Intrabiliary rupture of hydatid cyst: diagnosis with MRI and hepatobiliary isotope study

Left hepatectomy for hepatic hydatid cyst with intra-biliary rupture: Better to be radical

Echinococcal liver cysts are predominantly located in the right lobe of the liver and are mostly asymptomatic. A frank intra-biliary rupture (IBR) of hydatid cyst is uncommon, having variable clinical presentation and treatment options. We present a case of a 60-year-old male patient who presented with pain in the upper abdomen associated with vomiting but without jaundice. On investigations, he was diagnosed to have a left lobe hepatic hydatid cyst (HHC) with IBR for which left hepatectomy with bile duct exploration was performed. It highlights the benign nature of the disease for which seldom major hepatectomies have to be performed.

Histopathological and immunological study of rats liver hydatid cysts isolated from human, sheep, goat and cows

In endemic places, liver hydatidosis is a life-threatening health issue. Many consequences such as hepatomegaly, infiltration with inflammatory cells and histopathological changes might arise as a result of liver hydatidosis. This study aimed to look into pathogenic changes in the livers of the rats that experimentally infected with hydatid cysts. These hydatid cysts were isolated from naturally infected humans, sheep, goats and cows. Liver hydatid cysts were collected from the main abattoir of Al-Muthanna province while human hydatid cysts were collected from Al-Hussein Teaching Hospital in Al-Muthanna province. The hydatid cysts were grossly and histology examined for inspection of hydatid cysts. The in vivo experiments were done by injection of hydatid protoscoleces or sand (fluid) in rats intraperitoneally. The results showed that the gross signs were same in all infected livers which range from paleness, hepatomegaly, hemorrhage and calcification. The hydatid cysts isolated from sheep and goat livers were highly fertile compared to others isolated from humans and cows. Injection of hydatid protoscoleces and hydatid fluid isolated from sheep and goat livers in rats induced the highest immune response compared to that isolated from humans and cows. The liver sections of rats that were injected with human, goat and sheep hydatid protoscoleces and fluids showed hyperplasia in the bile duct, aggregation nonnuclear cells with congested blood vessels. While liver sections of rats were received goat hydatid fluid, cow hydatid protoscoleces and hydatid fluid showed normal liver tissue. These findings suggested that the immunogenicity of hydatid materials is different according to the host and the component of hydatid cysts.

A retrospective analysis of surgical techniques and outcomes of hydatid disease in Wasit, Iraq

Echinococcosis is a parasitic infestation with high prevalence in Iraq. Surgical treatment remains the standard gold method for treating this disease. The selection of surgical approach depends on the general condition of the patient and characters of the cyst, e.g., size, location, number of cysts, intraoperative findings, and complications such as adhesion, bile leakage, and bleeding. Our study aimed (1) to summarize the most common surgical approaches for treating liver hydatid cyst (HC) in our locality, and (2) to highlight common intraoperative and postoperative complications and the duration of hospital stay. We analyzed the clinical data of 42 patients operated for liver HC. We found that the highest incidence rate of HC was anatomically in the right hepatic lobe with or without synchronous cysts in other organs. The most frequent type of surgery was partial pericystectomy with external tube drainage (ETD) or simple endocystectomy with omentoplasty and ETD. The most important intraoperative finding was cystic-biliary communication. The majority of patients had uneventful postoperative recovery. There is no standardized surgical procedure for hepatic HC. The surgical technique should be modified according to the cyst size, anatomic location of cyst/cysts, number of cysts, cystobiliary communications, cystic infection, and the presence of extrahepatic hydatid cyst or cysts. The surgeon's experience plays a vital role in selecting the surgical technique for hepatic hydatid cystectomy.

