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 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.