Endoscopic management of biliary parasitic diseases

A Novel Technique for the Management of Persistent Biliary Fistulas Developing After Liver Hydatid Cyst Surgeries: Drain Clamping Technique

BACKGROUND

External biliary fistula, where the residual cyst is associated with the biliary tree, is one of the most common complications after liver hydatid cyst surgery. Surgical procedures become a consideration for patients in whom the biliary fistula persists despite all endoscopic procedures. However, reoperation for biliary fistula after hydatid cyst surgery leads to additional complications and increases morbidity and mortality.

AIM

This study aims to treat persistent biliary fistulas that develop after liver hydatid cyst surgery using a simple noninvasive technique.

MATERIALS AND METHODS

External drainage surgery was performed on 295 patients with liver hydatid cysts. Endoscopic treatment methods were used in patients who developed biliary fistula after surgery. Despite all endoscopic treatment methods, 14 patients developed persistent biliary fistulas. These patients were subsequently treated using the drain clamping technique.

FINDINGS

All persistent fistulas occluded in 11.86 days (with a range of 8-20 days). No complications were observed in the one-year follow-up visits.

CONCLUSION

Drain clamping, a novel approach to the treatment of persistent biliary fistulas developed despite all available endoscopic methods, can be safely used. This technique resulted in a complete recovery in patients without the need for surgical procedures.

Cholangiohydatidosis. Clinical features, postoperative complications and hospital mortality. A systematic review

BACKGROUND

Cholangiohydatidosis (CH) is an evolutionary complication of hepatic cystic echinococcosis, associated with increased morbidity and mortality. The aim of this study was to describe the available evidence regarding clinical characteristics of CH, postoperative complications and hospital mortality.

METHODOLOGY/PRINCIPAL FINDINGS

Systematic review. Studies related to CH with no language or publication restriction were included. Sensitive searches were performed in Trip Database, SciELO, BIREME-BVS, WoS, PubMed, EMBASE and SCOPUS. MeSH and free terms were used, including articles up to April 2023. The main outcome variables were postoperative complications and hospital mortality; the secondary ones were publication year, origin and design of primary studies, main clinical manifestation, anatomical location and type of cysts, hospital stay, surgical procedure performed, reinterventions; and methodological quality of primary studies, which was assessed using MInCir-T and MInCir-P scales. Descriptive statistics, calculation of weighted averages and their comparison by least squares logistic regression were applied. 446 studies were retrieved from the searches performed, 102 of which met the inclusion and exclusion criteria. The studies analyzed represent 1241 patients. The highest proportion of articles was published in the last decade (39.2%). Reports are mainly from Turkey (28.4%), Greece (9.8%), Morocco and Spain (8.8% each). With a weighted mean of 14.3 days of hospital stance; it was verified that 26.2% of patients developed postoperative complications (74,3% Clavien y Dindo III y IV), 6.7% needed re-interventions, and 3.7% died. When comparing the variables age, postoperative complications, hospital mortality, and reinterventions in two periods of time (1982-2006 vs. 2007-2023), no statistically significant differences were found. When applying the MInCir-T and MInCir-P scales, the methodological quality of the primary studies was 9.6±1.1 and 14.5±4.3 points, respectively.

CONCLUSION/SIGNIFICANCE

CH is associated with severe postoperative complications and significant hospital mortality, independent of the development of therapeutic support associated with the passage of time.

Case Report: Fascioliasis Hepatica Precisely Diagnosed by Metagenomic Next-Generation Sequencing and Treated With Albendazole

The clinical manifestations of fascioliasis hepatica in humans are unspecific. Traditional diagnosis relies on evidence of live parasites or eggs in the bile or feces. However, due to similar imaging manifestations, they are often misdiagnosed as malignant tumors. Here, we report a case of a 43-year-old woman with fever and space-occupying liver disease. Liver biopsy, parasite-specific antibody screening, and stool testing did not find any pathogens. Therefore, metagenomic next-generation sequencing (mNGS) and routine microbiological examinations were performed. Finally, Fasciola hepatica was only identified by mNGS. The body temperature of the patient and the eosinophil count remained normal, and the space-occupying liver lesions were significantly absorbed after more than 7 months of treatment with albendazole. The details of this case highlight the timely use of mNGS to identify parasites and judge therapeutic effects after treatment, providing important help for clinical decision-making.

