DOI:10.2214/AJR.04.1270
AJR 2005; 185:1211-1213
© American Roentgen Ray Society
Fistulous Communication Between a Hepatic Hydatid Cyst and the Gallbladder: Diagnosis with MR Cholangiopancreatography
Ibrahim Adaletli1,
Serpil Yilmaz2,
Yavuz Cakir2,
Resat Kervancioglu2 and
Metin Bayram2
1 Department of Radiology, Cerrahpasa Medical Faculty, Istanbul University,
Kocamustafapasa, Istanbul 34300, Turkey.
2 Department of Radiology, Medical Faculty, Gaziantep University, Gaziantep,
Turkey.
Received August 12, 2004;
accepted after revision October 15, 2004.
Address correspondence to I. Adaletli.
Introduction
Communication of a hydatid disease with the biliary tree has been described
in up to 90% of hepatic hydatid cysts
[1]. This is due to the
incorporation of biliary radicles into the pericyst
[2]. However, frank rupture
into the biliary tree occurs in only 5–15% of cases
[1]. Although the communication
with the intrahepatic bile ducts is common, its occurrence between a hepatic
hydatid cyst and the gallbladder is rare
[3].
We present an unusual case of a fistulous communication between a hepatic
hydatid cyst and the gallbladder. The MR cholangiopancreatography (MRCP)
features have been discussed.
Case Report
A 46-year-old man with complaints of right upper quadrant pain, fever,
icterus associated with clay-colored stools, and itching was admitted with a
diagnosis of obstructive cholangitis. Physical examination revealed tenderness
in the epigastric region and right upper quadrant of the abdomen. Laboratory
investigations showed increased serum total bilirubin (7.3 mg/dL; normal
range, 0.3–1.1 mg/dL), direct bilirubin (2.7 mg/dL; normal range,
0–0.3 mg/dL), serum glutamic oxaloacetic transaminase (107 IU; normal
range, 49 IU), serum glutamic pyruvic transaminase (175 IU; normal range, 49
IU), and serum alkaline phosphatase (1,264 IU; normal range, 270 IU)
levels.
Abdominal sonography examination showed a 5 x 4 cm cystic lesion in
the right lobe anterior segment of the liver with a heterogeneous echogenic
interior and a ringlike pattern of calcification
(Fig. 1A). The gallbladder was
considered normal on sonography. There was a slight dilatation (7 mm) in the
common bile duct. The intrahepatic bile duct segments were not dilated on
sonography.
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Fig. 1A —46-year-old man with complaints of right upper quadrant pain,
fever, icterus associated with clay-colored stools, and itching was admitted
with diagnosis of obstructive cholangitis. Abdominal sonography image shows 5
x 4 cm cystic mass in right lobe anterior segment of liver with ringlike
pattern of calcification (arrows).
|
|
Abdominal MRI and MRCP were performed for further confirmation of the
sonographic diagnosis. Axial T1-weighted (TR/TE, 583/15) and T2-weighted
(785/60) images revealed a 5 x 4 cm well-defined heterogeneous cystic
lesion (Figs. 1B and
1C). The gallbladder also was
normal on the axial T1- and T2-weighted images. The intrahepatic bile duct
segments and common bile duct were not dilated on MRI.
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Fig. 1B —46-year-old man with complaints of right upper quadrant pain,
fever, icterus associated with clay-colored stools, and itching was admitted
with diagnosis of obstructive cholangitis. Axial T1-weighted MR image (TR/TE,
583/15) shows 5x4cm well-defined heterogeneous hypointense cystic lesion
in right lobe anterior segment of liver.
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|
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Fig. 1C —46-year-old man with complaints of right upper quadrant pain,
fever, icterus associated with clay-colored stools, and itching was admitted
with diagnosis of obstructive cholangitis. Axial T2-weighted MR image (785/60)
shows 5x4cm well-defined heterogeneous hyperintense cystic lesion
surrounded by hypointense rim (arrows).
|
|
MRCP (8,000/800; scan time, 40 sec; slice, 1/5; field of view, 250/1.3;
matrix, 256 x 256) showed a cystic lesion in the right lobe anterior
segment of the liver and a direct fistulous communication between a cystic
lesion and the gallbladder (Fig.
1D). The common bile duct and left main hepatic duct were mildly
dilated on MRCP images.
