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Case Presentation

Case Presentation. Maha Akkawi Bayan Abu-Eisheh Supervised By: Dr Yaser Abu Safeyeh. The patient course. Initial Presentation 1 st admission………. SURGERY Refferal for…………. ERCP Readmission….. Ascending cholangitis Referral to Al-Maqasid …… Stenting Treatment of billiary hydatid disease.

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Case Presentation

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  1. Case Presentation Maha Akkawi Bayan Abu-Eisheh Supervised By: Dr Yaser Abu Safeyeh

  2. The patient course • Initial Presentation • 1st admission………. SURGERY • Refferal for…………. ERCP • Readmission….. Ascending cholangitis • Referral to Al-Maqasid …… Stenting • Treatment of billiary hydatid disease

  3. Case Presentation, History A 47 year old married female from Qabatyeh-Jenin presented with: • Intermittent, progressive epigastric pain since the beginning of last September. • Pain radiated to the back & Rt. shoulder, not related to food, relieved by leaning forward.

  4. Case Presentation, History • Pain associated with nausea, dyspnea • At that time no jaundice , change in stool and urine color, or itching. • The patient had cholecystectomy in 1996 and free past medical history.

  5. Case Presentation, History • Seen by many OP doctors, Abdominal U/S done &…………. Partly solid partly cystic 5.5 cm cyst in the Rt. Subdiaphragmatic area

  6. Case Presentation, History • She had contact with sheep 20 years ago. • Some neighbors reported the same problem to her.

  7. Admission to Jenin, surgery So She was admitted to Jenin Governmental Hospital on 12/11/2007 For elective surgery on the next day

  8. Admission to Jenin, surgery CBC Serum electrolytes Liver Function tests WERE ALL Normal Kidney function tests CXR

  9. During Surgery… • Kocher incision, Large oval cyst found (10x5x5 cm) in the Rt. Lobe of the liver immediately below diaphragm • Aspiration of the cyst content, injection of hypertonic saline & deroofing & excision was done, drain inserted in the big cavity left

  10. Case Presentation, Hospital course In the immediate postoperative period the patient was fairly doing well, afebrile, not jaundiced , and her lab results were expected. BUT The drain was giving out large amount of green colored output (600-800cc/day) Patient Started on Albendazole tablet 400mgx2

  11. High drain output………ERCP • She was admitted to specialized Arab hospital in 28/11/2007 for ERCP • ERCP • sphincterotomy • extraction of multiple daughter hydatid cysts • Injection of hypertonic saline 10%

  12. Case Presentation, Hospital course Drain at site of excised cyst Dilated CBD Multiple filling defects Side viewing camera

  13. ERCP

  14. ERCP After ERCP drain output decreased, & she was discharged home in stable condition

  15. Jenin admission, Ascending cholangitis In 18/12/2007 the patient was readmitted to Jenin Hospital with jaundice, generalized fatigability, attacks of fever, & pruiritis Physical examination revealed tinge of jaundice & scratch marks Drain output 100-200cc/day of thick yellow discharge

  16. CBC: HB: 10 WBC: 12.000 Plt: 365.000 KFT: Cr: 0.3 BUN: 6 LFT: ALT: 137 AST: 163 ALP: 1790 TSB: 2.2 INR: 1.7 PTT: 36 Jenin again, Ascending cholangitis

  17. Jenin again, Ascending cholangitis • Swab culture & Sensitivity from the drain: Pseudomonus Aurigenosaresistant to all available antibiotics • Treated by Ceftazidime & Metronidazole While waiting referral to Al-Maqasid Hospital

  18. From Jenin to……. Almaqasid • In Al-Maqasid another culture taken which was positive for klebsiella pnemoniae ; resistant for all antibiotics except tazopactam + pepracillin • The patient was treated with tazopactam + pepracillin (4.5 gm*4) IV, albendazole and supportive treatment for ascending cholangitis

  19. Almaqasid………stent • In the 5th hospitalization day after stabilization of her condition she was referred to Augusta Victoria Hospital and ERCP was done there with stent insertion in CBD. • Later the patient clinically improved, the lab data also improved. • 4 days later the drain was removed due to decreased output, & discharged home thereafter

  20. Before stent After stent

  21. The patient finally……. Well • In 13/3/2008 the patient was looking well, afebrile, not jaundiced, adding weight, and free of symptoms. • Examination was unremarkable except for minimal oozing of the drain side • abdominal x-ray showed stent in place.

  22. Stent Stent

  23. Summary Initial presentation Surgery Treatment ERCP Stenting Ascending cholangitis

  24. Hydatid disease of the biliary tree • Hepatic hydatid disease (HHD) is a major endemic problem in sheep-rearing regions of the world. • Communication between cysts and the biliary tree is detected at a rate of approximately 20%. • Intrabiliary rupture, which has an incidence of 5-17%, is a common complication of hydatid cysts Reference : Gastroenterology and hepatology journal

  25. Hydatid disease of the biliary tree • A rupture into the biliary tree can lead to obstruction by the daughter cysts, producing cholangitis. • Imaging techniques are highly sensitive for detecting liver hydatidosis, but usually fail to locate the involvement of the biliary tree. • The presence of a dilated common bile duct (CBD), jaundice, or both, in addition to a cystic lesion on (US) and (CT), are suggestive of biliary hydatid disease (BHD). Reference : Gastroenterology and hepatology journal

  26. Hydatid disease of the biliary tree • ERCP with endoscopic sphincterotomy and extraction of the cysts from the CBD has emerged as a safe and an effective treatment for patients with intrabiliary rupture of hepatic hydatid cysts. Plus Albendazole. • Surgery is an alternative.. Reference : The internet journal of gastroenterology.

  27. Thank You Thanx for…………………

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