Am. J. Trop. Med. Hyg., 79(2), 2008, pp. 147-148
Copyright © 2008 by The American Society of Tropical Medicine and Hygiene
Cysto-biliary Fistula in a Septic Patient with Cystic Echinococcosis
Dennis Tappe*,
Wolfgang Scheppach, AND
August Stich
Department of Tropical Medicine, Medical Mission Hospital, Würzburg, Germany; Department of Gastroenterology and Rheumatology, Stiftung Juliusspital, Würzburg, Germany
A diagnosis of cystic echinococcosis (CE) with two partly calcified hepatic lesions was made in a Turkish patient who immigrated to Germany 38 years ago. One lesion, which was 10 cm x 10 cm, was located in the quadrate lobe close to the gallbladder. The other lesion, which was 4.3 cm x 3.5 cm, was located in the left lobe of the liver. These lesions showed no internal structures and were considered inactive, corresponding to type 5 of the World Health Organization classification.1 The patient had cholecystolithiasis and developed biliary pancreatitis. Laparotomy and cholecystectomy were performed.
Four months later, severe bacteremic cholangitis was diagnosed. Abdominal computed tomography showed cysto-biliary fistula of the echinococcal lesion in the quadrate lobe. The fistula had a diameter of 2.5 cm (Figure 1A
, arrow). The choledoch duct was dilated. Endoscopic retrograde cholangiopancreatography demonstrated an amorphous mass discharging into the duodenum after incision of the duodenal papilla (Figure 1B). Microscopic examination of the material showed echinococcal membranes and detritus (Figure 1C). The lesion in the quadrate lobe was then resected and remaining echinococcal material was evacuated from the choledoch duct. Results of a follow-up examination were uneventful. Cystic echinococcosis is a cosmopolitan zoonosis and this clinical image illustrates its most common complication, spontaneous rupture into the biliary tract.2
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FIGURE 1. A, Abdominal computed tomography of the patient showing a cysto-biliary fistula of an echinococcal lesion in the quadrate lobe (arrow). The fistula had a diameter of 2.5 cm. B, Endoscopic retrograde cholangiopancreatography of the patient showing an amorphous mass discharging into the duodenum after incision of the duodenal papilla. C, Microscopic examination of the material from the patient showing echinococcal membranes and detritus. This figure appears in color at www.ajtmh.org.
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Received April 14, 2008.
Accepted for publication May 14, 2008.
* Address correspondence to Dennis Tappe, Department of Tropical Medicine, Medical Mission Hospital, Salvatorstrasse 7, 97067 Würzburg, Germany. E-mail: dtappe{at}hygiene.uni-wuerzburg.de 
Authors’ addresses: Dennis Tappe and August Stich, Department of Tropical Medicine, Medical Mission Hospital, Salvatorstrasse 7, 97067 Würzburg, Germany, E-mails: dtappe{at}hygiene.uni-wuerzburg.de and stich{at}missioklinik.de. Wolfgang Scheppach, Department of Gastroenterology and Rheumatology, Stiftung Juliusspital, Juliuspromenade 19, 97070 Würzburg, Germany, E-mail: w.scheppach{at}juliusspital.de.
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REFERENCES
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- World Health Organization Informal Working Group, 2003. International classification of ultrasound images in cystic echinococcosis for application in clinical and field epidemiological settings. Acta Trop 85: 253–261.[Web of Science][Medline]
- Bedirli A, Sakrak O, Sozuer EM, Kerek M, Ince O, 2002. Surgical management of spontaneous intrabiliary rupture of hydatid liver cysts. Surg Today 32: 594–597.[Web of Science][Medline]
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