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“An unusual complication of a cystic liver lesion”
Journal Pre-proof “An unusual complication of a cystic liver lesion” Sreelakshmi Kotha, Jonathan Potts, Douglas Thorburn
PII: DOI: Reference:
S0016-5085(20)30090-1 https://doi.org/10.1053/j.gastro.2019.11.306 YGAST 63141
To appear in: Gastroenterology Accepted Date: 25 November 2019 Please cite this article as: Kotha S, Potts J, Thorburn D, “An unusual complication of a cystic liver lesion”, Gastroenterology (2020), doi: https://doi.org/10.1053/j.gastro.2019.11.306. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 by the AGA Institute
Title: “An unusual complication of a cystic liver lesion”
Sreelakshmi Kotha, Jonathan Potts, Douglas Thorburn Affiliations: 1) Department of Gastroenterology, Royal Free Hospital, London, United Kingdom Correspondence:
Sreelakshmi Kotha, Department of Gastroenterology, Department of Gastroenterology, Royal Free Hospital, London, United Kingdom [email protected] 00447949871727
Disclosures:
No conflicts of interest. No financial support or competing interests.
Author Contributions:
SK: Patient care, writing manuscript.
JP: Patient care, writing manuscript.
DT: Patient care, revising manuscript.
Clinical presentation:
A middle-aged patient presented with cholangitis and cholestatic liver tests. He was originally from Albania but had lived in the UK for 10 years. He reported recurrent episodes of fever with abdominal pain over the last 3 months. There was no significant past medical or surgical history. On admission, he had intermittent febrile episodes, but vitals were stable. Physical examination revealed tenderness in right upper quadrant without guarding. He was commenced on antibiotics and contrast-enhanced computed tomography (CT) revealed a large lesion in the liver. Appropriate laboratory investigations were sent based on this finding. However, liver tests continued to worsen and a magnetic resonance cholangiopancreatography (MRCP) was performed. This revealed erosion and communication of the liver lesion with the right posterior intra-hepatic duct with multiple filling defects within the common right duct (Fig 1).
An endoscopic retrograde cholangiopancreatography (ERCP) was performed and cholangiogram revealed a non-dilated CBD but significant dilatation in the right posterior duct with multiple filling defects (Fig 2). A sphincterotomy was performed and large amount of gelatinous matter was removed with a balloon trawl (Fig 3 &4). A double pigtail stent was placed to prevent further episodes of obstruction. Treatment was altered appropriately based on this finding. Question: What is the lesion in the liver? What is aetiology of biliary obstruction? How would you manage this patient?
Answer: The large lesion is a hydatid cyst in the liver fistulating into biliary system causing biliary obstruction due to cyst fluid and daughter cysts. Aetiology is infection with Echinococcus granulosus and the cysts are usually asymptomatic until their size causes pressure on surrounding structures. The communication between a cyst and the biliary tract is the most common complication of this with a reported incidence between 13%-37%(1,2). Fistulas are either a result of high intra-cystic pressure leading to rupture into bile duct or due to compression, erosion and necrosis into the biliary wall. Minor cysto-biliary fistulas develop in 80% to 90% of all hepatic hydatid cysts and are usually asymptomatic and only discovered intraoperatively. Frank fistulas can lead to obstructive jaundice, pancreatitis, cholangitis and have high morbidity. Cyst diameter>10cm, alkaline phosphatase >133U/L, bilirubin >1.2 mg/dl and white blood cells >10,000/mm are predictors of fistula formation. Undetected fistulas can lead to significant postoperative morbidity and mortality due to biliary leaks and biliary abscesses. Symptomatic pre-operative fistulas can be managed effectively with ERCP. Our patient went on to have an ERCP with stenting, treatment with albendazole followed by surgical cyst excision and is currently well.
References:
1) Kayaalp C, Bostanci B, Yol S, et al. Distribution of hydatid cysts into the liver with reference to cystobiliary communications and cavity-related complications. Am J Surg 2003;185:175-9
2) Bedirli A, Sakrak O, Sozuer EM, et al. Surgical management of spontaneous intrabiliary rupture of hydatid liver cysts. Surg Today2002;32:594-7.
