Formosan Journal of Surgery (2015) 48, 98e101

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CASE REPORT

Acute rupture of a peritoneal hydatid cyst

Toufik Berri*

Department of Surgery, Tourabi Boudjemaa Hospital, Bechar, Algeria

Received 7 September 2014; received in revised form 26 October 2014; accepted 2 January 2015Available online 2 July 2015

KEYWORDSechinococcosis;hydatid cyst;peritoneum;rupture;trauma

Conflicts of interest: The author d* Corresponding author. DepartmentE-mail address: t.berri@yahoo.fr.

http://dx.doi.org/10.1016/j.fjs.2015.1682-606X/Copyright ª 2015, Taiwan

Summary Echinococcus granulosus, the pathogen responsible for hydatid disease, mostlysettles in the liver and lungs but affects the peritoneum less frequently. Rupture of a cyst intothe peritoneal cavity is a potentially life-threatening incident. Although numerous studies onruptured hepatic hydatid cysts have been published, few cases of peritoneal cyst rupture havebeen reported. We describe the case of a 19-year-old woman who presented with an acuteabdomen and allergic reactions after a fall. Ultrasonography and computed tomography re-vealed a hydatid cyst of the liver and ruptured pelvic hydatid cyst. First, the patient receivedappropriate measures to prevent anaphylactic shock and later underwent emergency surgery.Partial cystectomy of the ruptured pelvic hydatid cyst, peritoneal washing, and unroofing ofthe large unruptured hepatic hydatid cyst were conducted. Albendazole was administeredpostoperatively for 3 months. No recurrence was noticed during 3 years of follow-up. Althoughrarely documented, acute rupture of a peritoneal hydatid cyst is the most severe complicationof peritoneal echinococcosis. Typically after trauma, it must be considered in the presence ofan acute abdomen with allergic reactions. Ultrasonography and computed tomography havehigh sensitivity in demonstrating rupture of a hydatid cyst. Emergency surgery is the onlyeffective treatment and should aim at the complete removal of a cyst, if possible, and perito-neal washing with scolicidal agents. Additional studies should be conducted to evaluate thefeasibility of laparoscopy. Albendazole should be prescribed postoperatively to prevent recur-rence. Mortality is closely related to anaphylaxis; hence, early and accurate diagnosis andappropriate preventive measures are crucial.Copyright ª 2015, Taiwan Surgical Association. Published by Elsevier Taiwan LLC. All rightsreserved.

eclares no conflicts of interest.of Surgery, Tourabi Boudjemaa Hospital, Bechar, BP 71 Maghnia 13300, Tlemcen, Algeria.

01.001Surgical Association. Published by Elsevier Taiwan LLC. All rights reserved.

Acute rupture of a peritoneal hydatid cyst 99

1. Introduction

Hydatid disease is a zoonosis caused by the larval form ofEchinococcus granulosus. Humans become intermediatehosts of the parasite after accidental ingestion of its eggs.When these eggs penetrate the intestinal wall, most ofthem migrate into the liver (75%) and lungs (24%), whileperitoneal involvement is much less frequent.1 Rupture of ahydatid cyst into the peritoneal cavity is a potentially life-threatening incident. Numerous cases and retrospectivestudies on ruptured hepatic hydatid cysts have been pub-lished, whereas few cases of a ruptured peritoneal hydatidcyst (PHC) have been reported.

We report a case of a young patient with acute trau-matic rupture of a PHC.

2. Case Report

A 19-year-old woman presented to our emergency depart-ment with acute abdominal pain, nausea, headache, cough,and palpitations, which occurred just after she suffered afall. She had a 2-year history of progressive growth of herabdomen but denied any digestive, gynecological, or uro-logical symptoms. On examination, diaphoresis, conjunc-tival injection, and tachypnea were observed. Arterialblood pressure was 90/50 mmHg with a pulse rate of 125beats/min and temperature of 37.8�C. The abdomen wasdistended with intense pain, guarding, and dullness topercussion in the lower abdomen. Digital rectal examina-tion was painful and showed a bulging pouch of Douglas.