Treatment response and long-term outcomes in biliary ascariasis: A prospective study

BACKGROUND AND STUDY AIMS

Anti-helminthic therapy and endoscopic worm extraction had variable success rates in biliary ascariasis. Recurrent biliary events after worm clearance are common. We aimed to evaluate the outcomes of management in biliary ascariasis and find out the incidence and risk factors for the development of recurrent biliary events.

PATIENTS AND METHODS

Consecutive patients with biliary ascariasis detected on abdominal ultrasound (AUS), were selected. Initial conservative treatment with oral Albendazole (400 mg) and analgesics was started in all. Successful therapy was defined as symptomatic resolution, and AUS confirmed biliary clearance after three weeks. ERCP (Endoscopic retrograde cholangiopancreatography) was performed in patients with failed conservative management. The patients were prospectively followed up for a minimum period of 1 year.

RESULTS

Among 98 patients with biliary ascariasis, 23 (23.5%) responded to medical management alone. A presentation with obstructive jaundice (p = 0.04) and cholangitis (p = 0.007) was significantly associated with failure to medical management. Sixty-five (86.7%) among 75 patients had successful biliary clearance with ERCP. During a median follow up of 16 months, 24 (24.5%) patients had recurrent biliary events. Lower socioeconomic status (OR = 0.78, p = 0.023) and longer follow-up (OR = 1.16, p = 0.001) were independent risk factors for recurrent biliary events.

CONCLUSION

Early ERCP among high-risk patients and proper hygiene are the keys to successful management in biliary ascariasis.

Fasciola Hepatica Induced Hepatic Abscess Treated with Triclabendazole

Fascioliasis is a zoonotic disease caused by Fasciola hepatica that infects mainly cattle, sheep, and goats. Humans can be infected by water or aquatic plants contaminated with metacercariae. The authors encountered two cases of F. hepatica infection. One patient reported abdominal discomfort with marked eosinophilia. The other patient had chest discomfort with marked eosinophilia. The abdominal CT images revealed hypodense lesions in the liver. The ultrasonography-guided liver biopsy findings in both patients were indicative of parasitic infections. Serological tests confirmed the definite diagnoses. Both patients were treated with a single dose of triclabendazole, which is the treatment of choice for fascioliasis. These findings suggest that a diagnosis of fascioliasis, particularly in the acute phase, should be considered in patients with abdominal pain, marked eosinophilia, and hypodense hepatic lesions on CT.

Treatment failure after multiple courses of triclabendazole in a Portuguese patient with fascioliasis

Fascioliasis is a trematode flatworm infection caused by Fasciola hepatica Humans are incidental hosts, and the infection is most often acquired by eating watercress grown in contaminated water in livestock-rearing areas. Triclabendazole is the only highly effective treatment, with a reported cure rate of >90%. Treatment failure may be due to several factors, though resistance is rare in humans and scarcely reported, most probably a reflection of the widespread use of anthelmintics in livestock. There are three papers describing cases of treatment failure, possibly due to resistance, in the Netherlands, Chile and Peru. We document for the first time one case of failure after multiple treatment courses with triclabendazole in Portugal, probably due to resistance to the anthelmintic. Our aim is to alert for the emergence of resistance across continents, with consequent predictable difficulties in the management of the disease and encourage more investigation in the field.

