Brief Reports P Ranjeev, K Goh,M Rosmawati, et al. Figure 2. Retrograde cholangiogram showing hydatid cyst cavity (A), left hepatic duct with nasobiliary drain in place (B), and right hepatic duct (C). leak after cholecystectomy, and recurrent cholangi- tis. Their great advantage is that they are easily removed and that a cholangiogram can be obtained prior to removal. Their main disadvantage is dis- comfort to the patient. Surgery is the only method of treatment of hydatid cysts when complications are present (e.g., pain, rupture, pressure), because phar- macologic agents (levamisole) have not proved to be effective. In our patient further surgery seemed unavoid- able and would have increased the general problems associated with management of an already bedrid- den person. ERCP offered a prompt solution and resulted in prompt healing of the fistula. Vagianos et al. 4 reported a similar case. After the drain was accidentally removed in our patient there was no further drainage, whereas up to that moment it was still draining 30 mL/day. This raises the possibility that the drain itself was preserving the fistula. The drain was not firmly sutured and the patient con- fessed he was manipulating it. The polyp at the papilla could have been hindering bile flow. REFERENCES 1. Voros D. Pericystectomy as a radical method of treating hydatid disease of the liver [in Greek]. Acta Chir Hellen 1994;66:331-4. 2. VorosD. Current trends on diagnosis and surgical treatment of liver echinococcal disease: the importance of total cystectomy (cystopericystectomy) [abstract, in Greek]. 8th Mediterranean Congress of Chemotherapy 1992. Athens, Greece: 1992. 3. Barros JL. Hydatid cyst of the liver. Am J Surg 1978;135:597- 600. 4. Vagianos C, Polydorou A, Karatzas T, Vagenas C, Stavropoulos M, Androulakis J. Successful treatment of post- operative external biliary fistula by selective naso-biliary drainage. HPB Surg 1992;6:115-24. Intrahepatic biloma: an unusual compli- cation of cholangiocarcinoma treated endoscopically Prabhakeran Ranjeev, MD, Khean-Lee Goh, MD, Mohammed Rosmawati, MD, Yan-Mei Tan, MD Intrahepatic rupture of the biliary tree due to nontraumatic causes is an unusual event. Biloma, either intrahepatic or extrahepatic, usually occurs as a result of trauma or iatrogenic injury including abdominal surgery, percutaneous catheter drainage From the Division of Gastroenterology, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia. Reprint requests: Prabhakeran Ranjeev, MD, Division of Gastroenterology, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur 59100, Malaysia. Copyright 9 1999 by the American Society for Gastrointestinal Endoscopy 0016-5107/99/$8.00 + 0 37/54]100337 and transhepatic cholangiogram. 1-3 Nontraumatic rupture of the biliary tree usually occurs in the com- mon bile duct in the presence of biliary stones. It is extremely unusual for intrahepatic duct rupture to result in biloma formation 4 in the presence of cholan- giocarcinoma. We report a case of spontaneous rup- ture of the intrahepatic biliary tree with biloma for- mation in association with cholangiocarcinoma. CASE REPORT A 71-year-old woman initially presented with progres- sive jaundice and weight loss of 2 weeks duration. CT showed dilated intrahepatic ducts and an ERCP revealed a tight stricture from subhilar to the intrahepatic ducts (type 3 Klatskin's tumor). Cytologic specimens obtained by brushing during the procedure indicated the presence of adenocarcinoma. A 12 cm, 10F plastic biliary endopros- thesis (Amsterdam type straight stent; Wilson-Cook Medical Inc, Winston-Salem, NC) was inserted into a dilated right intrahepatic duct with good flow of bile. The patient's jaundice subsided and her general condition VOLUME 50, NO. 5, 1999 GASTROINTESTINAL ENDOSCOPY 711