Rupture of a hepatic hydatid cyst (HHC) into the biliary tract is the most frequent and serious complication, leading to significant morbidity. Traditionally, management relied on surgery, but the advent of endoscopic retrograde cholangiopancreatography (ERCP) has considerably modified practices over the past decades. The objective of our study was to evaluate the contribution of ERCP in the management of complicated forms of HHC, particularly those fistulized into the biliary tract.

We conducted a retrospective descriptive study within the Department of Hepato-Gastroenterology over the period from January 2021 to August 2025. Data were collected from ERCP records and concerned patients with complicated hepatic hydatid cysts.

A total of 85 cases of fistulized HHC were included. The mean age of patients was 38 years, with a male-to-female ratio of 1.8. Reported medical histories included prior surgery for HHC (28%), cholecystectomy (13%), and known uncomplicated HHC (9%). Clinically, obstructive jaundice was the predominant symptom (81%), followed by hepatic colic (41%); fever >38.2 °C was present in 59%.

Radiological investigations (ultrasound, CT, MRI) showed dilatation of the common bile duct (CBD) in 71% of cases and of the intrahepatic bile ducts in 48%. Hydatid material within the CBD was found in 69% of patients.

The main indications for ERCP were: acute cholangitis (63%), postoperative or post-drainage biliary fistula (33%), and acute biliary pancreatitis (4%). Endoscopic sphincterotomy was performed in all patients (100%).

Post-ERCP evolution showed resolution of jaundice within 5–15 days on average, and closure of biliary fistulas within 10–16 days. Complications were rare: two cases of post-ERCP pancreatitis (2.3%) and one case of procedure-related bleeding (5.2%). The relative risk of bleeding after sphincterotomy was significantly lower in patients without a history of HHC surgery (RR = 0.439; p = 0.01).

ERCP is an effective and safe therapeutic modality in the management of complicated hepatic hydatid cysts. It ensures rapid resolution of jaundice and closure of fistulas, with a satisfactory safety profile (bleeding RR: 0.43). These results highlight the central role of ERCP in the therapeutic arsenal for complicated HHC, as a complement or an alternative to surgery.