A Challenging Case of Refractory Biliary Leak in a Patient With Hydatid Liver Disease

Hydatid liver disease (HLD) is the most common form of hydatid disease, and it is caused by a zoonotic infection with a tape worm. It is endemic mostly in sheep-farming countries and rare in the United States. Liver involvement is usually asymptomatic, but symptoms develop upon growth of the cyst leading to many complications, most common of which is intra-biliary rupture, and less likely biliary obstruction. Diagnosis is clinical, serologic and radiologic. Therapeutic approaches to HLD include surgery, anthelminthic medications and medico-surgical procedures. Here we present a case of HLD that presented in advanced stage leading to grave consequences, complicated course and difficult therapeutic options. Given the rarity of hydatid disease in Northern America, physicians have to keep high index of suspicion especially in a patient with history of travel to endemic areas, as early diagnosis and treatment is important to avoid high morbidity and mortality.

Rupture of Hydatid Cyst in the Gallbladder Leading to Acute Cholangitis

Hydatid disease is a health problem in endemic areas such as the Mediterranean region caused by Echinococcus granulosus which can develop anywhere in the human body, but it is most frequently located at the liver. Liver hydatid cyst may rupture into the biliary tract, thorax, peritoneum, viscera, digestive tract, or skin, but its rupture in the gallbladder remains rare. We report a rare case of rupture of liver hydatid cyst in the gallbladder leading to acute cholangitis. The diagnosis was suspected on radiological imaging, and the patient was taken to open surgery which confirmed the imaging findings. The gallbladder and adjacent cyst were excised, and a transcystic drain was placed. Postoperative recovery was uneventful.

Laparoscopic management of hydatid cysts with biliary communication: clips may rescue when suture fails - report of three cases

Hydatid disease is a parasitic zoonosis caused by the larval form of the Echinococcus worm. Hepatic hydatidosis is the most common form of the disease in humans. Centrally located, large hydatid cysts have the tendency to rupture into the adjoining bile duct and form a fistulous communication. Suture closure of the cysto-biliary communication detected during surgery is recommended to avoid postoperative complications related to bile leak. In the era of minimally invasive surgery, laparoscopic management of the cysto-biliary communication can be challenging, and laparoscopic suturing may not always be feasible. Postoperative endoscopic biliary decompression is necessary in such situations, but it has its own set of potential risk and complications. This case report aimed at presenting a simple and easy technique for laparoscopic closure of the cysto-biliary communication when suture ligation is technically not possible.

Current status of diagnosis and treatment of hepatic echinococcosis

Echinococcus granulosus (E. granulosus) and Echinococcus multilocularis (E. multilocularis) infections are the most common parasitic diseases that affect the liver. The disease course is typically slow and the patients tend to remain asymptomatic for many years. Often the diagnosis is incidental. Right upper quadrant abdominal pain, hepatitis, cholangitis, and anaphylaxis due to dissemination of the cyst are the main presenting symptoms. Ultrasonography is important in diagnosis. The World Health Organization classification, based on ultrasonographic findings, is used for staging of the disease and treatment selection. In addition to the imaging methods, immunological investigations are used to support the diagnosis. The available treatment options for E. granulosus infection include open surgery, percutaneous interventions, and pharmacotherapy. Aggressive surgery is the first-choice treatment for E. multilocularis infection, while pharmacotherapy is used as an adjunct to surgery. Due to a paucity of clinical studies, empirical evidence on the treatment of E. granulosus and E. multilocularis infections is largely lacking; there are no prominent and widely accepted clinical algorithms yet. In this article, we review the diagnosis and treatment of E. granulosus and E. multilocularis infections in the light of recent evidence.

Value of cyst localization to predict cystobiliary communication in patients undergoing conservative surgery with hydatid cyst

OBJECTIVE

The objectives of this study were to investigate the relationship between the segmental localization of liver hydatid cyst by computed tomography (CT) and the presence of cystobiliary communication (CBC) and to identify the risk factors for CBC.

PATIENTS AND METHODS

One hundred and eleven of 163 patients who underwent liver hydatid surgery between January 2011 and September 2014 were included in this study and analyzed retrospectively. The size, number, stage, and segmental and lobar localization of the cysts were investigated by CT. The presence of CBC and preoperative laboratory findings were recorded from operation notes.

