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.
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.