Indian Journal of Radiology and Imaging Indian Journal of Radiology and Imaging

ABDOMINAL
Year
: 2005  |  Volume : 15  |  Issue : 3  |  Page : 345--346

Ruptured cyst with peritoneal seeding - a case report


KK Sabharwal, AL Chouhan, R Chowdhri 
 Department of Radio-Diagnosis, Dr S. N. Medical College and M.G. Hospital, Jodhpur - 342 003, India

Correspondence Address:
K K Sabharwal
Dept. of Radio-diagnosis, C-86, Shastri Nagar, Jodhpur - 342 003
India




How to cite this article:
Sabharwal K K, Chouhan A L, Chowdhri R. Ruptured cyst with peritoneal seeding - a case report.Indian J Radiol Imaging 2005;15:345-346


How to cite this URL:
Sabharwal K K, Chouhan A L, Chowdhri R. Ruptured cyst with peritoneal seeding - a case report. Indian J Radiol Imaging [serial online] 2005 [cited 2020 Oct 22 ];15:345-346
Available from: https://www.ijri.org/text.asp?2005/15/3/345/29151


Full Text

 Introduction



Hydatid disease is caused by larval stage of either Echinococcus granulosus or Echinococcus alveolaris. The liver is the most frequently parasitized organ in humans, with about 60% infestation rate. Rupture of Echinococcal cysts can be classified into three types: contained, communicating and direct.

We would like to present a case report of Ruptured hydatid cyst of liver with peritoneal seeding.

 Case Report



A 45 year old male presented with severe pain and tenderness in Right hypochondrium. He was involved in a road traffic accident two days before. The abnormality noted on physical examination was tenderness and guarding in the Right hypochondrium and fullness in flanks. The patient denied any liver disease in the past.

Ultrasound examination of the abdomen showed mild bilateral pleural effusion and a large transonic area in the right lobe of the liver with incomplete echogenic rim, debris and few small cystic areas within it. The wall of the large transonic area was incomplete on the right anterolateral aspect and surrounded by high intensity echoes. There was moderate amount of ascitic fluid with low level internal echoes. These appearances were interpreted as being due to ruptured hydatid cyst with a few daughter cysts inside and hemoperitoneum.

Following ultrasound examination, pre and postcontrast CT scan of the liver was carried out for better definition of the ruptured cyst of the right lobe of the liver. It revealed bilateral pleural effusion, multiple fractures of right ribs and a nonenhancing, low attenuation mass with an incomplete hyperdense rim. There were a few low attenuation nonenhancing areas inside the large mass. The wall of the mass was incomplete on the right anterolateral aspect.

In segment VIII of liver a linear hypodense area reaching up to the liver margin is seen merging with discontinuity of the cyst wall. Few small well defined rounded non enhancing low attenuation areas seen in the pelvic high density ascitic fluid. This appearance is characteristic of liver laceration (Right lobe) with ruptured hydatid cyst of liver resulting in peritoneal dissemination of the daughter cysts.

Plain abdominal radiograph showed a soft tissue density mass with incomplete calcific rim in the right hypochondrium. Serological tests were strongly positive for hydatidoses and fragments of the echinococcus were found in peritoneal aspirates. It is interesting that, the patient did not show any acute allergic manifestations such as the commonly quoted anaphylactic reaction, due to the sudden rupture of the cyst. He was treated medically with Albendazole for two weeks, followed by surgery.

 Discussion



Hydatid disease is prevalent throughout much of the world. The Hydatid cyst has three layers : Outer pericyst, middle ectocyst, Inner germinal layer the endocyst, where the scolices (larval stage of the parasite) and the laminated membrane are produced. Daughter vesicles (brood capsules) are small spheres that contain the protoscolices, are formed from the germinal layer.

The complication of hydatid disease of liver include rupture into the peritoneal cavity with peritoneal dissemination of daughter hydatid cyst, which appear as peritoneal seeding. Rupture of an echinococcal cyst may be the first indication that the patient has hydatid disease. Rupture may have several causes. Peritoneal hydatidoses is usually the result of traumatic or surgical rupture of a hydatid cyst. Trauma may tear the endocyst or both the endocyst or pericyst to cause direct rupture.

Rupture of echinococcal cyst are of three types : contained, communicating and direct. Contained rupture occurs when only the parasite endocyst ruptures and cyst content are confined within the host derived pericyst. When cyst contents escape via biliary or bronchial radicles that are incorporated in the pericyst, the rupture is communicating. Direct rupture occurs when both the endocyst and the pericyst tear, spilling cyst contents directly into the peritoneal or pleural cavity or occasionally into other structures. When because of traumatic etiology, both the pericyst and the endocyst are torn, cyst contents escape by a nonanatomic route into the peritoneal space.

Ultrasound and C.T. scans have been used for the diagnosis of ruptured hydatid cyst into the peritoneal cavity. Hydatid cysts of the liver, ultrasonically appear as sonolucent masses containing multiple 1-3 cm sonolucent cystic areas. (daughter cysts). C.T. scans of hydatid cysts usually show large, non enhancing low attenuation areas often with multiple small areas (daughter cysts) inside the hypervascular border surrounding the periphery of hydatid cyst. Both technique s are almost equally sensitive for diagnosis of liver hydatid cysts. The peritoneal echinococcosis is almost always secondary to hepatic disease. When a hydatid cyst of the liver ruptures into the peritoneal cavity, there is a break in the continuity of the wall and ascitic fluid forms. Cysts may be multiple and located anywhere in the peritoneal cavity.

In the present case, there were typical ultrasound and C.T. scan findings. The diagnosis was first suggested by ultrasonic examination which was confirmed by C.T., hence C.T. is the modality of choice in affected patients because it allows imaging of the entire abdomen and pelvis.[6]

References

1John R. Haaga, Charles F. Lanzieri and Robert C. Gilkenson: CT and MR Imaging of the Whole Body (Volume-2), fourth edition 2003. Mosby 1309-1311.
2Manorama Berry, Veena Chowdhury and Sudha Suri : Diagnostic Radiology ( Hepatobiliary and Gastrointestinal Imaging), second edition 2003. Jaypee 252-254.
3David B. Lewall and Scott J. McCorkell. Rupture of Echinococcal cysts. Diagnosis, Classification, and clinical implications. AJR 1985; 146:391-394.
4Ian Beggs. The Radiology of hydatid Disease. AJR 1985; 145:639-648.
5Marti-Bonmati L, Serrano FM : Complications of hepatic hydatid cysts : Ultrasound, computed tomography, and magnetic resonance diagnosis. Gastrointest. Radiol. 1990, 15:119-125.
6Carol M. Rumack, Stephanie R. Wilson, J. William Charboneau. Diagnostic Ultrasound (Volume-1) Second edition, 2003, Mosby, 107-110.