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Large pancreatic hydatid cyst presenting with obstructive jaundice
Arab Journal of Gastroenterology 11 (2010) 47–49
Contents lists available at ScienceDirect
Arab Journal of Gastroenterology journal homepage: www.elsevier.com/locate/ajg
Case Report
Large pancreatic hydatid cyst presenting with obstructive jaundice M. Boubbou a,*, S. Boujraf b, N.H. Sqalli a, M. Maaroufi a, S. Tizniti a a b
Department of Medical Imaging, University Hospital of Fez, Morocco Department of Biophysics and Clinical MRI Methods, University Hospital of Fez, Morocco
a r t i c l e
i n f o
Article history: Received 1 November 2009 Accepted 5 January 2010
Keywords: Hydatid cyst Pancreas
a b s t r a c t Primary hydatid disease of the pancreas is very rare. We report about the case of a 38-year-old man who presented with jaundice, abdominal pain and epigastric mass. Abdominal ultrasound and computed tomography (CT) scan demonstrated a large, thick-walled pancreatic cystic mass compressing the common bile duct and causing obstructive jaundice. The treatment involved eccentration and the resection of the protruding mass by cystogastrostomy. The procedure was successful and no recurrence or complication occurred postoperatively. Hydatid disease should be considered in the differential diagnosis of all cystic masses in the pancreas, especially in the geographical regions where the disease is endemic. Ó 2010 Arab Journal of Gastroenterology. Published by Elsevier B.V. All rights reserved.
Introduction Hydatid cyst of the pancreas is very rare; it constitutes <1% of all localisations. Medical imaging modalities, such as ultrasound and computed tomography (CT) scan, are diagnostic modalities for investigating cystic pancreatic lesions. This article documents a case of a large pancreatic hydatid cyst causing obstructive jaundice [1,2]. Case report A 38-year-old patient was admitted for jaundice associated with abdominal pain, mainly epigastric, which had evolved during 6 months. Abdominal ultrasound (Fig. 1) demonstrated a large thick-walled pancreatic cystic mass containing several cystic vegetations compressing the common bile duct. Abdominal CT scan confirmed the ultrasound cystic finding (Fig. 2). Furthermore, it showed discrete heterogeneous and dense characteristics associated with the common bile duct and intrahepatic biliary dilatation. The lesion was localised at the pancreatic head. The final diagnosis was established in the preoperative stage by aspirating the cystic mass revealing a mucous liquid and hydatid membrane (Fig. 3). Removal of the cyst content was done without any spillage which included puncture of the cyst, aspiration of fluid, instillation and respiration of hypertonic saline solution * Corresponding author. Address: Lot Oued El Makhazine, Rue S4, Numero 2, Oujda, Morocco. E-mail addresses: [email protected] (M. Boubbou), [email protected] (S. Boujraf), [email protected] (N.H. Sqalli), [email protected] (M. Maaroufi), [email protected] (S. Tizniti).
followed by catheterisation and therapy with absolute ethanol. This was followed by free drainage of the cavity and, cystogastrostomy was performed. The laparoscopic endogastric cystogastrostomy appears to be a safe, effective and minimally invasive approach for internal drainage of large retrogastric pancreatic cysts. There were no postoperative complications with only a short hospital stay and resolution of the cyst was radiologically evident.
Discussion The localisation of hydatid cyst in the pancreas is very rare; it constitutes <0.14% of all localizations. The mode of infection is most likely through the blood circulation after passage of the dual-filter composed of the liver and the lung. The most common site for pancreatic cysts is the head in 57% of cases, body in 24% of cases and tail in 19% of cases [3,4]. The clinical presentation varies with the size of the cyst and anatomic location. Important serological investigations are hydatid immunoelectrophoresis, enzyme-linked immunosorbent assay (ELISA), latex agglutination and indirect hemagglutination (IHA) test. The treatment of hydatid cysts is mainly surgical. However, preand postoperative 1-month course of albendazole and 2 weeks of praziquantel can help in sterilising the cyst, decrease the chance of anaphylaxis and reduce the recurrence rate postoperatively [5,6]. According to some authors, surgical exploration of the abdomen is the only way to reach a definitive diagnosis. Depending on the site, various methods of surgical treatment have been used. For cysts located in the body and tail, subtotal cystectomy, leaving only adventia behind, is preferred (as in our case); and for cysts located
1687-1979/$ - see front matter Ó 2010 Arab Journal of Gastroenterology. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.ajg.2010.01.003
48
M. Boubbou et al. / Arab Journal of Gastroenterology 11 (2010) 47–49
Fig. 3. High power (400) magnification of the hydatid cyst stained with haematoxylin and eosin. Fig. 1. Ultrasound image of a thick-walled cystic mass containing structures demonstrating endocystic vegetations.
