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Int J Surg Case Rep
Int J Surg Case Rep
International Journal of Surgery Case Reports
2210-2612
Elsevier

S2210-2612(24)01001-0
10.1016/j.ijscr.2024.110220
110220
Case Report
Peritoneal hydatidosis secondary to an asymptomatic liver hydatid cyst rupture: A case report
Zayati Mohamed a
Chaouch Mohamed Ali docmedalichaouch@gmail.com
a⁎
Mokni Salem a
Maaref Mohamed a
Gafsi Besma b
Noomen Faouzi a
a Department of visceral and digestive surgery, Monastir University Hospital, Monastir, Tunisia
b Department of Intensive Care, Monastir University Hospital, Monastir, Tunisia
⁎ Corresponding author. docmedalichaouch@gmail.com
28 8 2024
10 2024
28 8 2024
123 11022029 7 2024
20 8 2024
25 8 2024
© 2024 The Authors
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction and importance

Hydatid cysts, caused by Echinococcus granulosus, are a significant public health problem in regions such as Tunisia and Morocco. These cysts primarily affect the liver and lungs but can also involve the spleen, kidneys, bones, and brain. Peritoneal hydatidosis, involving the formation of hydatid cysts in the peritoneal cavity, is a rare manifestation of this disease. This case report aims to highlight the presentation, diagnostic process, and surgical management of a primary peritoneal hydatid cyst.

Case presentation

A 73-year-old asymptomatic woman with no significant medical history was found to have a hypoechoic mass with a calcified wall in the liver segment IV and multiple multiloculated cystic masses in the peritoneum on an incidental abdominal ultrasound. Further evaluation with a CT scan revealed a hydatid cyst in liver segments IV and V and additional cystic formations in the peritoneum. Surgical exploration via midline incision identified and treated cysts in the omentum, liver, spleen, and pouch of Douglas. A total pericystectomy and other relevant procedures were performed. The patient's postoperative course was uncomplicated, and she recovered well.

Discussion

Peritoneal hydatidosis is typically secondary to hepatic hydatid cysts, caused by the parasite Echinococcus granulosus. The diagnosis is made primarily through imaging techniques such as CT and ultrasonography, which help to delineate the cysts and their relationships with adjacent structures. Treatment involves both medical and surgical approaches, with surgery being the primary intervention to prevent complications and recurrence. Scolicidal solutions are essential during surgery to prevent the dissemination of scolices.

Conclusions

Primary peritoneal hydatidosis is a rare condition that is usually secondary to liver involvement. It is diagnosed by imaging and treated primarily through surgical intervention. Accurate diagnosis and timely management are crucial to prevent complications and ensure a favourable outcome.

Highlights

• The hydatid cysts were incidentally detected in a 73-year-old asymptomatic woman during a routine ultrasound, highlighting the importance of imaging in diagnosing asymptomatic cases.

• The patient underwent extensive surgical intervention, including total pericystectomy and resection of protruding cystic domes, which ensured complete removal and reduced the risk of recurrence.

• This case involved multiple hydatid cysts in the liver, peritoneum, spleen, and pouch of Douglas, demonstrating the potential for extensive spread and the need for thorough exploration and treatment in surgical management.

Keywords

Primary peritoneal hydatidosis
Hydatid cyst
Echinococcus granulosus
Pericystectomy
Case report
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pmc1 Introduction and importance

Hydatid cyst is a public health problem in several countries such as Tunisia and Morocco. A parasite, Echinococcus granulosus, causes it. The parasite usually relies on a definitive host, often a dog, and an intermediate host, often a sheep (1). Humans can inadvertently contract the infection by consuming contaminated water or vegetables that harbour parasitic eggs from dog faeces, thus inadvertently becoming intermediate hosts. The liver and lungs are the organs most commonly affected. Furthermore, this condition can also impact the spleen, kidneys, bones, and brain (2). Peritoneal hydatidosis involves the formation of hydatid cysts in the peritoneal cavity, which is the space within the abdomen that houses the intestines, liver, and other organs. In this article, we will make the point of this affection. This case report, according to the SCARE guidelines (3), aims to highlight the presentation, diagnostic process, and surgical management of a primary peritoneal hydatid cyst.

