Br. J. Surg. Vol. 65 (1978) 106

Rupture of a hydatid cyst of the liver into the biliary tract R A J A MUSTAFA A N D H A Z I M H A M E E D S A L I H *

SUMMARY The historv o f a vatient with intrabiliarv ruoture o f a hydatid &st’ of ‘the liver is reported The patient presented with a distended palpable gallbladder, which i s a most unusual feature of this condition.

Case report A 45-year-old female was admitted to hospital on 13 November 1975 complaining of right upper abdominal pain and rigors of 7 days’ duration: her urine had been slightly dark in colour for the last 4 days. She gave a history that 2 years previously she had had a similar attack of pain, lasting for 4 days but not accompanied by jaundice.

On examination there was slight jaundice, a temperature of 37.5 “C and regular three fingers’ enlargement of the liver. The gallbladder was palpably enlarged and slightly tender. Subsequently the pain and jaundice increased and rigidity developed. A diagnosis of obstructive acute cholecystitis with simultaneous calculous jaundice was made and on 18 December 1975 she was operated on urgently. The abdomen was opened through a right subcostal incision. The gallbladder was found to be hugely distended but not inflamed; on its right side on the under surface of the liver a whitish mass of uneven surface with adhesions was seen. For a while this was thought to be a metastatic tumour but no primary could be found. The common bile duct was greatly dilated.

To provide space in the operative field the gallbladder was evacuated; while aspirating it two small floating daughter cysts were seen and the diagnosis was then clear. The mass in the liver, which was a hydatid cyst, was cleared of its numerous daughter cysts and infected bile-stained contents. The condition of the patient did not allow further exploration so both the gallbladder and the cyst were drained externally and the abdomen was closed.

Attempted cholangiography through the cholecystostomy tube failed. At a second operation on 31 December 1975 cholecystectomy was done, and peroperative cholangiography showed a filling defect in the distal common duct. Exploration of the duct showed that this was caused by the membrane of a collapsed daughter cyst. This was removed and a T tube was inserted in the common duct; a repeat cholangiogram showed no filling defect.

On the fourteenth postoperative day a T tube cholangio- gram showed no obstruction and the T tube was removed. Convalescence was uneventful, and when seen 10 months later the patient was in good health.

Discussion The preoperative diagnosis of hydatid jaundice is usually only tentative, its absolute confirmation being made by finding daughter cysts or hydatid membrane in the faeces (Harris, 1965; Al-Hashimi, 1971). In niost reported cases the diagnosis has been made only at operation, the preoperative diagnosis being calculous jaundice. A palpable gallbladder on clinical examination seems exceptional, no instance of this having been reported in the recent literature. In the case reported by Atlas and Kamenear (1952) the small mass which was palpable in the right hypo- chondrium was diagnosed preoperatively as empyema of the gallbladder, but at operation it was found that the mass was caused by the cyst in the liver.

In the patient reported here the diagnosis of carcinoma of the head of the pancreas was considered, but the presence of severe pain and pyrexia made it unlikely. Kattan (1975) emphasizes that, even in an endemic hydatid area, in the absence of positive evidence, the diagnosis of intrabiliary rupture of an hepatic hydatid cyst as the cause of jaundice with pain and rigors should be looked upon with suspicion, and in fact in the patient reported here it was con- sidered that the most likely diagnosis was the simultaneous impaction of stones in the cystic and common bile ducts.

References AL-HASHIMI H. M. (1971) Intrabiliary rupture of hydatid cyst of

the liver. Br. J . Surg. 58, 228-231.

cyst into bile ducts simulating stones in the common bile duct. Am. J. Med. 13, 384-392.

HARRIS J. D. (1965) Rupture of hydatid cysts of the liver into the biliary tract. Br. J . Surg. 52, 210-212.

KATTAN Y. B. (1975) Intrabiliary rupture of hydatid cyst. Br. J. Surg. 62, 885-890.

Paper accepted 24.8.1977.

ATLAS D. H . and KAMENEAR H. (1952) Rupture Of echinococcus

* Raja Mustafa, Department of Surgery, Mosul University College of Medicine; Hazim Hameed Salih, Radiologist, Mosul General Hospital, Mosul, Iraq.