Fig. 2. CT scan of a thick-walled cystic mass responsible for a common bile duct and intrahepatic biliary dilatation. The mass is localised at the pancreatic head.
in the head of the pancreas, methods such as Whipple’s resection, marsupialisation and external drainage have been used [7,8]. We conclude that pancreatic hydatid disease is exceptional; however, it should be considered in the differential diagnosis of pancreatic cystic lesions, especially in endemic countries where hydatid disease is a public health problem. The preoperative diagnosis is mainly based on radiological and immunological approaches.
References [1] Moosavi SR, Kermany HK. Epigastric mass due to a hydatid cyst of the pancreas. A case report and review of the literature. J Pancreas 2007;8:232–4. [2] Safioleas MC, Moulakakis KG, Manti C, Kostakis A. Clinical considerations of primary hydatid disease of the pancreas. Pancreatology 2005;5:457–61. [3] Echenique-Elizondo M, Amondarain-Arratibel JA. Hydatid disease of the pancreas. J Pancreas 2004;5:51–2. [4] Balik A, Celebi F, Basoglu M, Oren D, Yildirgan I, Atamanalp S. Intraabdominal extrahepatic echinococcosis. Surg Today 2001;31:881–4.
M. Boubbou et al. / Arab Journal of Gastroenterology 11 (2010) 47–49 [5] Wani N, Shah O, Zargar J, Baba K, Dar M. Hydatid cyst of the pancreas. Dig Surg 2000;17:188–90. [6] Zakari S, Ajana A, Dhobb OH. Echographic aspects of hydatid cyst of the pancreas. A propose of two cases with review of the literature. Ann Radiol 1984;7:607–13.
49
[7] Gayral F, Bouree P, Jourdanne P, Millat B, Labayle D. Hydatid cyst of the pancreas. A case study. Nouv Presse Med 1981;10:3787–8. [8] Hassine W, Dupuch K, Gharbi HA. Value of US in hydatid liver disease: a report of 42 cases. J Radiol 1980;61:323–7.
Contents lists available at ScienceDirect
Arab Journal of Gastroenterology journal homepage: www.elsevier.com/locate/ajg
Case Report
Large pancreatic hydatid cyst presenting with obstructive jaundice M. Boubbou a,*, S. Boujraf b, N.H. Sqalli a, M. Maaroufi a, S. Tizniti a a b
Department of Medical Imaging, University Hospital of Fez, Morocco Department of Biophysics and Clinical MRI Methods, University Hospital of Fez, Morocco
a r t i c l e
i n f o
Article history: Received 1 November 2009 Accepted 5 January 2010
Keywords: Hydatid cyst Pancreas
a b s t r a c t Primary hydatid disease of the pancreas is very rare. We report about the case of a 38-year-old man who presented with jaundice, abdominal pain and epigastric mass. Abdominal ultrasound and computed tomography (CT) scan demonstrated a large, thick-walled pancreatic cystic mass compressing the common bile duct and causing obstructive jaundice. The treatment involved eccentration and the resection of the protruding mass by cystogastrostomy. The procedure was successful and no recurrence or complication occurred postoperatively. Hydatid disease should be considered in the differential diagnosis of all cystic masses in the pancreas, especially in the geographical regions where the disease is endemic. Ó 2010 Arab Journal of Gastroenterology. Published by Elsevier B.V. All rights reserved.
Introduction Hydatid cyst of the pancreas is very rare; it constitutes <1% of all localisations. Medical imaging modalities, such as ultrasound and computed tomography (CT) scan, are diagnostic modalities for investigating cystic pancreatic lesions. This article documents a case of a large pancreatic hydatid cyst causing obstructive jaundice [1,2]. Case report A 38-year-old patient was admitted for jaundice associated with abdominal pain, mainly epigastric, which had evolved during 6 months. Abdominal ultrasound (Fig. 1) demonstrated a large thick-walled pancreatic cystic mass containing several cystic vegetations compressing the common bile duct. Abdominal CT scan confirmed the ultrasound cystic finding (Fig. 2). Furthermore, it showed discrete heterogeneous and dense characteristics associated with the common bile duct and intrahepatic biliary dilatation. The lesion was localised at the pancreatic head. The final diagnosis was established in the preoperative stage by aspirating the cystic mass revealing a mucous liquid and hydatid membrane (Fig. 3). Removal of the cyst content was done without any spillage which included puncture of the cyst, aspiration of fluid, instillation and respiration of hypertonic saline solution * Corresponding author. Address: Lot Oued El Makhazine, Rue S4, Numero 2, Oujda, Morocco. E-mail addresses: [email protected] (M. Boubbou), [email protected] (S. Boujraf), [email protected] (N.H. Sqalli), [email protected] (M. Maaroufi), [email protected] (S. Tizniti).
