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 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.