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Intrabiliary rupture of hydatid cyst: diagnosis with MRI and ...
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Short Description: -mebrofenin hepatobiliary scintigraphy were able to establish a firm pre-. operative diagnosis. .... -mebrofenin hepato-. biliary study. (a) An early image ...
Content Inside: The British Journal of Radiology, 75 (2002), 271274 E 2002 The British Institute of Radiology Case report Intrabiliary rupture of hydatid cyst: diagnosis with MRI and hepatobiliary isotope study 1R KUMAR, DRM, DNB, 2S N REDDY, MS, FRCS Ed and 3S THULKAR, MD Departments of 1Nuclear Medicine, 2Surgery and 3Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India Abstract. Intrabiliary rupture is the most common complication of hepatic hydatid cyst yet it is unusual, occurring in only 317% of cases. The diagnosis is rarely difficult on ultrasound and CT when typical radiological features are present. In rare cases of complete evacuation, when characteristic findings of hydatid cyst are absent or when there is no evidence of the previous existence of liver hydatid cyst, the diagnosis may be difficult. In difficult cases, MRI, MRCP, ERCP and 99Tcm-mebrofenin hepatobiliary scintigraphy are employed. We present a rare case of surgical obstructive jaundice due to rupture of a liver hydatid cyst into the biliary tract and gall bladder, with complete evacuation of its contents leading to misdiagnosis on CT and ultrasound. MRCP and 99Tcm-mebrofenin hepatobiliary scintigraphy were able to establish a firm pre- operative diagnosis. Hepatic hydatid disease (HHD) is a major referred after a sudden episode of acute abdom- endemic problem in sheep-rearing regions of the inal pain, low grade fever and icterus associated world. The liver acts as a filter for hydatid larvae, with clay coloured stools and itching. On making it the most commonly affected organ. Up abdominal examination there was tenderness in to one-third of patients with HHD present with the epigastrium and right upper quadrant. complications such as rupture (into the biliary Laboratory investigations revealed serum biliru- tree, thorax or peritoneum), secondary infection, bin 156.4 mmol l21 (normal 1.717 mmol l21), anaphylactic shock, sepsis and liver replacement. serum glutamic oxaloacetic transaminase 56 The incidence of rupture into the biliary tree international units (IU), serum glutamic pyruvic has been reported as 317% [14]. It presents transaminase 78 IU (normal up to 50 IU) and clinically as pain, obstructive jaundice, cholangitis serum alkaline phosphatase 562 IU (normal or sepsis, and can be fatal without intervention. 80280 IU). Ultrasound of the abdomen showed Successful outcome depends on accurate pre- an anechoic small cyst in the right lobe of the liver operative diagnosis. Diagnosis of this complica- and a soft tissue mass in the gall bladder lumen tion can usually be made using ultrasound and with gall stones. Contrast enhanced CT revealed a CT. Complete evacuation of the contents of a hypodense lesion with enhancing walls in segment liver hydatid cyst is very rare and can present eight of the liver (Figure 1). The lesion was diagnostic problems. We present a case of com- communicating with the right hepatic duct. plicated HHD with intrabiliary rupture, which on Intrahepatic biliary radicles and the common ultrasound and CT was misdiagnosed. MRI, duct were dilated, with a few hypodense foci in magnetic resonance cholangiopancreatography their lumen. CT also showed focal thickening of (MRCP) and 99Tcm-mebrofenin hepatobiliary the gall bladder wall in the region of the fundus, scintigraphy made a definite pre-operative diag- with an isodense mass in the lumen. An oval nosis possible. subcapsular fluid collection with enhancing walls, possibly a subcapsular extravasation of the Case report contents of the cyst, was also seen in the vicinity. A differential diagnosis of inflammatory/malig- A 45-year-old farmer with a history of recur- nant mass in the liver and gall bladder was made. rent episodes of right upper abdominal pain was MRI and MRCP (T2 weighted images) revealed a 4 cm64 cm well defined heterogeneously hyper- Received 24 May 2001 and in revised form 12 November intense cystic lesion surrounded by a hypointense 2001, accepted 21 November 2001. rim in segment eight of the liver. Thin detached Address correspondence to Dr Rakesh Kumar, F-74, infolded membranes within the cyst were seen as Ansari Nagar, AIIMS Campus, New Delhi 110 029, India. linear hypointense filling defects (Figure 2). The The British Journal of Radiology, March 2002 271
