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 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.