PII: DOI: Reference:
S0016-5085(20)30090-1 https://doi.org/10.1053/j.gastro.2019.11.306 YGAST 63141
To appear in: Gastroenterology Accepted Date: 25 November 2019 Please cite this article as: Kotha S, Potts J, Thorburn D, “An unusual complication of a cystic liver lesion”, Gastroenterology (2020), doi: https://doi.org/10.1053/j.gastro.2019.11.306. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 by the AGA Institute
Title: “An unusual complication of a cystic liver lesion”
Sreelakshmi Kotha, Jonathan Potts, Douglas Thorburn Affiliations: 1) Department of Gastroenterology, Royal Free Hospital, London, United Kingdom Correspondence:
Sreelakshmi Kotha, Department of Gastroenterology, Department of Gastroenterology, Royal Free Hospital, London, United Kingdom [email protected] 00447949871727
Disclosures:
No conflicts of interest. No financial support or competing interests.
Author Contributions:
SK: Patient care, writing manuscript.
JP: Patient care, writing manuscript.
DT: Patient care, revising manuscript.
Clinical presentation:
A middle-aged patient presented with cholangitis and cholestatic liver tests. He was originally from Albania but had lived in the UK for 10 years. He reported recurrent episodes of fever with abdominal pain over the last 3 months. There was no significant past medical or surgical history. On admission, he had intermittent febrile episodes, but vitals were stable. Physical examination revealed tenderness in right upper quadrant without guarding. He was commenced on antibiotics and contrast-enhanced computed tomography (CT) revealed a large lesion in the liver. Appropriate laboratory investigations were sent based on this finding. However, liver tests continued to worsen and a magnetic resonance cholangiopancreatography (MRCP) was performed. This revealed erosion and communication of the liver lesion with the right posterior intra-hepatic duct with multiple filling defects within the common right duct (Fig 1).
An endoscopic retrograde cholangiopancreatography (ERCP) was performed and cholangiogram revealed a non-dilated CBD but significant dilatation in the right posterior duct with multiple filling defects (Fig 2). A sphincterotomy was performed and large amount of gelatinous matter was removed with a balloon trawl (Fig 3 &4). A double pigtail stent was placed to prevent further episodes of obstruction. Treatment was altered appropriately based on this finding. Question: What is the lesion in the liver? What is aetiology of biliary obstruction? How would you manage this patient?
Answer: The large lesion is a hydatid cyst in the liver fistulating into biliary system causing biliary obstruction due to cyst fluid and daughter cysts. Aetiology is infection with Echinococcus granulosus and the cysts are usually asymptomatic until their size causes pressure on surrounding structures. The communication between a cyst and the biliary tract is the most common complication of this with a reported incidence between 13%-37%(1,2). Fistulas are either a result of high intra-cystic pressure leading to rupture into bile duct or due to compression, erosion and necrosis into the biliary wall. Minor cysto-biliary fistulas develop in 80% to 90% of all hepatic hydatid cysts and are usually asymptomatic and only discovered intraoperatively. Frank fistulas can lead to obstructive jaundice, pancreatitis, cholangitis and have high morbidity. Cyst diameter>10cm, alkaline phosphatase >133U/L, bilirubin >1.2 mg/dl and white blood cells >10,000/mm are predictors of fistula formation. Undetected fistulas can lead to significant postoperative morbidity and mortality due to biliary leaks and biliary abscesses. Symptomatic pre-operative fistulas can be managed effectively with ERCP. Our patient went on to have an ERCP with stenting, treatment with albendazole followed by surgical cyst excision and is currently well.
References:
1) Kayaalp C, Bostanci B, Yol S, et al. Distribution of hydatid cysts into the liver with reference to cystobiliary communications and cavity-related complications. Am J Surg 2003;185:175-9
2) Bedirli A, Sakrak O, Sozuer EM, et al. Surgical management of spontaneous intrabiliary rupture of hydatid liver cysts. Surg Today2002;32:594-7.