S5878 Unmasking the Biliary Trap: Diagnostic and Therapeutic Challenges of Cysto-Biliary Communication in Hepatic Hydatid Disease

Introduction: Hepatic hydatid disease, caused by Echinococcusgranulosus, often follows an indolent course but may lead to complication in up to 40% of patients. Cysto-biliary communication is the most common complication. Frank communication with intraductal migration of daughter cysts presents a diagnostic and therapeutic challenge, especially in elderly or comorbid patients. These cases may mimic neoplasms or pyogenic abscesses, leading to misdiagnosis and delayed treatment. Case Description/Methods: A 75-year-old woman with diabetes and hypertension presented with right upper quadrant abdominal pain, vomiting, anorexia, and acute encephalopathy with global aphasia. Liver enzymes revealed cholestatic injury (elevated alkaline phosphatase and gamma-glutamyl transferase). Ultrasound revealed a complex hepatic cyst; MRI showed an 11 × 8.6 × 8.5 cm T2-hyperintense lesion in the right lobe with internal daughter cysts, complex septations, and a tubular projection extending beyond the capsule – raising suspicion for cysto-biliary communication, confirmed on MRCP. Serology detected Echinococcus infection. Albendazole was initiated preoperatively. Exploratory laparotomy revealed an infected hydatid cyst adherent to the diaphragm with daughter cysts extending into the common bile duct. Cystopericystectomy, common bile duct clearance, and biliary stenting were performed. Neurologic function improved postoperatively and the patient remained well on follow-up. Discussion: This case highlights several clinical pearls. First, frank cysto-biliary communication with intraductal migration is rare and easily overlooked without high clinical suspicion. Second, advanced imaging, especially MRCP, is critical for detecting occult biliary communications and informing surgical planning. Third, radical surgical intervention remains the cornerstone of treatment in extensive cysto-biliary communication, with benzimidazole therapy playing and adjunctive role in perioperative management. Early anti-parasitic therapy reduces risk of intraoperative spillage and recurrence. Cysto-biliary communication in hepatic hydatidosis is under-recognized and frequently misdiagnosed. In elderly or immune-compromised patients, a multidisciplinary approach incorporating imaging, anti-parasitic therapy, and radical surgery is essential for optimal patient outcomes.