RESULTS

CBC was more frequent in single large cysts. CBC was most commonly detected in segment 1 (50%), 8 (48.3%), 7 (41.2%), and 4 (40%). CBC was more frequent in the right lobe (40.4%) and Gharbi stage 3 (41.8%) and 4 (55.6%) lesions. There were no differences in CBC according to distance from the hilus. In addition, preoperative total bilirubin, direct bilirubin, alkaline phosphatase (ALP), and gamma-glutamyl transferase (GGT) elevations were associated with higher CBC frequency (P<0.05). Cyst diameter, number of cysts, and ALP and GGT elevations were independent predictors of CBC presence.

CONCLUSION

The evaluation of hydatid cyst diameter, morphological stage, and segmental and lobar localization by abdominal CT and measurement of preoperative cyst diameter, number of cysts, and ALP and GGT values may predict the presence of CBC.

Navigation liver surgery for complex hydatid cyst with biliary tree communication

INTRODUCTION

Today, liver surgery navigation is utilized only in high-specialized centers for patients affected by malignant diseases. However, navigated surgery may also be of great interest for benign diseases such as hydatidosis in particular if the hydatid cyst is communicating with the biliary tree. With navigation we know exactly in each moment during the surgery the relationship of the cyst with the vascular/biliary structures around it.

PRESENTATION OF CASE

Herein, we report a case of a 20-year-old W/M affected by hepatic hydatid cyst communicating with the right bile duct, causing recurrent cholangitis. The diagnosis was confirmed by endoscopic retrograde cholangiography and magnetic resonance imaging. The liver cystectomy was easily performed using a navigation system incorporating instrument tracking and three-dimensional CT-reconstruction, thus permitting a selective suture of the bile duct communicating with the cyst.

CONCLUSIONS

The navigated system may guide the surgeon in patients with severe and complicated hydatid cysts.

Review of the treatment of liver hydatid cysts

A review was carried out in Medline, LILACS and the Cochrane Library. Our database search strategy included the following terms: “hydatid cyst”, “liver”, “management”, “meta-analysis” and “randomized controlled trial”. No language limits were used in the literature search. The latest electronic search date was the 7^th of January 2014. Inclusion and exclusion criteria: all relevant studies on the assessment of therapeutic methods for hydatid cysts of the liver were considered for analysis. Information from editorials, letters to publishers, low quality review articles and studies done on animals were excluded from analysis. Additionally, well-structured abstracts from relevant articles were selected and accepted for analysis. Standardized forms were designed for data extraction; two investigators entered the data on patient demographics, methodology, recurrence of HC, mean cyst size and number of cysts per group. Four hundred and fourteen articles were identified using the previously described search strategy. After applying the inclusion and exclusion criteria detailed above, 57 articles were selected for final analysis: one meta-analysis, 9 randomized clinical trials, 5 non-randomized comparative prospective studies, 7 non-comparative prospective studies, and 34 retrospective studies (12 comparative and 22 non-comparative). Our results indicate that antihelminthic treatment alone is not the ideal treatment for liver hydatid cysts. More studies in the literature support the effectiveness of radical treatment compared with conservative treatment. Conservative surgery with omentoplasty is effective in preventing postoperative complications. A laparoscopic approach is safe in some situations. Percutaneous drainage with albendazole therapy is a safe and effective alternative treatment for hydatid cysts of the liver. Radical surgery with pre- and post-operative administration of albendazole is the best treatment option for liver hydatid cysts due to low recurrence and complication rates.