Seroepidemiology of human fascioliasis and its relationship with anti-Fasciola IgG and liver enzymes as biomarkers of pathogenicity

BACKGROUND

Fascioliasis has never been considered a public health concern in Pakistan, although the increasing numbers of human cases reported in south Asia need a re-consideration in the country. The current study aimed to find the seroprevalence of human fascioliasis, associated risk factors and its relationship with liver enzymes as biomarkers of pathogenicity.

METHODS

The cross-sectional study was conducted in different districts of Punjab region from May 2014 to August 2016. A total of 546 respondents were screened by using enzyme-linked immunosorbent assay (ELISA) and serum biochemical tests.

RESULTS

Higher seroprevalence was recorded in Muzaffargarh (6.2%) and Bhara kahu (5.9%), while low infection rate in Gujranwala (1.1%) and Islamabad (1.5%). The results of multiple logistic regression analysis showed rural inhabitants (OR=7.9, 95%CI: 2.5-24.8), females (OR=3.5, 95%CI: 1.7-7.1), family size 3-7 (OR=1.7, 95%CI: 1.0-2.9) and socioeconomic condition (OR=3.9, 95%CI: 1.5-10.4) were the significantly (p<0.005) associated risk factors with disease. The results of liver enzymes i.e. aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, gamma-glutamyl transferase and cholesterol levels were significantly (p=0.001) elevated and associated with fascioliasis pathogenicity.

CONCLUSION

The higher prevalence recorded may explain with Fasciola IgG antibodies for both active and past infections and cross reactivity of the assay with other helminthes.

Fascioliasis presenting as colon cancer liver metastasis on 18F-fluorodeoxyglucose positron emission tomography/computed tomography: A case report

BACKGROUND

Fascioliasis is caused by watercress and similar freshwater plants or drinking water or beverages contaminated with metacercariae. Fascioliasis can radiologically mimic many primary or metastatic liver tumors. Herein, we aimed to present the treatment process of a patient with fascioliasis mimicking colon cancer liver metastasis.

CASE SUMMARY

A 35-year-old woman who underwent right hemicolectomy due to cecum cancer was referred to our clinic for management of colon cancer liver metastasis. Both computed tomography and ¹⁸F-fluorodeoxyglucose positron emission tomography revealed several tumoral lesions localized in the right lobe of the liver. After a 6-course FOLFOX (folinic acid, fluorouracil, oxaliplatin) and bevacizumab regimen, the hypermetabolic state on both liver and abdominal lymph nodes continued, and chemotherapy was extended to a 12-course regimen. The patient was referred to our institute when the liver lesions were detected to be larger on dynamic liver magnetic resonance imaging 6 weeks after completion of chemotherapy. Right hepatectomy was performed, and histopathological examination was compatible with fascioliasis. Fasciola hepatica IgG enzyme-linked immunosorbent assay was positive. The patient was administered two doses of triclabendazole (10 mg/kg/dose) 24 h apart. During the follow-up period, dilatation was detected in the common bile duct, and Fasciola parasites were extracted from the common bile duct by endoscopic retrograde cholangiopancreatography (ERCP). Triclabendazole was administered to the patient after ERCP.

CONCLUSION

Parasitic diseases, such as those caused by Fasciola hepatica, should be kept in mind in the differential diagnosis of primary or metastatic liver tumors, such as colorectal cancer liver metastasis, in patients living in endemic areas.

Management of liver hydatid cyst with cystobiliary communication and acute cholangitis: a 27-year experience

PURPOSE

The rupture of the hydatid cyst into the bile ducts is a common and serious complication. The rupture can be latent or revealed after a complication such as acute cholangitis. The objective of this study was to discuss the clinical features, radiographic findings, and surgical treatment of this rare complication.

METHODS

A retrospective analysis of patients operated for acute cholangitis caused by hydatid cyst between January 1990 and May 2016 was conducted.

