[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-0-en-105":3,"doc-seo-459165-105":59,"doc-detail-459165-en":130},{"code":4,"msg":5,"data":6},0,"success",[7,13,18,23,28,33,38,43,48,51,55],{"id":8,"doc_module":4,"doc_module_name":9,"category_name":10,"show_sort_weight":11,"slug":12},1,"Document","Story & Novel",90,"story-novel",{"id":14,"doc_module":4,"doc_module_name":9,"category_name":15,"show_sort_weight":16,"slug":17},2,"Literature",80,"literature",{"id":19,"doc_module":4,"doc_module_name":9,"category_name":20,"show_sort_weight":21,"slug":22},4,"Exam",70,"exam",{"id":24,"doc_module":4,"doc_module_name":9,"category_name":25,"show_sort_weight":26,"slug":27},5,"Comic",60,"comic",{"id":29,"doc_module":4,"doc_module_name":9,"category_name":30,"show_sort_weight":31,"slug":32},6,"Technology",50,"technology",{"id":34,"doc_module":4,"doc_module_name":9,"category_name":35,"show_sort_weight":36,"slug":37},7,"Healthcare",40,"healthcare",{"id":39,"doc_module":4,"doc_module_name":9,"category_name":40,"show_sort_weight":41,"slug":42},8,"Research & Report",30,"research-report",{"id":44,"doc_module":4,"doc_module_name":9,"category_name":45,"show_sort_weight":46,"slug":47},9,"Religion & Spirituality",20,"religion-spirituality",{"id":46,"doc_module":4,"doc_module_name":9,"category_name":49,"show_sort_weight":46,"slug":50},"World Cup","world-cup",{"id":52,"doc_module":4,"doc_module_name":9,"category_name":53,"show_sort_weight":52,"slug":54},10,"Lifestyle","lifestyle",{"id":56,"doc_module":4,"doc_module_name":9,"category_name":57,"show_sort_weight":24,"slug":58},19,"General","general",{"code":4,"msg":60,"data":61},"ok",{"site_id":62,"language":63,"slug":64,"title":65,"keywords":66,"description":67,"schema_data":68,"social_meta":123,"head_meta":125,"extra_data":127,"updated_unix":129},105,"en","a-fishy-situation-expanding-the-differential-diagnosis-of-the-fish-mouth-papilla","A fishy situation - expanding the differential diagnosis of the fish-mouth papilla","","A hepatic hydatid (echinococcal) cyst can rupture and produce endoscopic and ERCP findings that resemble a fish-mouth papilla, an appearance classically linked to main-duct intraductal papillary mucinous neoplasm (MD-IPMN). The case describes a 35-year-old man from North Africa with acute-on-chronic epigastric pain, later presenting after years with cholangitis and obstructive biliary defects. Thick white mucin-like membranes were expelled after sphincterotomy, and biliary aspirate microscopy identified hooklets. Treatment with albendazole and biliary decompression with endoscopic and surgical resection led to significant clinical and biochemical improvement.",{"@graph":69,"@context":122},[70,84,105],{"@type":71,"itemListElement":72},"BreadcrumbList",[73,77,79,82],{"item":74,"name":75,"@type":76,"position":8},"https://docshare.wps.com","Home","ListItem",{"item":78,"name":9,"@type":76,"position":14},"https://docshare.wps.com/document/",{"item":80,"name":35,"@type":76,"position":81},"https://docshare.wps.com/document/healthcare/",3,{"item":83,"name":65,"@type":76,"position":19},"https://docshare.wps.com/document/a-fishy-situation-expanding-the-differential-diagnosis-of-the-fish-mouth-papilla/459165/",{"url":83,"name":65,"@type":85,"image":86,"author":91,"headline":65,"publisher":94,"fileFormat":97,"inLanguage":63,"description":67,"dateModified":98,"datePublished":99,"encodingFormat":97,"isAccessibleForFree":100,"interactionStatistic":101},"DigitalDocument",{"url":87,"@type":88,"width":89,"height":90},"https://docshare.wps.com/thumbnails/a-fishy-situation-expanding-the-differential-diagnosis-of-the-fish-mouth-papilla/459165.png","ImageObject",300,407,{"name":92,"@type":93},"moss~","Person",{"url":74,"name":95,"@type":96},"DocShare","Organization","application/pdf","2026-11-07","2026-09-30",true,{"@type":102,"interactionType":103,"userInteractionCount":34},"InteractionCounter",{"@type":104},"ViewAction",{"@type":106,"mainEntity":107},"FAQPage",[108,114,118],{"name":109,"@type":110,"acceptedAnswer":111},"What classic diagnosis is the fish-mouth papilla appearance associated with?","Question",{"text":112,"@type":113},"It is typically considered pathognomonic for main-duct intraductal papillary mucinous neoplasm (MD-IPMN).","Answer",{"name":115,"@type":110,"acceptedAnswer":116},"How did clinicians confirm the actual cause in this case?",{"text":117,"@type":113},"Biliary aspirate evaluation with wet mount iodine microscopy identified numerous hooklets, confirming echinococcosis.",{"name":119,"@type":110,"acceptedAnswer":120},"What treatment strategy led to improvement?",{"text":121,"@type":113},"The patient received albendazole and underwent ERCP-related biliary management and subsequent hepatobiliary surgery, resulting in significant clinical and biochemical improvement.","https://schema.org",{"og:url":83,"og:type":124,"og:title":65,"og:site_name":95,"og:description":67},"article",{"robots":126,"canonical":83},"index,follow",{"doc_id":128,"site_id":62},459165,1790755320,{"code":4,"msg":5,"data":131},{"doc_id":128,"user_id":132,"nickname":92,"user_avatar":133,"doc_module":4,"category_id":34,"category_name":35,"doc_title":65,"doc_description":67,"doc_content":134,"file_id":135,"file_url":136,"file_type":137,"file_size":138,"view_count":34,"is_deleted":4,"is_public":8,"is_downloadable":8,"audit_status":8,"page_count":14,"language":139,"language_code":63,"site_id":62,"html_lang":63,"table_of_contents":140,"faqs":141,"seo_title":142,"seo_description":67,"update_tm":129,"read_time":24,"preview_page_count":4},962090895452,"https://ap-avatar.wpscdn.com/davatar_a8503ba1806abce46bf441b54a3ca4cd","Article published online: 2026-01-08  \nA fishy situation – expanding the differential diagnosis of the fish-mouth papilla  \nVideo 1 Fish-mouth papilla appearance of the ampulla, and discharge of thick, white membranes after sphincterotomy.  \nHydatid disease (echinococcosis) is a parasitic infection that presents with hepatic cysts and pulmonary involvement. Hepatic hydatid disease can lead to an obstruction of the biliary tree in the case of cyst rupture [1] . This case report provides endoscopic images of a hepatic hydatid cyst mimicking the fish-mouth appearance of papilla, usually pathognomonic for main duct intraductal papillary mucinous neoplasm (MD-IPMN [2]) . A 35-year-old man, from North Africa, presented with acute on chronic epigastric pain. Initial work-up revealed increased alanine aminotransferase (648IU/L) and total bilirubin (99μmol/L) levels. A computed tomographic scan showed a multilobulated, septated, calcified lesion in the inferior left liver, suggestive of a hepatic cyst ( ▶ Fig.1) . He was later lost to follow-up.  \nNine years later, he returned to the emergency room with work-up confirming cholangitis. MRCP showed poorly defined obstructive filling defects within a slightly dilated bile of 8mm in diameter ( ▶ Fig.2) . Interval growth of the hepatic cyst and left intrahepatic biliary ductal dilatation was noted.  \n▶Fig. 1 A CT scan showed a multi-lobulated, septated, calcified lesion in the inferior left liver, suggestive of a hepatic cyst. CT, computed tomography.  \n▶Fig.3 ERCP: a white, soft, mucinous substance protruding from the ampulla, suggestive of a fish-mouth papilla.  \nERCP demonstrated a white, soft, mucinous substance protruding from the ampulla ( ▶Video 1) . The endoscopic images were suggestive of a fish-mouth papilla ( ▶ Fig.3) . After biliary sphincterotomy, the spontaneous discharge of thick, white membranes occurred. Evaluation of the biliary aspirate with wet mount iodine microscopy identified numerous hooklets ( ▶ Fig.4) and confirmed the diagnosis of a compressive echinococcal cyst. He was first treated withalbendazole and then referred to hepatobiliary surgery for resection. Both ERCP and left hepatectomy conferred a signifi-  \n▶Fig.2 MRI revealed interval growth of the hepatic cyst and left intra-hepatic biliary ductal dilatation. MRI, magnetic resonance imaging.  \n▶Fig.4 Wet mount iodine microscopy: biliary aspirate with numerous hooklets, confirming echinococcosis.  \ncant clinical and biochemical improvement.  \nA ruptured hydatid cyst can lead to the fish-mouth papilla, which is typically pathognomonic for MD-IPMN. ERCP was effective in the treatment of cholangitisin the context of biliary obstruction from hydatid cyst rupture and biliaryaspirate confirmed the diagnosis.  \nEndoscopy_UCTN_Code_CCL_ 1AB_ 2AG_ 3AD  \nE28 El Ouarzadi Omar et al. A fishy situation… Endoscopy 2026; 58: E28–E29 | © 2026. The Author(s) .  \nOmar El Ouarzadi: Conceptualization, Data curation, Investigation, Methodology, Project administration, Writing – original draft, Writing – review & editing. Reda Goudrar: Conceptualization, Data curation, Writing – original draft, Writing – review & editing. Marc-André Smith: Data curation, Formal analysis, Investigation, Resources, Validation, Visualization, Writing – review & editing. Marcel Tomaszewski: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Supervision, Validation, Writing – review & editing.  \nConflict of Interest  \nDr. Marcel Tomaszewski is a consultant for Boston Scientific and Pendopharm. All other authors have no conflicts of interests to declare.  \nOmar El Ouarzadi1, Reda Goudrar1, MarcAndré Smith1,2, Marcel Tomaszewski1,3  \n1 Faculté de Médecine, Université de Montréal, Montreal, Canada  \n2 Department of Microbiology and Infectiology, Hôpital Sacré-Cœur de Montréal, Montreal, Canada  \n3 Department of Gastroenterology, Hôpital Sacré-Cœur de Montréal, Montreal, Canada  \nCorresponding au","cbCairFkGyji27V3","https://ap.wps.com/l/cbCairFkGyji27V3","pdf",2242685,"English","# Article overview\n## Case presentation and diagnostic work-up\n## Endoscopic findings and management\n## Differential diagnosis: hydatid cyst vs MD-IPMN","[{\"question\":\"What classic diagnosis is the fish-mouth papilla appearance associated with?\",\"answer\":\"It is typically considered pathognomonic for main-duct intraductal papillary mucinous neoplasm (MD-IPMN).\"},{\"question\":\"How did clinicians confirm the actual cause in this case?\",\"answer\":\"Biliary aspirate evaluation with wet mount iodine microscopy identified numerous hooklets, confirming echinococcosis.\"},{\"question\":\"What treatment strategy led to improvement?\",\"answer\":\"The patient received albendazole and underwent ERCP-related biliary management and subsequent hepatobiliary surgery, resulting in significant clinical and biochemical improvement.\"}]","A fishy situation - expanding the differential diagnosis of the fish-mouth papilla | PDF"]