2 Case presentation

A 73-year-old woman with no medical history. The patient is completely asymptomatic. An abdominal ultrasound incidentally revealed a hypoechoic mass with a calcified wall measuring 42 mm in segment IV of the liver, along with multiple multiloculated cystic masses in the peritoneum, some of which adhere to the liver and spleen. Clinically, the abdomen is soft, depressible, and painless, with no palpable masses. As concern the biological data, the complete blood count was normal. The C-reactive protein was 38 mg/dl. The hydatid serology was not performed. To better evaluate the cyst, an abdominopelvic CT scan was performed, which revealed a hydatid cyst spanning segments IV and V, partially calcified at the periphery, measuring 6 cm associated with a spleen hydatid cyst (Fig. 1). Additionally, there are multiple other hydatid cysts with exophytic development that span segment V and segment IV and an intraperitoneal cystic formation in the right iliac fossa measuring 58 × 18 mm. The patient underwent surgery via a midline incision. During exploration, a 3 cm cyst was found in the omentum (Fig. 2), a hydatid cyst in segments IVa and IVb, another cyst in segment VI, a hydatid cyst in the spleen, and a hydatid cyst in the pouch of Douglas. A total pericystectomy was performed on the omental cyst and the cyst in the Douglas pouch, and the protruding dome of the splenic cyst was resected (Fig. 3). Subsequently, a cholecystectomy was performed, a transcystic drain was placed, and the protruding dome of the hydatid cyst in segments IVa and IVb was resected, with the fistula closed (Fig. 4). Finally, the protruding dome of the cyst in segment VI was resected. The postoperative course was uneventful. The patient was discharged after five days.Fig. 1 Axial CT scan view showing the liver and spleen hydatid cysts.

Fig. 1

Fig. 2 Intraoperative view of the omental hydatid cyst.

Fig. 2

Fig. 3 Resection of the protruding dome of the splenic cyst.

Fig. 3

Fig. 4 Resection of the protruding dome of the liver hydatid cyst with a suture of the cysto-biliary fistula.

Fig. 4

2.1 Case discussion

The hydatid cyst is caused by Echinococcus granulosus. The forms that cause human infections are E. granulosus (cystic echinococcosis), E. multilocularis (alveolar echinococcosis), E. vogeli, and E. oligarthus. Dogs are the definitive hosts, while sheep and pigs serve as intermediate hosts. Humans become accidental intermediate hosts through the fecal-oral route by consuming vegetables contaminated with E. granulosus or through close contact with pets carrying the parasite (4,5). The most affected organs with this pathology are the liver (75 %); lung (15 %); spleen; kidney; bones; and brain (6). Peritoneal hydatidosis accounts for approximately 5 to 16 % of cases of hydatidosis (7). This condition can be primary or secondary. Primary peritoneal hydatidosis is more often rare and is defined by the peritoneal location of the hydatid cyst without the involvement of solid organs (8). Its primary form is believed to be due to hematogenous spread through the arterial route (9). Secondary hydatidosis in individuals without a history of surgery is due to spontaneous or traumatic micro-ruptures of a hepatic hydatid cyst. Another explanation for the cyst is hematogenous or lymphatic dissemination (10). Peritoneal hydatidosis can be asymptomatic or cause vague abdominal pain, anorexia, dyspepsia, and vomiting. The diagnosis of peritoneal hydatidosis is made by CT scan and ultrasonography. The CT scan is a crucial radiological examination as it allows for the detailed study of the cyst's vascular relationships and its interactions with neighbouring organs. Magnetic resonance imaging is rarely used for liver and peritoneal lesions (11). Different immunological serum tests (enzyme-linked immunosorbent assay, immunoglobulin G antibody detection, and cyst fluid antigen detection) follow for further diagnosis (5). Treatment of hydatid hydatidosis involves both medical and surgical approaches. Medically, the treatment is based on the prescription of albendazole. However, the primary treatment for peritoneal hydatidosis is surgical. The surgical approach should be broad and easily expandable as needed based on intraoperative findings. The use of scolicidal solutions, serum saline, is essential to prevent the dissemination of scolices into the peritoneal cavity and to sterilize peritoneal and potentially visceral cysts. However, we should not use this solution to sterilize the liver hydatid cyst with biliary communication because it could cause secondary sclerosis cholangitis. Surgical procedures that may be performed include total pericystectomy, pericystoresection, or omentectomy.

3 Conclusions

Peritoneal hydatidosis is rare, almost always secondary to hepatic hydatidosis, and easily recognized through ultrasound and CT scan. Its treatment is still surgical, but there is a significant risk of recurrence. In the future, the effectiveness of medical treatment is expected to prevent or cure this formidable parasitic disease.

Patient consent

Written informed consent was obtained from the patient to publish this case report and accompanying images. On request, a copy of the written consent form is available for review by the editor-in-chief of this journal.

Ethical approval

As a case report, it is exempted from ethical approval by the Institutional Board of Review, Monastir University Hospital, Monastir.

Funding

No funding.

Guarantor

Mohamed Ali Chaouch.

Research registration number

Not applicable.

Declaration of competing interest

The authors declare no competing interest.

Acknowledgements

There were no acknowledgements to mention.

Provenance and peer review

Not commissioned, externally peer-reviewed.
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