Asymptomatic intra-peritoneal rupture of hydatid cyst of the liver: case report
© Majbar et al.; licensee BioMed Central Ltd. 2014
Received: 16 January 2013
Accepted: 20 February 2014
Published: 26 February 2014
Intra-peritoneal rupture of hydatid cyst is a rare complication and there is no consensus about its treatment.
The reported case concerns a 25 years old female patient who had been complaining for four months from a moderate pain in the right upper quadrant. No clinical or biological signs of sepsis or allergic reactions were witnessed. Ultrasound and CT examinations showed a multilocular hepatic cyst in addition to multiple unilocular cysts in the abdomen. The suspected diagnosis was hepatic and peritoneal HC and a surgical treatment was scheduled four weeks later. Surgical exploration showed a large ruptured HC on the left lobe of the liver, with daughter cysts in the peritoneal cavity. Left lobectomy of the liver with complete ablation of all daughter cysts and a wide peritoneal lavage were performed. For the three months following the surgery, Albendazole had been given to the patient. No recurrence occurred after four years of follow-up.
Intra-peritoneal rupture of liver HC could be asymptomatic. This case showed that in some cases, occurrence of complications is not systematic. This suggests that urgent surgical treatment is not always mandatory in the absence of alarming signs. Well-conducted medical treatment would reduce the risk of occurrence of secondary peritoneal hydatidosis.
Intra-peritoneal rupture is a serious turning point in the evolution of hepatic hydatid disease. It is a rare complication and there is still a debate in the literature about a reliable treatment. The reported case concerns a patient suffering from an asymptomatic intra-peritoneal rupture of a hydatid cyst in the left liver, which was discovered intra-operatively, highlighting the implications of this atypical mode of presentation.
Intra-peritoneal rupture is a rare complication of hepatic hydatid disease even in endemic areas. Its incidence varies in the literature from 1.75 to 8.6% [1–3]. The rupture could be spontaneous or more often following a trauma. Akcan et al. reported that young age, cyst diameter superior to 10 cm and superficial position are factor risks for a rupture of the HC of the liver .
Most frequently, the rupture in the peritoneum is symptomatic, with constant abdominal symptoms [2, 5] (abdominal pain, vomiting, abdominal tenderness and/or rebound), as well as marked allergic symptoms in up to 25% of the cases  (cutaneous rash, urticaria, anaphylactic shock). These symptoms are related to complications (peritonitis, anaphylactic shock) secondary to intra peritoneal rupture, which are reported to occur in up to 100% of patients . However, as shown in this case, this evolution is not systematic. Intra peritoneal rupture was asymptomatic, probably because no abdominal or anaphylactic complications occurred, which explains the late diagnosis, made several weeks after the rupture, during the surgery.
There is no consensus regarding the treatment in the case of an intra-peritoneal rupture. The majority of authors recommend an emergency surgical treatment  due to the risk of peritonitis that could be fatal to the patient . But, as demonstrated here, the patient had a delayed surgical treatment with favourable outcomes. After the diagnosis of the intra-peritoneal rupture of a HC, prompt care with close monitoring must be initiated due to the risk of anaphylaxis and the occurrence of abdominal complications. The existence of sepsis, acute abdomen, intra-peritoneal bile leakage, or shock imposes an urgent surgical intervention. However, in the absence of complications, surgery may be postponed until a more appropriate time .
The recurrence rate following an intra-peritoneal rupture of the liver HC could reach 21% . The use of Albendazole to prevent secondary peritoneal echinococcosis is recommended by all the authors, but there is no consensus regarding the duration of the treatment. A minimum duration of three months is advised . In this case, the patient received medical treatment for three months, and did not show a recurrence after four years of follow-up.
The intra-peritoneal rupture of liver hydatid cysts could be asymptomatic and the occurrence of complications is not systematic. This suggests that in case of early diagnosis of intra peritoneal rupture, urgent laparotomy should not be mandatory in the absence of alarming signs, and could be performed after correct preparation. Well-conducted medical treatment would reduce the risk of occurrence of secondary peritoneal hydatidosis.
Written informed consent was obtained from the patient for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.
We would like to thank Mr Majbar Taha for his help in English correction.
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