Total rupture of hydatid cyst of liver in to common bile duct: a case report

Rupture of hydatid liver cyst into biliary tree is frequent complications that involve the common hepatic duct, lobar biliary branches, the small intrahepatic bile ducts,but rarely rupture into common bile duct. The rupture of hydatid cyst is serious life threating event. The authors are reporting a case of total rupture of hydatid cyst of liver into common bile duct. A 50-year-old male patient who presented with acute cholangitis was diagnosed as a case of totally rupture of hydatid cyst on Abdominal CT Scan. Rupture of hydatid cyst of liver into common bile duct and the gallbladder was confirmed on surgery. Treated by cholecystectomy and T-tube drainage of Common bile duct.

Cysto-biliary communication in liver hydatidosis

BACKGROUND

Liver hydatidosis is a severe health problem in endemic areas. Due to migration from these countries to other zones, now it is a worldwide problem. Liver hydatidosis can provoke many complications (abscess, fistula to adjacent organs, migration, etc.), but the most frequent and one of the most severe complication is the communication between the cyst and the biliary tree.

AIM

The aim of this study is to perform a review on the epidemiology, clinical features, diagnostic methods, and therapeutic options to treat the communication between the cyst and the biliary tree.

RESULTS

Due to the lack of randomized clinical trial or meta-analysis on this topic, we performed a classical review and included our personal algorithm.

CONCLUSIONS

The communication between the cyst and the biliary tree varies from a small communication to a frank intrabiliary rupture. The percentage of patients with the communication between the cyst and the biliary tree is not well known because there is no accepted definition. The therapeutic options are multiple and related to the size of the communication, the location of the cyst, and the experience of the hepatobiliary surgeon. ERCP is now an important tool for the treatment of the communication between the cyst and the biliary tree.

Complications of Hydatid Cysts of the Liver: Spiral Computed Tomography Findings

Background

The purpose of this retrospective study is to evaluate the role of Spiral Computed Tomography (CT) in the detection of the complications of hepatic hydatid cysts.

Methods

During a period of 8 years and after establishing the diagnosis of numerous hydatid cysts, 7 patients with complications of hydatid cysts were found. These 7 patients (5 females, 2 males, mean age 74.2 years, range 63 - 92 years) were studied. Four of them had a known medical history of hydatid disease, while all of them presented to our department as emergency cases.

Results

They underwent Spiral CT which revealed the following complications of hydatid cysts: intrabiliary rupture in 2 patients, rupture into the peritoneal cavity resulting to peritonitis in 1 patient, contained rupture and secondary transdiaphragmatic thoracic rupture in 1 patient, rupture into both biliary tract and hepatic subcapsular space in 1 patient, rupture into the subcapsular hepatic space in 1 patient and secondary bacterial infection of the cyst resulting to abscess formation in 1 patient. All of these CT findings were surgically confirmed.

Conclusions

CT provided a rapid and accurate diagnosis in all of these cases and proved to be a very useful preoperative imaging method.

Percutaneous alcohol sclerotherapy of a hepatic hydatid cyst after balloon occlusion of a large biliary communication

OBJECTIVE

To present a case of hepatic hydatid cyst with a biliary communication that was not suitable for surgery and hence necessitated sclerotherapy with absolute alcohol after occluding the biliary communication with a balloon catheter.

CLINICAL PRESENTATION AND INTERVENTION

A 50-year-old Asian man presented to the surgical emergency department with a 1-year history of repeated attacks of obstructive jaundice and right hypochondrial pain. Ultrasound and contrast computed tomography revealed a cyst, and endoscopic retrograde cholangiopancreatography and cystography revealed a biliocystic communication. An indirect hemagglutination test for echinococcosis showed the presence of antibodies to Echinococcus species at a titer of 8 establishing the diagnosis of hydatid cyst. Although surgery is the accepted modality of treatment in these cases, the patient was deemed unfit for surgery due to his underlying cardiac problem. While percutaneous treatment with absolute alcohol is contraindicated in his case, it was successfully attempted after balloon occlusion of the biliocystic communication.

CONCLUSION

This case showed that in this patient with hepatic hydatid disease and biliocystic communication, who was not fit for surgery, percutaneous sclerotherapy with absolute alcohol after balloon occlusion was successfully performed by an interventional radiologist.