RESULTS

Our study included 55 cases of acute cholangitis caused by ruptured hydatid cyst: 35 were men and 20 were women. Five patients had medical history of hydatid cyst. On imaging, all patients had a dilated bile duct. In 51 cases, there was a single hydatid cyst. Hydatid cysts with fistula were located in the right lobe of the liver in 49 cases and in the left lobe in 6 cases. Seven patients underwent an emergency surgery after admission, while others were operated after 3-8 days. A conservative procedure associated with drainage was applied in 49 cases. Endoscopic treatment was performed in four cases which failed in two cases. Twenty-eight cases developed postoperative complications, among which the most common complication was biliary fistula (n - 17). There were eight cases of postoperative deaths (14.5%).

CONCLUSIONS

Liver hydatid cyst with cystobiliary communication and superadded acute cholangitis is a serious clinical problem requiring the early diagnosis and surgery in the absence of endoscopic therapy.

Focal Biliary System Obstruction and Atypical Liver Mass: Intrabiliary Ruptured Cyst Hydatid Case Report

Background

Hydatid disease can involve any part of the body, but the liver is the most frequently affected organ. Intrabiliary rupture is one of the most serious complications of a hepatic hydatid cyst. Radiological findings, especially magnetic resonance imaging and magnetic resonance cholangiopancreatography (MRI/MRCP), are helpful in the diagnosis of hydatid disease.

Case Report

We present a 48-year-old female patient with complaints of abdominal pain and jaundice. Radiological examination showed a heterogeneous lesion that contained cystic-solid components and millimetric calcifications in the liver. Adjacent intrahepatic bile ducts were dilated.

Conclusions

In geographical areas endemic for hydatid disease, cyst rapture into the bile ducts should be included in the differential diagnosis even in seronegative cases, although it is not typical for hydatid cyst to be found as a mass lesion in the liver on US in patients with right upper quadrant pain and jaundice.Detailed imaging by MRI/MRCP should be done.

Role of endoscopic retrograde cholangiopancreatography in the management of hepatic hydatid disease

Most cases of hepatic hydatid disease exhibit uncomplicated clinical course and management. However, the diagnosis and management of complicated hepatic hydatid disease is a special issue. One of the most common and serious complications of hepatic hydatid disease is the rupture of the cyst into intrahepatic bile ducts. The clinical appearance of intrabiliary rupture can range from asymptomatic to jaundice, cholecystitis, cholangitis, liver abscess, pancreatitis and septicemia. Current treatments for major ruptures can result in high morbidity and mortality rates. Furthermore, ruptures that cannot be diagnosed preoperatively can induce complications such as biliary fistulae, biloma, cavitary infection and obstructive jaundice. In the past, these complications were diagnosed and treated by surgical methods. Currently, complications in both the pre- and postoperative periods are diagnosed and treated by non-invasive or minimally invasive methods. In clinical practice, endoscopic retrograde cholangiopancreatography (ERCP) is indicated for patients with preoperative frank intrabiliary rupture in which hydatid elements are clearly seen in the bile ducts, or for biliary adverse events after surgery, including persistent biliary fistulae and jaundice. However, controversy concerning routine preoperative ERCP and prophylactic endoscopic sphincterotomy in patients suspected of having minor cystobiliary communications still remains. In this article, the role of ERCP in the diagnosis and management of hepatic hydatid disease during the pre- and postoperative periods is reviewed.

Etiology and outcome of acute pancreatitis in children in Kashmir (India). An endemic area of hepatobiliary ascariasis

BACKGROUND

The purpose of the present study was to determine the etiology, management, and outcome of acute pancreatitis (AP) in children in an endemic area of hepatobiliary ascariasis (HBA).

METHODS

This was a prospective, hospital-based study over a 9-year period that included 156 children younger than 12 years of age who had a diagnosis of AP.

