48uep6bbphidcol2|ID

48uep6bbphidvals|1929

48uep6bbph|2000F98CTab_Articles|Fulltext

Hypoplasia and agenesis of the liver lobe are rare abnormalities¹. It is often associated with other deviations from normal anatomy like biliary system abnormalities, high location of the right kidney and right colon interposition². It is known that these patients are prone to the formation of gallstones and portal hypertension. Hydatid cyst is a parasitic disease caused by the larval stage of Echinococcus granulosus. Dogs are the primary hosts, and the intermediate hosts are sheep, horses and cattle. Humans are accidental intermediate hosts, and become infected by handling soil, dirt or animal hair that contains eggs. Although liver and lungs are the organs most commonly involved, hydatid cyst can occur in all visceral organs and soft tissues with signs and symptoms varying based on the site of involvement. Muscular hydatidosis has previously been documented in literature, but the involvement of the abdominal wall is a rare condition with only seven cases reported up to date.³

We report the case of a 65-year-old gentleman with history of fever, upper abdominal pain and a mass protruding through the umbilicus for the past 3 months. He consulted a nearby hospital and was referred for imaging. A large calcified cystic lesion in the liver was picked up by ultrasound and the patient was sent for a contrast enhanced CT scan (Figure 1). Thus, the case was diagnosed as hydatid disease with a cyst involving the right lobe of the liver with another cyst at the umbilicus (Figure 2). The marked reduction in size of the right lobe of the liver was apparent in the image, which was interpreted to be complete atrophic changes resulting from the infection. The patient was referred to our center and we put the patient on albendazole (400mg tablet once daily) for 2 months. A laparotomy was planned for definitive intervention. After taking the necessary precautions to deal with an intra-operative anaphylactic reaction, we proceeded with the surgery. Through a Makuuchi incision, the abdominal cavity was entered. The umbilical hydatid was removed completely. An abdominal wall defect wasnoted corresponding to the location of the umbilical hydatid cyst and it was repaired to prevent any herniation. The liver hydatid was opened, contents aspirated and the wall was removed in fragments. Agenesis of the right lobe of liver was noted during the surgery and this was confirmed by the absence of liver to the right of gallbladder. There was compensatory enlargement of the left lobe of liver. However, no other anatomical anomalies were found. The hydatid cyst had occupied the space available due to agenesis of right lobe of liver and it had made a biliary communication resulting in death and calcification of the larva. The biliary communication was carefully closed with polydioxanone suture. A cholecystectomy was also done.

Postoperatively the patient had prompt recovery. Oral feeding was started on the second day and the wound remained healthy. 

Discussion 

Although the burden of  hydatid disease is low in India,cases presenting as umbilical hernia must be managed, keeping the rare possibility of an abdominal wall hydatid in mind. Abdominal wall defects must be looked for after the resection of such a lesion and should be repaired if necessary. Liver atrophy following a hydatid should be differentiated from a hypoplastic liver because the latter is more prone to have other associated anomalies and might pose surgical surprises⁴. Biliary communication of hydatid cysts should be carefully looked for and repaired if found.