White blood cell count, hemoglobin level, hematocrit,and parameters of clinical blood serum chemistry, hepatictests, and renal function tests were normal. Plain radio-graphs of the abdomen and chest showed an elevated righthemidiaphragm (Fig. 1). Abdominal ultrasonography (US)and computed tomography (CT) demonstrated an anechoic

Figure 1 Elevation of the right hemidiaphragm.

homogeneous unilocular cyst of 121 mm � 129 mm withwell-defined borders. The lesion was located in segmentsIV, V, VII, and VIII of the liver with no peripheral contrastenhancement or calcifications (Fig. 2). In addition, a largeintraperitoneal cyst of 139 mm � 88 mm with somedaughter vesicles inside was shown. This cyst seemed to beruptured in its lower pole into the Douglas space (Fig. 3).Furthermore, a small amount of free fluid in the abdominalcavity and a right ovarian cyst of 29 mm in diameter wereobserved. US/CT imaging revealed a hydatid cyst of theliver staged CE1 and a ruptured pelvic hydatid cyst stagedCE2.

Our patient first received appropriate measures, namelyhigh-flow oxygen therapy, cardiac monitoring, saline solu-tion, and intramuscular medications (epinephrine 0.5 mgand ranitidine 50 mg), to prevent anaphylactic shock. Oncehemodynamic and respiratory parameters normalized 15minutes after the initial management, the patient under-went emergency surgery for an acute abdomen caused by alikely rupture of a PHC. Her abdomen was opened using alarge midline incision and 150 mL of clear peritoneal fluidwas sucked out. A huge pelvic hydatid cyst fissured in itsinferior wall was found. From this cyst, a large parasite andmultiple daughter vesicles were extracted (Fig. 4). The cystadhered to the small intestine, mesentery root, uterus,urinary bladder, and posterior parietal peritoneum. Theperitoneal cavity was washed with hydrogen peroxide andpartial cystectomy was conducted (Fig. 5). A large unrup-tured hydatid cyst on the right hepatic lobe was observedwith the rest of the liver in an intact form. Puncture andaspiration of a clear fluid, injection of hydrogen peroxide,cystotomy, and extraction of a unique germinal membranewere performed. After a meticulous search, no biliocysticfistula was found and the cyst was managed by conductingan unroofing procedure. Cystectomy was conducted for theserous right ovarian cyst. At the end of the surgery, a drainwas inserted in the hepatic residual cavity and another inthe Douglas space.

Figure 2 Computed tomography scan showing the unrup-tured hydatid cyst in the right hepatic lobe.

Figure 3 Computed tomography scan demonstrating theperitoneal hydatid cyst.

Figure 4 The parasite extracted from the pelvic hydatidcyst.

Figure 5 The residual part of the peritoneal cyst, whichadhered firmly to the mesentery root and retroperitonealvessels.

100 T. Berri

The patient was discharged from the hospital 8 daysafter an uneventful postoperative period. Albendazole(500 mg/d in 2 divided doses) was administered post-operatively for 3 months. During 3 years of follow-up, USand an indirect hemagglutination test were conductedannually but no recurrence was observed.

3. Discussion

Peritoneal echinococcosis accounts for approximately 6% ofall abdominal hydatidosis2 and is typically secondary torupture of a hepatic, splenic, or mesenteric cyst. Intra-peritoneal dissemination may also occur during surgery orneedle drainage. In exceptional cases, the parasite settlesin the peritoneal cavity through hematogenic or lymphaticroutes and causes the primitive disease. This form is

retained when the peritoneum is the only localization of ahydatid cyst in the abdominal cavity. Thus, the presentedcase is considered as a secondary form of peritonealhydatidosis caused by the mostly asymptomatic micro-rupture of a hepatic cyst. Peritoneal hydatidosis is classi-fied into four groups: localized, disseminated, hydatidcarcinomatosis, and hydatidoperitoneum.2

Secondary bacterial infection, compression of adjacentstructures, and cystic rupture are the three main compli-cations of PHCs. Acute rupture is the most severe and life-threatening incident. It may occur after trauma or spon-taneously because of increased intracystic pressure.3 Pre-disposing factors for rupture of a cyst are young age, a largecyst (> 10 cm), superficial localization, and thin walledcyst.4 Our patient presented all of these risk factors.

