Keywords
pregnancy - ERCP - hydatid cyst
A 24-year-old female primigravida with 6 weeks of gestation age presented with right
upper abdominal pain and obstructive jaundice. Ultrasound abdomen showed large cystic
lesion in liver with sludge in dilated common bile duct. Computed tomography was not
considered due to contraindication from pregnancy. Endoscopic ultrasonography showed
echogenic membranes floating in dilated common bile duct. There was minimal intrahepatic
biliary radicles dilation. There was a large cystic lesion in caudate lobe (88 × 96
mm). There was another adjacent cystic lesion (43.2 × 42.3 mm) in left lobe of the
liver, close to diaphragm. The cyst showed thick septae (cart-wheel appearance) suggestive
of hydatid cyst ([Video 1]
[Figs. 1]
[2]). In view of the first trimester of pregnancy, she underwent endoscopic retrograde
cholangiopancreatography (ERCP) without fluoroscopy. Common bile duct was selectively
cannulated using sphincterotome and guidewire combination ([Video 1]) and bile was aspirated to confirm the position. A wide biliary sphincterotomy was
done followed by balloon sweeps using stone retrieval balloon which revealed multiple
hydatid membranes. A 7-Fr 7-cm double pigtail biliary stent was placed. She improved
symptomatically soon after. A surgical intervention was planned in second trimester.[1]
Video 1
Cannulation of bile duct.
Fig. 1 EUS imaging showing hydatid cyst of liver with classical cartwheel
appearance.
Fig. 2 EUS imaging showing hydatid membranes within the CBD.
Liver is one of the most common site of hydatid infection.[2]
[3] It usually presents with pain, vomiting, jaundice, cholangitis, or mass. Hepatic
hydatid cyst rupture into the bile ducts (intrabiliary rupture) is the common and
serious complication that can occur during course of pregnancy. They can present with
fever, severe abdominal pain, cholangitis, pancreatitis, and sepsis.[2]
[3] Early diagnosis and treatment are crucial, because it involves two lives (mother
and fetus) and mortality is high when it progresses to cholangitis and sepsis. Such
circumstance imposes limitations in management options due to risk of abortion, premature
labor, and teratogenicity.[4]
[5]
Though the treatment of choice is surgery in intrabiliary rupture of hepatic hydatid
cyst, ERCP is useful when there is obstructive jaundice and cholangitis after which
elective surgery can be planned.
