Teaching Case

A young woman from Eastern Europe presented to the emergency room with an acute abdominal pain at the left flank. Routine blood tests showed elevation of white cell blood count (18.3x10⁹/L) and increase of serum C-reactive protein (4.53 mg/dL, upper normal limit 0.50 mg/dl).

Ultrasonography detected multiple abdominal cystic lesions with different sonographic patterns, disseminated through the whole abdomen; a hepatic cyst as well as a splenic cyst were also present (Fig. 1 a, b). A collapsed cyst was appreciable at the left flank (Fig. 1c).

Abdominal CT confirmed the presence of multiple intra-abdominal cyst, some of them showing a hyperattenuating rim (Fig. 2, 3, 4). The collapsed cyst located at the left flank contained air bubbles and was surrounded by a small fluid collection (Fig. 2d, 3). Communication between the collapsed cyst and the descending colon was also demonstrated (Fig. 4b, c).

The patient was operated on intra-abdominal cysts; the splenic cyst was thereafter successfully treated with percutaneous drainage.

Hydatid disease is caused by Echinococcus granulosus; humans are intermediate hosts, dogs and ships being definitive and intermediate hosts respectively. Infection occurs through contact with a definitive host or intake of contaminated food or water; the liver is the organ mainly involved [1].
Peritoneal echinococcosis is an infrequent condition. It is almost always secondary to a hepatic hydatid disease, which is a complication in 13% of cases, whereas primary peritoneal echinococcosis is rather rare [1, 2]. Mechanism of primary peritoneal seeding remains unclear. Contamination of the peritoneal cavity is due to a spontaneous rupture of an echinococcal hepatic cyst in up to 12% of patients but in most of cases it is secondary to an intraoperative spillage of the hydatid fluid during surgery for a hepatic disease. In few cases, asymptomatic micro-rupture of a hepatic hydatid cyst, whether spontaneous or post-traumatic, is advocated as a possible pathologic mechanism of peritoneal seeding [1, 2].
Peritoneal echinococcosis usually remains asymptomatic until cysts become large enough to produce a mass effect [1, 2]. Cysts can be isolated or multiple, and may implant everywhere in the abdominal cavity; they can show different imaging patterns according to their own evolutive stage (Fig. 5).
Cysts occupying the whole peritoneal cavity may mimic a multiloculated mass, a condition known as encysted peritoneal hydatidosis [1].
Spontaneous rupture of a hydatid cyst within a hollow viscus is a very rare complication with an estimated incidence of 0.5% of cases [1]; it can clinically present with hydatidemesis or hydatidorrhea with regard to the perforation site [1-3].
An echinococcal cyst-enteric rupture is usually diagnosed during surgery, although it seldom may be suspected in pre-surgical radiologic work up [1-3]. Ultrasonography is the first-level method for identifying and classifying a hydatid cyst [4], but CT is the method of choice for detecting and diagnosing an abdominal echinococcosis, whose appearance resemble findings of hepatic disease [1-5]. Some hydatid cyst may characteristically show a hyperattenuating rim on non-enhanced CT scan: this finding is not wholly elucidated, but it may depend on tiny calcium deposit or pericystic fibrotic reaction [6].
Rupture within a hollow viscus can be established when CT detects an air-fluid level within an abdominal cyst. Scans in lateral decubitus can aid in the diagnosis as filling or emptying of the cystic cavity can be demonstrated; the communication between the cyst and the hollow viscus can be seldom demonstrated with CT scans obtained with the contrast medium administered orally or by enema [1].