Concomitant Rupture of Hydatid Cyst of Liver in Hepatic Duct and Gallbladder: Case Report

Hydatid cyst liver rupture into the biliary tree may involve the common hepatic duct, lobar biliary branches, the small intrahepatic bile ducts or rarely the gallbladder. Rupture can be occult or frank. A frank intrabiliary rupture of hepatic hydatid cyst is a rare but serious event. The authors are reporting a case of concomitant rupture of hydatid cyst of liver into right hepatic duct and the gallbladder. A 50-year-old female patient who presented with acute cholangitis was confirmed as a case of intrabilary rupture on ultrasonography, endoscopic retrograde cholangiopancreatography and magnetic resonance cholangiopancreatography. Rupture of hydatid cyst of liver in right hepatic and the gallbladder was confirmed on surgery. Suture repair of cystobiliary fistula, choledochoduodenostomy with cholecystectomy was done.

Endoscopic management of biliary parasitic diseases

AIM/MATERIALS AND METHODS: Between January 2000 and June 2007, 3,548 endoscopic retrograde cholangiopancreatography (ERCP) were performed for extrahepatic cholestasis, cholangitis, and choledocholithiasis. The results of ERCPs were evaluated retrospectively and examined carefully to investigate the management and endoscopic therapy of biliary parasites.

RESULTS

Of the 3,548 patients who underwent ERCP, 24 (0.66%) were found to have biliary parasitosis. The mean age of the biliary parasitosis patients (16 women) was 48.6 (15-77) years. Of these 24 cases, 16 patients had hydatid cystic disease (eight with partial obstruction of the biliary tract, and eight with ruptured cysts), four patients had Fasciola hepatica, and four patients had Ascaris lumbricoides infestation. Endoscopic sphincterotomy was performed, after which the choledochus was examined carefully by balloon catheter and basket procedure.

CONCLUSION

The ERCP procedure is very useful in the therapy of biliary parasitic infestations.

The diagnostic MRCP examination: overcoming technical challenges to ensure clinical success

The magnetic resonance cholangiopancreatography (MRCP) examination has all but replaced the diagnostic endoscopic retrograde cholangiopancreatography (ERCP) examination for imaging the biliary tree and pancreatic ducts in many practical aspects of the clinical setting. Despite this increase in popularity, many magnetic resonance imaging (MRI) radiographers still find aspects of the MRCP examination quite challenging. The aim of this tutorial paper is to provide useful technical advice on how to overcome such perceived challenges and thus produce a successful diagnostic MRCP examination. This paper will be of interest to novice MRI radiographers who are at the beginning of their learning curve in MRCP examination. Other MRI radiographers who are interested in practical tips for protocol variations may also find the paper useful.

Hydatid hepatic cysts rupture into the biliary tract, the peritoneal cavity, the thoracic cavity and the hepatic subcapsular space: specific computed tomography findings

BACKGROUND

This study attempts to demonstrate the role of computed tomography in the diagnosis of hepatic hydatid cyst rupture based on specific imaging findings and to propose combinations of the imaging findings diagnostic for specific types of rupture.

METHODS

Eleven patients were studied with computed tomography of the abdomen, with 4-8 mm slice thickness, after the oral administration of contrast material and intravenous contrast material in 6 cases.

RESULTS

Based on a combination of imaging findings the types of hepatic hydatid cyst rupture were: intrabiliary rupture in 7 patients, intraperitoneal rupture in 1 patient, intrathoracic rupture in 1 patient, hepatic subcapsular rupture in 2 patients. Structural deformity of the cyst was present in all cases, combined with: dilatation of the intrahepatic bile ducts (intrabiliary rupture); intraperitoneal fluid collections with diffuse haziness and stranding of the mesenteric fat (intraperitoneal rupture); an inhomogeneous lesion in the thorax with ipsilateral pleural effusion (intrathoracic rupture); a hydatid cyst located peripherally, with discontinuity of its adjacent to the hepatic capsule wall and subcapsular fluid collection (subcapsular rupture). The imaging findings were surgically and pathologically confirmed.

