Hydatid disease of the liver with gall-stones in the hydatid cavity

History and clinical findings: A 65-year-old woman was hospitalized with suspected cholelithiasis. The only contributary item in the history was jaundice of uncertain cause 15 years previously. Physical examination elicited pain in the right upper abdomen on deep palpation. Investigations: Alkaline phosphatase and gamma-GT activities were raised (324 and 407 U/ml, respectively). Ultrasound revealed cholecystolithiasis; the bile duct was 5 mm in diameter. Intravenous contrast-medium cholangiography showed choledocholithiasis and circular flat calcification in the bifurcation of the hepatic duct. Computed tomography revealed this structure to be a space-occupying mass (10 x 6 x 5 cm), with a calcified border (density of 27 Hounsfield units), raising the suspicion of a blood-containing hydatid cyst. Additionally there were two calculi in the left hepatic duct. But the echinococcus test (by indirect haemagglutination and enzyme-linked immunosorbent assay) was negative. Treatment and course: Endoscopic retrograde cholangiography (ERC) with papillotomy was performed and two choledochal concrements removed. Concrements within the mass were also visualized. Obstructive jaundice developed 3 days after the ERC and a laparotomy was performed. Excision of the hydatid was not possible because the stone-filled hydatid cavity could not be punctured. Choledochal exploration discovered membranes which histologically were chitin-like structures and corresponded to scolices. Under chemical Litholysis the hydatid became smaller. in addition, albendazole was given in two four-week cycles (400 mg twice daily). The patient quickly recovered and 5 months later was symptom-free.