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

2. 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

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. Subdiaphrag matic 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 Side viewing camera Dilated CBD Multiple filling defects Drain at site of excised cyst

13. ERCP

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

17. Jenin again, Ascending cholangitis  Swab culture & Sensitivity from the drain: Pseudomonus Aurigenosa resistant 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 5 th 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. Measured/date27/12/20077/1/2008 WBC 9.8 10 Hb 11.4 10 TSB 14.3 7.7 Direct billirubin 11 2.8 ALP 3370 1725 ALT 236 47 Platelets 369 519 Creatinine 1.4 0.9 Before stentAfter 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

23. Summary Initial presentationSurgery ERCP Ascending cholangitis Stenting Treatment

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. Thanx for…………………