CONCLUSIONS

Using combinations of specific imaging findings we correctly diagnosed the type of hepatic hydatid cyst rupture in all cases.

Endoscopic management of a relapsing hepatic hydatid cyst with intrabiliary rupture: a case report and review of the literature

Hydatid disease, although endemic mostly in sheep-farming countries, remains a public health issue worldwide, involving mainly the liver. Intrabiliary rupture is the most frequent complication of the hepatic hydatid cyst. Endoscopy is advocated, preoperatively, to alleviate obstructive jaundice caused by intracystic materials after a frank rupture and is also a useful and well-established adjunct in locating postoperative biliary fistulas. Endoscopic retrograde cholangiography with sphincterotomy has been successful as the sole and definitive means of treatment of intrabiliary ruptured hydatid cysts. A case of an elderly woman with frank rupture is presented, where the rupture was definitively managed endoscopically in conjunction with sphincterotomy to remove the intrabiliary obstructive daughter cysts and to achieve decontamination of the biliary tree. Endoscopic retrograde cholangiography provided an excellent diagnostic and therapeutic modality in the present case and, thus, it should be considered as definitive treatment in similar cases especially if surgical risk is anticipated to be high.

The usefulness of endoscopic retrograde cholangiopancreatography and (99m)Tc-labeled albumin macroaggregates in diagnosing hydatid disease fistulae

Hydatid disease is an important health problem in areas where it is endemic. There are several therapeutic modalities, the most important being surgery, antibiotherapy, and percutaneous treatment. In recent years percutaneous treatment has become popular, and for this method or surgery it is sometimes lifesaving to know the relation between the biliary ducts and the cyst cavity. The aim of this study was to examine the usefulness of endoscopic retrograde cholangiopancreatography and (99m)Tc-labeled albumin macroaggregates in diagnosing hydatid disease fistulae before percutaneous or surgical treatment. A total of 72 patients diagnosed with hepatic hydatid disease via ultrasound and serologic tests were enrolled in the study. Endoscopic retrograde cholangiopancreatography was successfully performed in all patients. (99m)Tc-labeled albumin macroaggregates also were injected into cysts at a dose of 1.5-2 mCi just before the treatment. All but three patients were treated percutaneously. Scintigraphy of abdominal and thoracic areas was performed with a GE Starcam 3200 XC/T gamma camera at 30 and 120 min after Tc-labeled albumin macroaggregate injections. Endoscopic retrograde cholangiopancreatography revealed communications between biliary ducts and cyst cavities in nine patients (12.5%). However, (99m)Tc-labeled albumin macroaggregates showed not only leakage into the systemic circulation in nine patients but also into the biliary ducts in two (15.4%). In one patient, mild acute pancreatitis occurred as a complication of endoscopic retrograde cholangiopancreatography. No complications of (99m)Tc-labeled albumin macroaggregates injection were seen. Three patients were surgically treated because of clinically manifested cystobiliary fistulae. We conclude that endoscopic retrograde cholangiopancreatography is a gold standard technique for the diagnosis of communication between the biliary duct and the cyst cavity, and (99m)Tc-labeled albumin macroaggregate injection is useful for revealing leakage into the systemic circulation. The diagnosis of biliary fistulae before percutaneous treatment of hydatid disease may enable planning of the optimal therapy.

Magnetic resonance cholangiopancreatography of biliary system abnormalities in children

OBJECTIVE

The aim of this study was to assess the usefulness of magnetic resonance cholangiopancreatography (MRCP) with a single-shot fast spin-echo sequence as a noninvasive method to evaluate the biliary system in children.

