Case Report

A 22 year old unmarried female presented to the surgical OPD of SKIMS Medical College with history of progressive and painless distension of the abdomen of 8 months duration. There were no symptoms related to gastrointestinal or genitourinary system. Her menstrual cycles were normal and there was no history of exposure to pets. There was no past history of any surgery.

She was well built with nothing significant on General Physical, Chest and Cardiovascular examination. Abdominal examination revealed distended lower abdomen with a mass palpable which was non tender, spherical and had size of 20 & 25 cms in vertical & horizontal dimensions. The mass was mobile in horizontal direction only. It had rounded margins and inferior margin was not felt.

Her Hemoglobin was 9.3 gm/dl. Kidney & Liver Function tests were normal. Hydatid serology was weakly positive. CA-125 was negative. A CT of the abdomen revealed multiple intra-abdominal cysts with one large cyst extending from subhepatic region downwards (Fig. 1, 2 & 3).

Figure 1

Figure 2

Figure 3

At laparotomy the subhepatic cyst was identified as huge ovarian cyst arising from right ovary with one and a half turn around its pedicle (Fig. 4).

Figure 4

Right oopherctomy was performed. There were two hydatid cysts, one in left lobe of liver (Fig. 5) managed by left partial pericystectomy and capittonge.

Figure 5

Another Hydatid cyst in Sigmoid mesocolon (Fig. 6) was marsupilized and drained to the exterior. The postoperative period was uneventful and the patient was discharged on Albendazole. The patient is recurrence free 6 months after surgery.

Figure 6

Discussion

The earliest mention of Hydatid disease dates back to Hippocrates who used the term “Liver filled with water”. Famous Arab Physician Al-Rhazes wrote about the disease more than one thousand years ago [₁]. It is a zoonotic illness caused by cysts of Echinococcus granulosis, whose primary host is the dog. Human disease occurs when tapeworm ova are ingested by humans either by consuming unwashed and uncooked vegetables or as a result of close contact with a working or a pet dog [₂]. Although liver [75% of cases] and lungs [15% of cases] are the organs most commonly involved, peritoneal hydatidosis represents an uncommon but significant manifestation of the disease [₃]. Peritoneal cavity involvement in Hydatid disease is found in 10 – 16 % cases [₄].

Peritoneal hydatidosis could be either primary or more frequently secondary to hydatid cysts in Liver or rarely in Spleen. Primary peritoneal hydatidosis is rare, and has been reported to occur in only 2 percent of all abdominal hydatid disease cases [₅]. The mechanism of peritoneal infestation is not clear. Dissemination via lymphatics [₆] or systemic circulation [₇] has been implicated as a possible route to produce primary hydatid disease outside the liver or lungs.

Secondary Peritoneal Hydatidosis is recorded in 16% of patients admitted for liver Hydatid [₈]. It is almost always secondary to Hepatic Hydatid disease related to seeding from spontaneous rupture of Hepatic cyst or rarely splenic cyst into peritoneum or spillage of cyst fluid during previous surgery [₉].Of the three types of rupture ie contained, communicating or direct rupture, the latter has greatest clinical consequences including anaphylaxis, Hydatid dissemination and secondary Bacterial infection or peritonitis[₁₀]. The incidence of anaphylaxis and secondary hydatidosis resulting from cyst fluid spillage during surgery have been reported to be 2-25% in different series[₁₁,₁₂].

Diagnosis of peritoneal hydatidosis is usually radiological and aided by serological testing. USG is the first line of screening and leads to diagnosis in 95% cases[₁₃]. However CT Scan gives wider field of view and correct topographical evaluation for radical surgical treatment[₁₃]. It is also used to assess response to medical therapy by showing changes in size, number, and density of lesion. Indirect Heamagglutination test & ELISA have approximately 85% sensitivity [₁₄].

Surgery remains the best curative or palliative treatment for peritoneal echinococcosis, although antihelminthics can be effective alternative for the treatment of small and asymptomatic cysts[₃]. Combination therapy of Albendazole and Praziquantel is more effective than either agent alone [₁₅]. Preoperative high dose Mebendazole have also been used to achieve shrinkage of multiple cysts so as to enable surgery [₁₆].

Complete removal of the cysts is the gold standard, but its feasibility is related to location of the cyst [₁₁]. Drainage and wide unroofing of cysts is safer and effective alternative in cysts adherent to the intraperitoneal viscera. In case of intraperitoneal spillage, antihelminthic drugs should be used [₃].

Conclusion

The case illustrates that peritoneal hydatidosis should be considered in differential diagnosis of abdominal lumps in endemic areas. One should look for cysts in other areas of peritoneal cavity while performing surgery of hepatic hydatid and also put some emphasis on avoiding spillage of hydalid fluid during surgery and proper use of scolicidal agents and if it has occurred use antihelminthics to avoid secondary peritoneal echinococcosis.

Correspondence to

Dr. Fazal .Q. Parray 44- Rawalpora, Govt. Housing Colony [Sanat Nagar], Srinagar. 190005. J&K , INDIA. Telephone : 0194-2433433. E-mail : fazlparray@rediffmail.com