A 79-year-old man presented with fever and jaundice. Laboratory tests revealed elevated inflammatory markers and hepatobiliary enzymes. Magnetic resonance imaging revealed a 20 × 16 cm giant hepatic cyst compressing the intrahepatic bile ducts. Emergency endoscopic retrograde cholangiopancreatography revealed intrahepatic bile duct dilatation secondary to cystic compression. An endoscopic nasobiliary drainage tube was inserted. After the cholangitis improved, the tube was replaced with a plastic stent. The patient was discharged but was readmitted 11 days later with recurrent fever and loss of appetite. Computed tomography revealed thickening of the cyst wall and internal debris, consistent with an infected hepatic cyst. Given the patient's poor general condition and presence of compressed vessels and bile ducts along the percutaneous puncture route, endoscopic ultrasound-guided cyst drainage (EUS-CD) with nasocystic drainage was performed. After clinical improvement, surgical fenestration was attempted but aborted due to inflammation and friability with bleeding around the endosonographically/EUS-guided created route (ESCR). On day 25 after EUS-CD, conversion to internal trans-ESCR drainage was performed using a 7-Fr, 15-cm double-pigtail stent, and the transpapillary stent was removed because bile duct compression had resolved. The infection recurred 22 days later owing to stent occlusion, requiring stent exchange and additional drainage via ESCR. Finally, three plastic stents were placed, and the patient had no further infection recurrence. After infection control with nasocystic drainage using EUS-CD, multiple stent placements via ESCR can provide safe, effective, and durable treatment for giant infected hepatic cysts that are unsuitable for percutaneous drainage or surgery.
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