Saudi Journal of Gastroenterology

CASE REPORT
Year
: 2007  |  Volume : 13  |  Issue : 4  |  Page : 191--193

Primary hydatid cyst of the pancreas causing obstructive jaundice


Saad R Jai, Khalid El Hattabi, Fatimazahra Bensardi, Farid Chehab, Driss Khaiz, Abdelmajid Bouzidi 
 Department of Surgery III; Ibn Rochd University Hospital, Casablanca, Morocco

Correspondence Address:
Saad R Jai
4, Rue El Ganzra, Residence El Boustane, Appt. 11. Agdal 10000, Rabat
Morocco

Abstract

Primary hydatid cyst in the head of pancreas is rare. We report a case of a 26-year-old patient, who presented with obstructive jaundice. The imaging studies, while demonstrating a fusiform dilatation of the common bile duct, was unhelpful in identifying the etiology. A pancreatic head cyst was discovered at the time of surgery. Diagnosis was confirmed by subsequent serology and identification of scolices on microscopic examination. From the reported data, we discuss the diagnostic and therapeutic modalities of this rare disease.



How to cite this article:
Jai SR, El Hattabi K, Bensardi F, Chehab F, Khaiz D, Bouzidi A. Primary hydatid cyst of the pancreas causing obstructive jaundice.Saudi J Gastroenterol 2007;13:191-193


How to cite this URL:
Jai SR, El Hattabi K, Bensardi F, Chehab F, Khaiz D, Bouzidi A. Primary hydatid cyst of the pancreas causing obstructive jaundice. Saudi J Gastroenterol [serial online] 2007 [cited 2020 Apr 9 ];13:191-193
Available from: http://www.saudijgastro.com/text.asp?2007/13/4/191/36752


Full Text

Hydatid disease is a serious health problem in endemic areas; primary pancreatic localization is a rare case of this disease.

The diagnosis is rarely made before surgery; however, it may be facilitated by computed tomography (CT) scan and magnetic resonance imaging (MRI). Herein, we report a case of hydatid cyst of the head of the pancreas causing obstructive jaundice.

 Case Report



A 26-year-old man was admitted to Ibn Rochd University Hospital to evaluate the progressing cholestasis of 2-month duration associated with epigastric pain and pruritus. His personal and medical history was unremarkable.

Physical examination revealed deep jaundice and scratch marks all over the body; there was no hepatomegaly and no mass was palpable.

Laboratory examination showed a serum bilirubin level of 339 mmol/L (reference range 8-20mg/L); aspartate aminotransferase, 207IU/L (reference range 6-40IU/L); alanine aminotransferase, 266IU/L (reference range 0-50IU/L); alkaline transferase, 358IU/L (reference range 100-290IU/L); and glutamyl transpeptidase, 888IU/L (reference range 10-50IU/L).

Abdominal ultrasonography revealed a dilated common bile duct (1.3cm) with cystic dilatation (3.5cm) at the lower end of the duct. Abdominal CT scan showed an aspect mimicking a pseudocyst in the head of pancreas (3cm) [Figure 1]. Magnetic resonance imaging was performed and saccular dilatation of the retro-pancreatic portion of the common bile duct was observed [Figure 2].

Laparotomy was performed and the cystic mass was found to be bulging from the pancreas posteriorly. After protecting the operative area by a scolicidal solution (H 2 O 2 , 1/10 volume), the aspiration of the cyst yielded a transparent fluid. Further, the cyst was opened and a germinative membrane was extracted. A partial cystectomy was performed and no communication was found between the cyst and the pancreatic duct or the biliary duct and the cystic cavity was drained.

The presence of scolex in the cystic fluid tested positive and a subsequent hydatid serology performed by an enzyme-linked immunosorbent assay was positive. The postoperative period was uneventful and the patient was discharged on the twelfth postoperative day.

The patient was free of symptoms and followed up after 24 month without any other abdominal localizations.

 Discussion



Hydatid disease produced by Echinococcus granulosus is still an endemic problem in many regions such as the Mediterranean countries, Australia, New Zealand, South America, South East and Far East Asia, and the Middle-Eastern countries. [1],[2] The prevalence in Europe and North America has increased by immigration. [3]

Isolated pancreatic localisation of the disease is rare; it has been estimated to be from 0.14 to 2% in other studies. [4],[5],[6],[7] The location of the cyst in the pancreas has different distributions: head (57%), corpus (24%) and tail (19%). [8],[9],[10] Clinical presentation is variable and insidious, depending on the location and the size of the cyst. [11],[12] Epigastric pain is the most frequent symptom. [6] Jaundice is caused by the extrinsic compression of the common bile duct. [2],[11],[13] Cysts in the corpus and tail rarely caused any symptoms and may be revealed by an abdominal mass.

However, hydatid pancreatic cyst may be revealed by a complication such as a rupture into the biliary three or into the peritoneal cavity or gastrointestinal tract, [14] abscess formation [15] or the compression of splenic vein causing portal hypertension. [15],[16] Other cysts may lead to acute pancreatitis by obstructing the pancreatic duct. [13]

The diagnosis of pancreatic cystic lesion may be performed by ultrasonography, CT scan or MRI. [17] However, in patients living in endemic areas, the presence of calcifications [6] and hyperechoic band corresponding to daughter cysts or association with another abdominal localization leads to suspect the diagnosis of hydatid disease. [18]

In our case, CT scan and MRI failed to provide a diagnosis because of the intimal contact between the cyst and the common bile duct, mimicking a pseudocyst in CT scan, and MRI failed due to a false identification as a congenital dilatation of the common bile duct.

Surgery remains the treatment of choice in hydatid disease, and to prevent parasitic dissemination, the protection of the operative site and sterilization of the cyst with a scolicidal solution such as hypertonic (20%) saline solution is necessary. [19]

Many surgical techniques are available to remove the cyst; however, pericystectomy with drainage of the residual cavity is the technique of choice. [11],[19] Because of the localization of the cyst near a major biliary or vascular structures and high risk of pancreatic fistula, [20] total pericystectomy cannot be done in some cases and partial pericystectomy would be the choice. Distal pancreatectomy with splenic conservation is the treatment of choice for hydatid cyst localized in the tail of pancreas. [11]

Percutaneous drainage of the cyst is a good alternative to surgery in patients with high surgical risk and in this case it must be combined to medical chemoprophylaxis using albendazole. [2]

In our endemic country, we assume that hydatid cyst must be considered as a differential diagnosis of cystic lesions in the pancreas and the conservative treatment (partial or total pericystectomy) remains the procedure of choice for this pathology.

 Conclusion



Primary hydatid cyst in the head of pancreas is extremely rare, even in endemic areas. Hydatid cyst should be included in the differential diagnosis of cystic lesions of the pancreas.

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