METHODS

Twenty-five MRCP examinations of 23 patients were evaluated. On the basis of surgical (n=5), endoscopic retrograde cholangiopancreatography (n=4), liver biopsy (n=4), clinical data, and follow-up observation, 6 children were considered to have no significant abnormality. The other 17 children were found to have pancreaticobiliary disease, including choledochal cyst, biliary system dilatation, choledocholithiasis, biliary atresia, multiseptated gallbladder, anomalous pancreaticobiliary union, ruptured hydatic cyst, and biloma. The findings were correlated with the ultrasonography, computed tomography, surgical, and endoscopic retrograde cholangiopancreatography results.

RESULTS

Magnetic resonance cholangiopancreatography showed the first branch of the intrahepatic duct, the common hepatic duct, the gallbladder, and the common bile duct in 14 children. Cystic duct was not seen in infants, but was partially visible in younger children. Although the main pancreatic duct was visible in head and body portions in 65% of the patients, it was visible in 17% of the patients in the tail. The diagnostic accuracy of MRCP was 100% in patients with choledochal cysts and stenoses. In a patient with hydatic cyst, cystobiliary communication was successfully demonstrated.

CONCLUSION

Magnetic resonance cholangiopancreatography can be used effectively for the evaluation of the biliary system in children.

Intrabiliary rupture of a large liver echinococcal cyst in an adolescent managed with endoscopic sphincterotomy and albendazole

We report the case of a 17-year-old male with a rupture into the biliary tract. The patient was urgently admitted to the surgical department with the clinical diagnosis of cholangitis. Modern imaging techniques and specific serologic tests established the diagnosis of intrabiliary rupture of a liver hydatid cyst due to E. granulosus. Despite the fact that surgery remains the cornerstone of treatment, conservative management was preferred, due to the location of the echinococcal cyst in the right lobe of the liver adjacent to the inferior vena cava and the age of the patient. Endoscopic sphincterotomy was performed with subsequent evacuation of the biliary tree, followed by a sixcycle treatment with albendazole. At one-year follow-up, the patient is in good health, with no radiologic or serologic evidence of relapse.

Latent fatality due to hydatid cyst rupture after a severe cough episode

Hydatid disease is a parasitic disease caused by Echinococcus granulosus characterised by cyst formation in various organs. The infestation mostly involves the liver. Hydatid cysts of the liver can rupture either spontaneously or due to trauma. Incidence of rupture is about 3-17% of all cases with hydatid disease. Unless treated surgically, rupture can result in death. Here, we present a case of hydatid cyst ruptured after a severe cough episode and disseminated first to the subcapsular area, then to the peritoneal space. Probably due to a decrease in parenchymal pressure in the liver after decompressive effect of rupture, the patient felt an improvement in abdominal pain, refused operation, and left the hospital on his own responsibility. This unfortunate relief resulted in a delay of 55 hours in management. The leakage of liquid materials into peritoneal space resulted in a severe inflammatory reaction and eventually death of the patient. The patient died of a late peritonitis rather than anaphylaxis, which is the most common reason for death in such patients. As a conclusion, physicians should be aware of a temporary relief in abdominal pain after cyst rupture that may cause a delay in management and in turn loss of patient due to peritonitis.

Sonographic and computed tomographic demonstration of hydatid cysts communicating with the biliary tree

Hepatic hydatid disease is usually silent and discovered incidentally. Rupture of a hydatid cyst into the biliary tree is a serious complication and produces a clinical picture of biliary obstruction. We present the cases of 2 patients who had only nonspecific symptoms and laboratory test results indicative of biliary tract obstruction. The results of sonographic examinations of both patients strongly suggested the presence of hepatic hydatid cysts communicating with the biliary tree. CT examination provided additional information in 1 patient but only confirmed the sonographic findings in the other. Both cases were surgically confirmed. Demonstration of the cyst and intrabiliary hydatid contents should form the basis for the diagnosis of a hydatid cyst's rupture into the biliary tree; detecting the point of communication further supports the diagnosis. An accurate preoperative diagnosis of this disease is essential for its prompt surgical management.