Two interesting cases of jaundice presented in past 12 months.
Case 1 of Jaundice
Fit 60yr black female deeply jaundiced (painless). Palpable GB. USSCan and CT showed dilated CBD and possible pancreatic lesion, but nothing definite. ERCP showed narrowing of intrapancreatic CBD, not wonderful definition, possible cholangioCA. At surgery the pancreatic head was a little bulky, and going on the likelihood of a Ca in an otherwise fairly fit patient I did a pylorus preserving Whipple’s. Dissecting the specimen afterwards a 2cm Hydatid cyst – unilocular, shelled out of the head of pancreas. It had eroded through into the CBD. Patient made an uneventful post op recovery.
Case 2 of Jaundice
Fit 30yr black female deeply jaundiced (painless). Again palpable GB. USScan and CT showed dilated ducts to pancreas, 5cm thin walled apparently unilocular thin walled cyst in region of head of pancreas. ERCP not done (this does involve a several day to weeks wait and a transfer under less than ideal transport 200Km to Durban). At laparotomy pancreas head bulky and slightly fluctuant. Needle aspiration revealed clear fluid from a cyst – no bile. Pancreas showed no signs of pancreatitis. I mobilised the pancreatic head fully and found the lesion nearest to the posterior aspect of the pancreas. I aspirated the cyst as much as possible, and incised the pancreatic head posteriorly, enucleating a thin walled unilocular hydatid cyst. I left a drain in the hole in the pancreas, which dried up rapidly and the patient is now ready for discharge, jaundice rapidly diminishing. There are very few sheep in the area, cattle being the main livestock, with some goats. Hydatid disease is rare here and in 4 years of practise we have had no others at our hospital (catchment area about 2.5 million.
I would welcome comments if others have had experience diagnosing and managing hydatids – clearly we didn’t do too well on the diagnostic side. Would you have done a formal drainage procedure of the CBD in the second patient.