Clinical presentation of rupture of a cyst includesallergic reactions, abdominal symptoms, or both. Pain andperitoneal irritation dominate the symptoms of acuterupture, while allergic reactions and anaphylactic shock areless frequent.4 Fatal anaphylaxis and sudden death afterrupture of a cyst have been reported previously.5 Intra-peritoneal rupture is occasionally asymptomatic and itsdiagnosis may be delayed for several years. It is typicallydiagnosed with both radiological imaging and serodiag-nostic techniques; although serodiagnostic techniques areunavailable in an emergency situation. US and CT have asensitivity of 85% and 100%, respectively, in demonstratingrupture of a hydatid cyst.6 CT scan shows a structuraldeformity of the ruptured cyst and collection of intraperi-toneal fluid with the presence of daughter cysts in theperitoneal cavity.7

Rupture of a PHC should be evoked in the presence of anacute abdomen in endemic regions and included in thedifferential diagnosis of peritoneal cysts, such as cysticlymphangiomas, pancreatic pseudocysts, duplication cysts,mesothelial cysts, dermoid cysts, abscesses, ovarian cysts,mesotheliomas, appendicular mucoceles, and pseudomyx-oma peritonei.

Emergency surgery is the first choice for the treatmentof acute cystic rupture.3 It aims at the removal of all cysts(total cystectomy when possible; otherwise, deroofing ifthe cyst firmly adheres to neighboring tissues), peritoneal

Acute rupture of a peritoneal hydatid cyst 101

washing with scolicidal agents, and drainage. Scolicidalagents used in surgery include hypertonic saline, hydrogenperoxide, povidone iodine, absolute alcohol, formalin,chlorhexidine, cetrimide, silver nitrate, and albendazole.Hypertonic saline (20%) is the recommended scolicidalagent with a waiting period of 15 minutes.8 It kills theparasite and prevents further propagation of viable proto-scolices by creating a strong osmotic gradient across theouter cuticular membrane of a protoscolex, resulting in itslysis. Derici et al3 reported that hypertonic saline maydamage the peritoneum and cause hypernatremia.3 Thelaparoscopic approach has established its role in the man-agement of hepatic echinococcosis in selected patients whorequire special care to avoid spillage of cyst contents. Somecases of laparoscopic management of peritoneal hydati-dosis have been reported.9 However, additional studiesmust be conducted to evaluate its safety and applicabilityin ruptured PHCs. Albendazole (10e15 mg/kg/d) in 2equally divided doses is commonly prescribed for severalweeks postoperatively to prevent recurrence.

Morbidity and mortality associated with perforated hy-datid cysts were higher than those associated with non-perforated cysts.10 In a retrospective study conducted byGunay et al, 50% of patients developed complications ofsurgery for traumatic rupture of hydatid cysts with a post-operative mortality rate of 6%.6

In conclusion, although rarely documented, acuterupture of a PHC is the most serious complication of peri-toneal echinococcosis. It must be considered in the pres-ence of an acute abdomen, particularly with allergicreactions. Emergency surgery is the only effective treat-ment and should aim at the complete removal of the cyst, ifpossible, and peritoneal washing with scolicidal agents.Laparoscopy seems to be a safe alternative approach, butadditional studies should be conducted to evaluate itsfeasibility. Albendazole should be prescribed post-operatively to prevent recurrence. Mortality is closely

related to anaphylaxis; therefore, an early and accuratediagnosis and appropriate preventive measures are crucial.

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