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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…………………