A 59-year-old Bosnian male presented with abdominal discomfort. A 20 × 10 cm2 suprapubic mass was palpable. An abdominal ultrasound scan (US) revealed a large complex pelvic mass, subsequent abdominal and pelvic computed tomography (CT) revealed multiple complex peritoneal cysts suggestive of hydatid disease (Fig. ).\nAs a child he reported frequent contact with livestock and dogs. Upon military conscription, aged 17, investigations revealed a pulmonary mass, resection of which confirmed echinococcosis. Five years later, he was diagnosed with splenic hydatid disease culminating in splenectomy. The multiple large cysts and daughter cysts now seen on his CT were presumed secondary to spillage and peritoneal seeding of hydatid cysts during his splenectomy 37 years prior.\nHe commenced Albendazole for 9 weeks prior to planned surgical resection. During laparotomy, one pelvic and four abdominal cystic structures were discovered. The pelvic cyst was sizeable and densely adherent to the bladder anteriorly and rectum posteriorly. As the cyst entered the true pelvis dissection proved problematic, as such the cyst was surrounded by hypertonic saline soaked packs to inhibit contents spillage. Four stay sutures were placed into the cyst wall and a cystostomy performed. The contents was judiciously evacuated (Fig. ). Once decompressed, the cyst was sutured closed and resected (Fig. ).\nHistology showed hydatid cysts and a diagnosis of EG was postulated. He completed a 7-day post-operative course of Praziquantel and 6 months of Albendazole. One year post-surgery repeat CT and MRI abdomen and pelvis show no recurrence.
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.