followed by catheterisation and therapy with absolute ethanol. This was followed by free drainage of the cavity and, cystogastrostomy was performed. The laparoscopic endogastric cystogastrostomy appears to be a safe, effective and minimally invasive approach for internal drainage of large retrogastric pancreatic cysts. There were no postoperative complications with only a short hospital stay and resolution of the cyst was radiologically evident.
Discussion The localisation of hydatid cyst in the pancreas is very rare; it constitutes <0.14% of all localizations. The mode of infection is most likely through the blood circulation after passage of the dual-filter composed of the liver and the lung. The most common site for pancreatic cysts is the head in 57% of cases, body in 24% of cases and tail in 19% of cases [3,4]. The clinical presentation varies with the size of the cyst and anatomic location. Important serological investigations are hydatid immunoelectrophoresis, enzyme-linked immunosorbent assay (ELISA), latex agglutination and indirect hemagglutination (IHA) test. The treatment of hydatid cysts is mainly surgical. However, preand postoperative 1-month course of albendazole and 2 weeks of praziquantel can help in sterilising the cyst, decrease the chance of anaphylaxis and reduce the recurrence rate postoperatively [5,6]. According to some authors, surgical exploration of the abdomen is the only way to reach a definitive diagnosis. Depending on the site, various methods of surgical treatment have been used. For cysts located in the body and tail, subtotal cystectomy, leaving only adventia behind, is preferred (as in our case); and for cysts located
1687-1979/$ - see front matter Ó 2010 Arab Journal of Gastroenterology. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.ajg.2010.01.003
48
M. Boubbou et al. / Arab Journal of Gastroenterology 11 (2010) 47–49
Fig. 3. High power (400) magnification of the hydatid cyst stained with haematoxylin and eosin. Fig. 1. Ultrasound image of a thick-walled cystic mass containing structures demonstrating endocystic vegetations.
Fig. 2. CT scan of a thick-walled cystic mass responsible for a common bile duct and intrahepatic biliary dilatation. The mass is localised at the pancreatic head.
in the head of the pancreas, methods such as Whipple’s resection, marsupialisation and external drainage have been used [7,8]. We conclude that pancreatic hydatid disease is exceptional; however, it should be considered in the differential diagnosis of pancreatic cystic lesions, especially in endemic countries where hydatid disease is a public health problem. The preoperative diagnosis is mainly based on radiological and immunological approaches.
References [1] Moosavi SR, Kermany HK. Epigastric mass due to a hydatid cyst of the pancreas. A case report and review of the literature. J Pancreas 2007;8:232–4. [2] Safioleas MC, Moulakakis KG, Manti C, Kostakis A. Clinical considerations of primary hydatid disease of the pancreas. Pancreatology 2005;5:457–61. [3] Echenique-Elizondo M, Amondarain-Arratibel JA. Hydatid disease of the pancreas. J Pancreas 2004;5:51–2. [4] Balik A, Celebi F, Basoglu M, Oren D, Yildirgan I, Atamanalp S. Intraabdominal extrahepatic echinococcosis. Surg Today 2001;31:881–4.
M. Boubbou et al. / Arab Journal of Gastroenterology 11 (2010) 47–49 [5] Wani N, Shah O, Zargar J, Baba K, Dar M. Hydatid cyst of the pancreas. Dig Surg 2000;17:188–90. [6] Zakari S, Ajana A, Dhobb OH. Echographic aspects of hydatid cyst of the pancreas. A propose of two cases with review of the literature. Ann Radiol 1984;7:607–13.
49
[7] Gayral F, Bouree P, Jourdanne P, Millat B, Labayle D. Hydatid cyst of the pancreas. A case study. Nouv Presse Med 1981;10:3787–8. [8] Hassine W, Dupuch K, Gharbi HA. Value of US in hydatid liver disease: a report of 42 cases. J Radiol 1980;61:323–7.