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 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.