A 24-year-old Bulgarian woman presented to the Emergency Department with a 2-hour history of acute onset epigastric pain which had migrated to the lower abdomen. She reported mild, intermittent, dull epigastric pain for the preceding year. There was no history of trauma or any past medical history of note. At presentation, she was haemodynamically stable with a pulse rate of 69 bpm and blood pressure of 108/36 mmHg. There was no respiratory compromise and O2 saturation was 98% on room air. Her temperature was 36.9°C. Palpation of the abdomen elicited significant epigastric and suprapubic tenderness with guarding and percussion tenderness. A faint erythematous rash was noted over her face and arms. Thirty minutes later she became shocked, tachypnoeic, and hypothermic at 35.2°C. The rash was more extensive, appeared urticarial and she had developed periorbital oedema. Her condition was stabilised with aggressive fluid resuscitation and intravenous steroids (Hydrocortisone 200 mg) and antihistamines (Chlorpheniramine 20 mg).\nInitial blood investigations were normal apart from a haemoglobin of 16.1 g/dL (12–16), glucose of 11.7 mmol/L (3–7), and lactate of 2.73 mmol/L (0.5–2.2). Liver and renal function tests were normal and there was no leucocytosis or eosinophilia. Venous blood gas demonstrated a pH of 7.287 (7.35–7.45), bicarbonate of 22.6 mEq/L (22–29), and base excess of −1.6 (−2 to 2) with normal pO2 and pCO2. Urine dipstick and β-HCG were negative. Contrast CT of her abdomen and pelvis revealed a large, well-defined area of low density occupying almost the entire left lobe of the liver with serpiginous enhancing strands within. Significant free fluid was noted throughout the abdomen and pelvis (see ). The appearances were highly suggestive of a ruptured hepatic hydatid cyst.\nThe decision was made to perform a diagnostic laparoscopy with a view to proceeding to laparotomy if required. Laparoscopy revealed a large ruptured cystic mass within the left lateral lobe of the liver, almost completely replacing the hepatic parenchyma (see ). There were also features of cholecystitis noted. Large amounts of free fluid were noted in all four quadrants. Removal of the cyst was achieved by way of an open left partial hepatectomy and the peritoneal cavity was washed out with hypertonic saline with a drain left in the subhepatic space. A cholecystectomy was also performed. Post-operatively she was managed in ITU and was commenced on Albendazole and Tazocin (Piperacillin/Tazobactam) with ongoing therapy for anaphylaxis. Praziquantel was also commenced but the patient subsequently became bradycardic to 30 bpm (although remained haemodynamically stable). No other cause was identified and resolved after discontinuation of Praziquantel. She was discharged 9 days post-operatively on reducing dose oral steroids and 3 cycles of Albendazole (4 weeks on, 2 weeks off). At follow-up, she remained well.\nHistology of the resected tissue confirmed the presence of a hyalinised, PAS-positive pseudocapsule (Brodie's capsule) with numerous scolices present, thus confirming the diagnosis of a hydatid cyst (see ). Histology of the gall bladder showed mild cholecystitis. No protoscolices or hooklets were seen in the drain fluid. Echinococcal serology (Hydatid ELISA) was positive.
A 17-year-old man referred to the emergency department after falling from motorcycle. He also complained from abdominal pain and vomiting. He was admitted just 30 minutes following the accident. His blood pressure was 100/60 mmHg, heart rate of 80 per minute, respiratory rate 23 breath per minute and axillary temperature of 37.2 ºC, and oxygen saturation of 96% on room air. On physical examination (PE) only right upper abdominal pain and rebound tenderness were observed. PE on other organs did not reveal any positive findings. Chest and abdominal X-ray were normal. Initial blood investigation showed leukocytosis (15700/mm3) and other indexes were normal. Twenty minutes after admission, a diffuse urticarial rash on the whole body, mainly on his face and trunk, and generalized tenderness were noted.\nThe patient received oxygen, intravenous fluid (Ringer and Dexter an -saline serum) in addition to intravenous steroids (Hydrocortisone 200mg) and antihistamines (Chlorpheniramine 20mg) as the supportive treatment.\nFocused abdominal sonography for trauma (FAST) of his abdomen demonstrated on the presence of free fluid noted in all abdominal quadrants, especially in the morison pouch (). Also by using ultrasonography a large hyperechogenic area with local cystic (40 mm diameter) in the right lobe of the liver was showed. Based on the above information a diagnostic laparotomy was performed. Laparotomy revealed a ruptured cystic mass within the right lobe of the liver and yellow fluid containing daughter cysts and liver laceration. The cyst was removed by an open right partial hepatectomy, the peritoneal cavity washed out with hypertonic saline, and a tube drain placed in right the sub-hepatic space. He was managed in intensive care unit (ICU) and received oral Albendazole 15mg/kg/day. The drain was detached on the 7th day after operation. He was discharged ten days post-operation with a prescription of Albendazole tablet 15mg/kg/day in divided dose for six months. He was followed up on 6th and 12th months post operation. He was kept well and control trans-abdominal ultrasonography demonstrated no recurrences of the disease.