RESULTS

Of the 156 patients, 71 were boys and 85 were girls with a mean age of 8.4 ± 1.5 years (range 3-12 years). The various factors contributing to AP were biliary ascariasis in 93 cases (60 %), gallstones 16 (10 %), trauma 5 (3 %), choledochal cyst 4 (3 %), impacted bile duct stone 3 (2 %), and gallbladder sludge 2 (1 %). Idiopathic group 33 cases (21 %). Diagnosis was based on clinical picture, abdominal ultrasonography, and elevated serum amylase level. Pancreatitis was mild in 113 (72 %) patients and severe in 43 (28 %). With conservative therapy, 123 patients (79 %) improved, whereas the remaining 33, who had intractable abdominal pain, cholangitis, or worsening cholecystitis, underwent emergency endoscopic retrograde cholangiopancreatography for removal of worms (26 patients) and stones in the bile duct (7 patients). Bile duct stones were extracted in all 7 patients with that condition, and worms were extracted from 23 of the 26 patients with ascariasis. Emergency surgery was performed in five patients. Three patients died. Pancreatitis recurred in 16 patients due to HBA.

CONCLUSIONS

Pancreatitis is not uncommon in children. Ascariasis is a leading cause of AP in endemic areas. Patients usually respond to conservative management, but endoscopic treatment is effective. Surgery is rarely required.

Cysto-biliary communication in liver hydatidosis

BACKGROUND

Liver hydatidosis is a severe health problem in endemic areas. Due to migration from these countries to other zones, now it is a worldwide problem. Liver hydatidosis can provoke many complications (abscess, fistula to adjacent organs, migration, etc.), but the most frequent and one of the most severe complication is the communication between the cyst and the biliary tree.

AIM

The aim of this study is to perform a review on the epidemiology, clinical features, diagnostic methods, and therapeutic options to treat the communication between the cyst and the biliary tree.

RESULTS

Due to the lack of randomized clinical trial or meta-analysis on this topic, we performed a classical review and included our personal algorithm.

CONCLUSIONS

The communication between the cyst and the biliary tree varies from a small communication to a frank intrabiliary rupture. The percentage of patients with the communication between the cyst and the biliary tree is not well known because there is no accepted definition. The therapeutic options are multiple and related to the size of the communication, the location of the cyst, and the experience of the hepatobiliary surgeon. ERCP is now an important tool for the treatment of the communication between the cyst and the biliary tree.

Clinical presentation and management of Fasciola hepatica infection: Single-center experience

AIM: To identify the characteristic clinical, laboratory and radiological findings and response to treatment in patients with fascioliasis.

METHODS: Patients who were diagnosed with Fasciola hepatica infection were included in this prospective study. Initial clinical, laboratory and radiological findings were recorded. All patients were followed until a complete response was achieved or for 6 mo after treatment discontinuation.

RESULTS: Fasciola hepatica infection was diagnosed in 30 patients (24 females; mean age: 42.6 years) between January 2008 and February 2011. Twenty-two (73%) patients had hepatic phase fascioliasis, 5 patients had biliary phase, and 3 patients had biliary phase associated with acute pancreatitis. Of the 8 patients with biliary phase fascioliasis, 2 patients displayed features that overlapped with both hepatic and biliary phase. Abdominal pain and right upper abdominal tenderness were the most prominent signs and symptoms in all patients. Eosinophilia was the most prominent laboratory abnormality in both patients with hepatic and biliary phase (100% and 50%, respectively). Multiple nodular lesions like micro-abscesses on abdominal computerized tomography were the main radiological findings in patients with hepatic phase. Small linear filling defects in the distal choledochus were the main endoscopic retrograde cholangiopancreatography (ERCP) findings in patients with biliary phase. Patients with hepatic phase were treated with triclabendazole alone, and patients with biliary phase were treated with triclabendazole and had live Fasciola hepatica extracted from the bile ducts during ERCP.

CONCLUSION: Fasciola hepatica infection should be considered in the differential diagnosis of patients with hepatic or biliary disease and/or acute pancreatitis associated with eosinophilia.