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Fig. 1D —46-year-old man with complaints of right upper quadrant pain,
fever, icterus associated with clay-colored stools, and itching was admitted
with diagnosis of obstructive cholangitis. MR cholangiopancreatography image
(8,000/800; scan time, 40 sec; slice, 1/5; field of view, 250/1.3; matrix, 256
x 256) shows direct fistula between hydatid cyst and gallbladder
(arrowheads) and mild dilatation of common bile duct and left main
hepatic duct.
|
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Subsequent ERCP showed a mildly dilated common bile duct without
intrahepatic biliary tree dilatation. The hydatid cyst and the fistulous
communication were not visualized on ERCP.
We considered hepatic hydatid cyst rupture into the gallbladder on the
basis of the MRCP findings. The findings on MRCP were confirmed at surgery.
Surgery also disclosed cholecystitis secondary to rupture of the hydatid cyst
into the gallbladder.
Discussion
Hydatid disease primarily affects the liver and typically shows
characteristic imaging findings. However, there are many potential local
complications such as intrahepatic complications, exophytic growth,
transdiaphragmatic thoracic involvement, perforation into hollow viscera,
peritoneal seeding, portal vein involvement, abdominal wall invasion, and
frank biliary communication, which has been reported in only 5–15% of
cases [1]. It occurs in the
right duct in 55–60% of cases, in the left duct in 25–30%, and
rarely in the confluence or gallbladder (as in the present case)
[3]. When rupture into the
biliary tract occurs, the cystic fluid escapes into the biliary tract with
daughter cysts discharged into the common bile duct, causing biliary colic,
obstructive jaundice, and possibly liver abscess
[1,
4,
5]. Our patient presented with
right upper quadrant pain, fever, and jaundice.
On imaging studies, a dilated intrahepatic bile duct segment in association
with an adjacent cystic lesion and dilatation of the common bile duct are
generally the indirect findings of rupture of a hydatid cyst into the biliary
tree. Sonography may identify the daughter cysts within the biliary tree. The
fistulous communication between the hydatid cyst and biliary tract may
sometimes be directly identified on different imaging studies
[3]. In the present case,
sonography showed a cystic lesion with a heterogeneous echogenic interior and
a ringlike pattern of calcification suggestive of hepatic hydatid disease. No
apparent intra- or extrahepatic biliary tree dilatation was found on
sonography. Moreover, a direct communication between the cyst and gallbladder
could not be seen.
MRI and MRCP are used in difficult cases, such as intrabiliary rupture, in
which CT and sonography findings may be inconclusive. The MRI finding in
ruptured hydatid cyst can be direct or indirect
[3]. That is, the only direct
sign of rupture into the biliary tree may be the visualization of the cyst
wall defect or communication between the cyst and a biliary radicle
[1]. In the present case, MRCP
successfully identified the communication between the hydatid cyst and the
gallbladder.
ERCP is the gold standard with which to confirm biliary tract involvement
and may be of therapeutic value in selected cases. On ERCP, a swollen ampulla
of Vater may be seen, with hydatid material protruding out. Dilated ducts with
debris and daughter cysts may appear as radiolucent filling defects
[3]. Although ERCP is the gold
standard in the diagnosis of hydatid cyst rupture into the biliary tree, ERCP
findings were negative in our patient. We believe that the negative ERCP
findings were due to insufficient filling of the gallbladder with contrast
medium.
In conclusion, rupture of a hepatic hydatid cyst into the gallbladder is
extremely rare. Isolated rupture into the gallbladder may present with signs
different from those associated with intrahepatic biliary rupture. Rupture of
a cyst into the gallbladder must be included in the differential diagnosis
especially in cases in which the cyst is close to the gallbladder and direct
and indirect signs of intrahepatic biliary rupture are absent.
References
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disease: radiologic and pathologic features and complications.
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- Lewall DB, McCorkell SJ. Rupture of echinococcal cysts: diagnosis,
classification, and clinical implications. AJR1986; 146:391
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- Kumar R, Reddy SN, Thulkar S. Intrabiliary rupture of hydatid cyst:
diagnosis with MRI and hepatobiliary isotope study. Br J
Radiol 2002; 75:271
–274[Abstract/Free Full Text]
- Marti-Bonmati L, Menor F, Ballesta A. Hydatid cyst of the liver:
rupture into the biliary tree. AJR 1988;150
:1051
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- Kornaros SE, Aboul-Nour TA. Frank intrabiliary rupture of hydatid
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Introduction
Case Report
