Case Presentation

Maha Akkawi Bayan Abu-EishehSupervised By: Dr Yaser Abu Safeyeh

The patient course

Initial Presentation

1st admission………. SURGERY

Refferal for…………. ERCP

Readmission….. Ascending cholangitis

Referral to Al-Maqasid …… Stenting

Treatment of billiary hydatid disease

Case Presentation, History

A 47 year old married female from Qabatyeh-Jenin presented with:

Intermittent, progressive epigastric pain since the beginning of last September.

Pain radiated to the back & Rt. shoulder, not related to food, relieved by leaning forward.

Case Presentation, History

Pain associated with nausea, dyspnea

At that time no jaundice , change in stool and urine color, or itching.

The patient had cholecystectomy in 1996 and free past medical history.

Case Presentation, History

Seen by many OP doctors, Abdominal U/S done &………….

Partly solid partly cystic

5.5 cm cyst in the Rt.

Subdiaphragmatic area

Case Presentation, History

She had contact with sheep 20 years ago.

Some neighbors reported the same problem to her.

Admission to Jenin, surgery

So She was admitted to Jenin Governmental Hospital on 12/11/2007For elective surgery on the next day

Admission to Jenin, surgery

CBCSerum electrolytesLiver Function tests WERE ALL

NormalKidney function tests

CXR

During Surgery…

Kocher incision, Large oval cyst found (10x5x5 cm) in the Rt. Lobe

of the liver immediately below diaphragm

Aspiration of the cyst content, injection of hypertonic saline & deroofing & excision was done,

drain inserted in the big cavity left

Case Presentation, Hospital course

In the immediate postoperative period the patient was fairly doing well, afebrile, not jaundiced , and her lab results were expected.

BUTThe drain was giving out large amount

of green colored output (600-800cc/day)

Patient Started on Albendazole tablet 400mgx2

High drain output………ERCP

She was admitted to specialized Arab hospital in 28/11/2007 for ERCP

ERCP sphincterotomy extraction of multiple daughter

hydatid cysts Injection of hypertonic saline 10%

Case Presentation, Hospital course

Side viewing camera

Dilated CBD

Multiple filling defects

Drain at site of

excised cyst

ERCP

ERCP

After ERCP drain output decreased, & she was discharged home in stable

condition

Jenin admission, Ascending cholangitis

In 18/12/2007 the patient was readmitted to Jenin Hospital with jaundice, generalized fatigability, attacks of fever, & pruiritis

Physical examination revealed tinge of jaundice & scratch marks

Drain output 100-200cc/day of thick yellow discharge

Jenin again, Ascending cholangitis

CBC: HB: 10WBC: 12.000Plt: 365.000

KFT:Cr: 0.3BUN: 6

LFT:LFT:

ALT: 137ALT: 137

AST: 163AST: 163

ALP: 1790ALP: 1790

TSB: 2.2TSB: 2.2

INR: 1.7PTT: 36

Jenin again, Ascending cholangitis

Swab culture & Sensitivity from the drain: Pseudomonus Aurigenosa resistant to all available antibiotics

Treated by Ceftazidime & Metronidazole While waiting referral to Al-Maqasid Hospital

From Jenin to……. Almaqasid

In Al-Maqasid another culture taken which was positive for klebsiella pnemoniae ; resistant for all antibiotics except tazopactam + pepracillin

The patient was treated with tazopactam + pepracillin (4.5 gm*4) IV, albendazole and supportive treatment for

ascending cholangitisascending cholangitis

Almaqasid………stent

In the 5th hospitalization day after stabilization of her condition she was referred to Augusta Victoria Hospital and ERCP was done there with stent insertion in CBD.

Later the patient clinically improved, the lab data also improved.

4 days later the drain was removed due to decreased output, & discharged home thereafter

Measured/dateMeasured/date 27/12/200727/12/2007 7/1/20087/1/2008

WBC 9.8 10

Hb 11.4 10

TSB 14.3 7.7

Direct billirubin 11 2.8

ALP 3370 1725

ALT 236 47

Platelets 369 519

Creatinine 1.4 0.9

Before stent After stent

The patient finally……. Well

In 13/3/2008 the patient was looking well, afebrile, not jaundiced, adding weight, and free of symptoms.

Examination was unremarkable except for minimal oozing of the drain side

abdominal x-ray showed stent in place.

Stent

Stent

Summary

Initial presentation Surgery

ERCP

Ascending cholangitis

Stenting

Treatment

Hydatid disease of the biliary tree Hepatic hydatid disease (HHD) is a major

endemic problem in sheep-rearing regions of the world.

Communication between cysts and the biliary tree is detected at a rate of approximately 20%.

Intrabiliary rupture, which has an incidence of 5-17%, is a common complication of hydatid cysts

Reference : Gastroenterology and hepatology journal

Hydatid disease of the biliary tree

A rupture into the biliary tree can lead to obstruction by the daughter cysts, producing cholangitis.

Imaging techniques are highly sensitive for detecting liver hydatidosis, but usually fail to locate the involvement of the biliary tree.

The presence of a dilated common bile duct (CBD), jaundice, or both, in addition to a cystic lesion on (US) and (CT), are suggestive of biliary hydatid disease (BHD).

Reference : Gastroenterology and hepatology journal

Hydatid disease of the biliary tree

ERCP with endoscopic sphincterotomy and extraction of the cysts from the CBD has emerged as a safe and an effective treatment for patients with intrabiliary rupture of hepatic hydatid cysts. Plus Albendazole.

Surgery is an alternative..

Reference : The internet journal of gastroenterology.

Thanx for…………………