm (IQR 12-15) and CBD clearance was obtained with only one EPLBD session in 81.3% of patients. Assessment of CBD clearance was evaluated in 93% of cases with cholangiography and in the remaining of cases with cholangioscopy or cross-sectional imaging. Intra-procedural and short-term adverse events (AEs) were recorded in 3.9% and 8% of patients respectively. During a median follow-up time of 921 days (IQR 513-1644) 143 patients (11.7%) experienced at least one episode of cholangitis that have occurred after a median time of 293 days from EPLBD (IQR 133-553 days). Cholangitis was caused by stones recurrence in 76% of cases. Cholangitis was managed in the majority of cases (83.5%) with ERCP and in the remaining with conservative antibiotic therapy. Global rate of biliary recurrence with need of ERCP was recorded in 16% of patients. At Kaplan-Meier analysis the risk of cholangitis or biliary recurrence was homogeneous during follow-up time and was not affected by dilator balloon diameter (more or less than 15 mm). At multivariate Cox regression analysis, risk factors for cholangitis were a previous ERCP before EPLBD (HR 95%CI 1.65; 1.16 to 2.34), presence of multiple biliary stones (HR 95%CI 1.67;1.18 to 2.36) and stone recurrence during follow-up (HR 95%CI, 2.86; 1.61 to 5.08) whereas cholecystectomy status was not associated to long-term complications.

Conclusion

Cholangitis is not an uncommon long-term complication of EPLBD. The risk of cholangitis is homogeneous during follow-up time and the major determinants of cholangitis are previous ERCP before EPLBD, the presence of multiple biliary stones and the occurrence of stone recurrence during follow-up.

Clinical Case Summary

Hydatid cyst disease, caused by the Echinococcus parasite, is a zoonotic infection that typically targets the liver, lungs, and nervous system. It commonly occurs in regions such as the Maghreb countries, where it presents a significant health concern. While hydatid cysts in the liver are usually asymptomatic, complications such as cyst rupture, infection, or obstruction can arise, with portal vein involvement being particularly rare. This case report describes a 56-year-old male with a history of surgery for hydatid liver cyst, who presented with portal vein invasion mimicking portal vein thrombosis. Diagnostic imaging, including Color Doppler ultrasound and MRI, revealed a multiloculated cyst in the fourth liver segment with communication to the portal vein, leading to thrombosis and cavernous transformation of the portal vein. Despite the rupture of the hydatid cyst into the portal vein, no anaphylactic shock occurred. Portal vein thrombosis and cavernous transformation due to hydatid cysts represent an exceptional and complex complication of echinococcosis, highlighting the importance of early recognition and appropriate management. Treatment strategies should address both the hydatid liver cyst and associated portal hypertension, with surgical intervention being the cornerstone, including hepatectomies and laparoscopic approaches. This case highlights the necessity of heightened clinical awareness in endemic regions for managing this rare, potentially life-threatening complication.

Introduction

Common bile duct (CBD) stones are one of the most frequent indications for endoscopic retrograde cholangiopancreatography (ERCP). Endoscopic complete sphincterotomy (EST) followed by balloon or basket extraction is widely considered the gold standard technique for the treatment of CBD stones; being successful in more than 90% of cases with approximately 5% overall rate of adverse events [1]. Endoscopic papillary large balloon dilatation (EPLBD) is an effective technique in treating large common bile duct (CBD) stones. However, the efficacy and safety of EPLBD in the setting of periampullary diverticula (PAD) are prospectively lacking.

Aims & Methods

This study aimed to compare the effectiveness and short-term safety of EPLBD after limited sphincterotomy with those of EST for extracting large CBD stones in the setting of PAD prospectively. Forty-eight patients with large CBD stone(s) > 1 cm were recruited. All patients had a PAD. Before the procedure patients were evaluated by history taking, clinical examination full investigations including proper imaging studies. During the procedure, patients were randomized to either group I; patients treated with EPLBD after limited sphincterotomy, and group II; patients treated with EST. CBD clearance was defined as a single procedure (EPLBD vs EST), single session (no repeat ERCP), and non-assisted (no lithotripsy used) stone extraction. After the procedure patients were hospitalized with clinical, laboratory, and imaging assessment.

Results

Table 1: Univariate regression of the parameters affecting stone extraction

PAD: periampullary diverticulum			* significant as P value≤ 0.05
	Odds ratio	95% CI	P value​
The used technique	5.92	1.32 to 25.3	0.009∗
Stone (s) number	0.62	0.17 to 2.25	0.468
Stone (s) diameter (mm)	2.59	0.63 to 10.56	0.187
Type of PAD​	1.32	0.65 to 2.67	0.437

The overall stone extraction rate in the current study was only 77.3% (n=34). The efficacy of stone extraction was significantly higher in the EPLBD (n= 21,87.5%) group compared to EST (n= 13, 54.17%) group (p = 0.011). The procedure-related adverse events were lower in the EPLBD group compared to the EST group. Pancreatitis was significantly higher in the EST (n=14, 58.33%) group than in the EPLBD (n=3, 12.5%) group (p= 0.001). There were no perforations or case fatalities in either group. The predictors of stone extraction were analyzed using univariate regression (Table 1), and it is noticeable that the used technique was the independent predictor of success in stone extraction (Odds Ratio: 5.92, 95% Confidence Interval: 1.38 to 25.30, p-value = 0.009).

Conclusion

The current practice guidelines of the ESGE and ASGE suggest that for large CBD stones, an EST followed by a large balloon dilatation is preferable to EST alone because combining dilatation with EST improves duct clearance and reduces the need for lithotripsy without adding risk. Our results among PAD patients seem to echo this: the EPLBD approach in comparison to EST yielded higher stone clearance on first attempt even without using lithotripsy by the study design. Hence, based on the current study these existing recommendations can be extrapolated to the PAD population based on our study which is one of the first randomized trials in the specific PAD subgroup.

References

1. Zippi M, Traversa G, Pica R, De Felici I, Cassieri C, Marzano C, et al. Efficacy and safety of endoscopic retrograde cholangiopancreatography (ERCP) performed in patients with Periampullary duodenal diverticula (PAD). Clin Ter. 2014;165(4):e291-4.