An apparently healthy 11-year-old boy presented with acute pain in central abdomen of 5 hours duration. He gave history of a trivial blunt abdominal trauma while at play. Patient also complained of a bothersome itching all over his body especially over limbs and the trunk starting soon after the injury. At presentation, the patient was lying still in bed with pulse rate of 110/min and BP 110/60 mm Hg. There was no pallor. Lesions resembling utricaria were seen over thigh and trunk. Abdominal examination revealed generalized rebound tenderness.\nBaseline investigations were normal except for leukocytosis (13200/ mm3). Roentgenograms of the chest and the abdomen were essentially normal. Ultrasonography revealed that liver was enlarged and there were 2 cystic lesions [6.4X4.6 cm and 8.1X 6.9 cm] in right lobe of liver with hypoechoic contents and floating echogenic membranes and peripheral calcifications. Lot of free fluid was also present.\nIntravenous fluids were started with a bolus of Ringer lactate (20ml/Kg) followed by Dextrose 5% in normal saline (0.9%). Intravenous Hydrocortisone and Pheniramine maleate were adminstered along with antibiotic prophylaxis. The clinical picture with sudden generalized pain in abdomen with rashes, frank peritonitis and sonographic findings were suggestive of ruptured hepatic hydatid cyst. Patient was taken for exploratory laparotomy. The peritoneal cavity was filled with approximately 500 ml of bilious fluid which was drained out. Inspecting the liver surface showed extruded bile stained flaccid hydatid cyst (Fig. 1).\nAnother intact hydatid cyst was palpable in segment VI which was removed by partial pericystectomy. The entire peritoneal cavity was lavaged with hypertonic (3%) and normal saline. The bed of the first cyst was inspected for any bile leak. As there was no evidence of large cysto-biliary communication, the cavity was packed with omentum. A tube drain was placed in right sub-hepatic space. Postoperative course was uneventful. The drain was removed on the on 7th post operative day. albendazole (15 mg/kg/day) was started and plan was to continue it for 6 months (3 weekly courses and drug free period of one week with a watch on the liver enzymes and counts).\nFour weeks later, the patient presented with upper abdominal fullness not associated with any other complaint. He was afebrile and hemodynamically stable. There was no icterus. On examination, there was distension of abdomen limited to the upper half of abdomen. There was no demonstrable free fluid and bowel sounds were normal. Laboratory values were: Hb-9.2 gms/dl, TLC-6900/mm3, serum bilirubin-0.8 mg%, ALT-17 U/ L, ALP 365 U/ L, AST-28 U/ L. Sonography revealed a large multiloculated cystic mass (15cmx13cmx18 cm) antero-superior to the liver. The intra-hepatic biliary radicals and the common bile duct were not dilated. There was no free fluid. CT scan was done to know further details. It showed 13cmx13cmx16 cm cystic lesion in the right lobe of liver with well defined septa of liver parenchyma within it (Fig. 2). Another cystic lesion was found in the left sub-hepatic space and lesser sac. Based on the findings it was diagnosed to be a “walled off” bile collection. A pig tail catheter was inserted percutaneously into the bilioma under sonographic guidance which was both diagnostic and therapeutic. It drained about 500 ml of greenish brown fluid overnight and culminated with disappearance of abdominal distension. The catheter was removed after 4 days when the effluent was negligible. Patient was discharged and on follow up 3 weeks later, found to be doing well. Currently patient is on albendazole therapy.
A 34-year-old Indo-Aryan male of Indian nationality, previously fit and healthy presented with 15 days history of epigastric pain, jaundice and 7 days history of fever. He was initially evaluated at a local hospital with ultrasound and CT scan of the abdomen and was treated with parenteral antibiotics. He came to our emergency department for sudden increase in the intensity of abdominal pain and vomiting over past 8 hours. On examination he looked unwell and sweaty, with a temperature of 38.5°C and a pulse rate of 120 beats/min. The abdomen was tender with localized peritonitis in the right upper quadrant. Blood investigations revealed total count of 16400/mm3, total bilirubin of 7.1 mg/dl (conjugated-5.8 mg/dl), and alkaline phosphatase 701 U/L (normal range-60 to 120 U/L). Hydatid serology was positive. CT scan abdomen 2 days prior to admission to our institution showed a large hydatid cyst in the posterior segment of right lobe of liver with separation of membrane. It looked dumbbell shaped () and there was perihepatic fluid. The patient underwent emergent operation with a tentative diagnosis of intraperitoneal rupture of hydatid cyst. At laparotomy, 1.5L of bile stained fluid and multiple daughter cysts were found in the peritoneal cavity. A large hydatid cyst occupying parts of segments VI, VII, and VIII was seen (). A rupture of the anterior wall of the pericyst, ectocyst and the endocyst was noted. The fluid was suctioned, daughter cysts removed, the anterior wall of the cyst deroofed and the endocyst removed. The cyst was then marsupialized with a 3-0 polydioxanone running suture. There was large defect in the intrahepatic bile duct and extrahepatic biliary tree was studded with hydatid debris. Cholecystectomy, CBD clearance and T tube drainage of CBD were done. Direct repair of intrahepatic bile duct defect was not possible. We introduced a 12 Fr T tube into the defect of intrahepatic bile duct and brought out through the skin. Two closed system drains were placed, one in the cyst cavity and one in the right subhepatic space. A thorough washout of cyst and peritoneal cavity was performed with both cetrimide and normal saline. Postoperatively, he developed biliary fistula, which was healed over a period of 34 days. T tube cholangiography on 42 days showed free flow of contrast in the duodenum and there was no extravasation of contrast or filling defect. The patient received a 6-week course of albendazole therapy in the postoperative period. At 4 months follow up, patient was without evidence of recurrence.