Dr Hari Prasad Yadav MD, DM CHL Apollo Hospital, Indore ERCP Video Dr Hari Prasad Yadav MD, DM CHL Apollo Hospital, Indore

21 year female c/o abdominal pain x 2 months intermittent fever with chills x 2 months Jaundice with pruritus x 1 1/2 months O/e Febrile Icteric ++, Pallor + , No oedema, lymphadenopathy Vitals : BP 90/60 Abdomen : Soft ,Liver 3 cm tender, soft. Spleen not palpable, No ascites

Investigations CBC HB 8gm% TLC 18,000 Plat count 4.9 lac LFT SGOT 72 SGPT 46 ALP 448 Bil 5/3.5 Protein 6.7/3.6 PT 24/13 INR 2.1 USG : Moderate hepatomegaly with dilatated IHBR large hepatic abscess ? communicating with biliary duct large mass near porta hepatis ? periampullary duodenal mass

MRCP

ERCP Video -1

Role of ERCP in hepatobiliary hydatid disease Diagnostic Therapeutic

Role of ERCP Preoperative may give permanent cure specifically in cases of frank intrabiliary rupture if evacuation of biliary tract and cystic cavity is manageable, Endoscopic treatment has a success rate of 80-90% in patients without having any surgery. when combined with preoperative endoscopic sphincterotomy may decrease the incidence of postoperative external fistula. Postoperative- for external fistula

Follow-up 8 days Asymptomatic

‘Cystobiliary fistula’ or ‘Cystobiliary communication’. Intrabiliary rupture is the most common and serious complication of hepatic hydatid cyst ‘Cystobiliary fistula’ or ‘Cystobiliary communication’. Incidence 1% to 25% 40-90% of cysts have some sort of communication Occult 10-30 % Frank 3-17 % Al-Hashimi HM.Intrabiliary rupture of hydatid cyst of liver.Br.J Surg 1999;58;228;232

Biliary obstruction occurs in 5-17% of cases after rupture of hepatic hydatid. Obstructive jaundice occurs in 57% to 100% of cases following intrabiliary rupture involving large bile duct. Development of abdominal pain, fever with chills, progressive or fluctuating jaundice are the clinical markers for suspecting biliary rupture

USG In frank communicating rupture, the cyst becomes smaller, and undulating membranes may be seen within it. Extrahepatic biliary dilatation is a constant feature Echogenic or non-echogenic material without posterior acoustic shadowing is seen in the biliary tree, suggestive of sludge and daughter cysts. Direct communication was visualized in only 20% of cases.

CT scan Detached undulating membranes and calcification of the cyst wall . A dilated CBD with low attenuation intraluminal material suggests the presence of hydatid sand and cysts in the CBD. An interrupted area of the cyst wall proximal to a dilated duct may be identified as representing the site of communication. Cyst wall discontinuity, a direct sign of rupture, is seen in only 75% of cases CT can demonstrate high attenuation material passing through the defect of the cystic wall and filling up the intrahepatic biliary radicles or CBD

MRCP Intrabiliary rupture of liver hydatid gives direct and indirect signs on MRCP A breach in the low intensity rim of the cyst wall with extrusion of cyst contents is a direct sign while increased echogenicity, fluid levels, presence of air and changes in signal intensity are indirect signs on MRCP.

ERCP indicated when other tests are uncertain, in patients who have recurrent biliary colic, especially if associated with icterus or cholangitis One study reported that biliary complications of hydatid cysts were detected by ERCP in 60 percent of cases compared to 25 percent by CT or US. Cholangiography often reveals minor communications, particularly with peripheral ducts, which are of unclear clinical significance. Duodenoscopy sometimes shows whitish, glistening membranes lying in the duodenum, or impacted in the papilla of vater.

Three patterns of intraductal filling defects on ERCP have been described: • Filliform, linear, wavy material in the common bile duct due to laminated hydatid membranes or ill-defined, irregular leaf-like filling defects due to fragmented membranes • Round or oval lucent filling defects, floating in the common bile duct due to daughter cysts  • Brown, thick, amorphous debris

Post operative ERCP Diagnostic - for recurrent symptoms Therapeutic -treat cholangitis & obstruction of biliary tree, sphincterotomy to help in managing postop external biliary fistula, secondary biliary stricture.

Comparison of endoscopic therapeutic modalities for postoperative biliary fistula of liver hydatid cyst: a retrospective multicentric study. Surg Laparosc Endosc Percutan Tech.  2010; 20(4):223-7 (ISSN: 1534-4908) Conclusion : ERCP and related therapeutic procedures are safe and valuable in the postoperative management of external biliary fistulae in the hepatic hydatid disease. In high-output fistulae (>300 mL/d), indicating a major cystobiliary communication, stent placement may be preferred. The diameter of the stent should preferably be 10 F. This 10 F stent is superior to other endoscopic approaches in the treatment of biliary fistulae.

Treatment Medical: Albendazole 10-15 mg per kg per day, OR Praziquantel 40mg per kg per day, OR Mebendazole 3-6 months with 1 month Course separated by drug free period of 1-2 wk 3o% complete response 30% partial response Young age Size <4 cm Thin wall PAIR PEVAC I Gharbi’s I,II,III Poor sx candidate Recurrence C/I Pedunculated cyst Superficial cyst Multiple Type III non drainable Type IV,V Biliary rupture Surgical Total Pericystectomy Open cystectomy +Omentoplasty Partial hepatectomy ERCP Cystobiliary Fistula Obstructive jaundice

Summary Delayed diagnosis and treatment of intrabilary rupture of liver hydatid is associated with serious morbidity (19.44- 43.03%) and mortality (1.8- 4.5%) Sepsis and hepatic failure are major causes of mortality. Localization of the cyst in the liver as well as the localization of the intrabiliary rupture is important in the strategy of the treatment Endoscopic sphincterotomy with extraction of retained of ruptured membranes or daughter cyst in CBD is a safe and definitive treatment for intrabiliry rupture when used in selected cases. Endoscopic treatment has a success rate of 80-90% in patients without having any surgery.