Tropical Doctor, October 1992
188
In our patient in spite of histological proof of schistosomal granuloma on the colonic mucosal biopsy and the fact that the patient was a fisherman, the diagnosis of non-Hodgkin's lymphoma was wrongly made on the basis of the patient's HIV status. We submit that a mass in the abdomen is not necessarily malignant just because a patient has HIV disease, unless the diagnosis of malignancy can be confirmed histologically. Another point of interest was that in spite of the HIV status of our patient, the bilharzioma responded dramatically well to anti-schistosomal chemotherapy, probably because there was little irreversible fibrosis in the granulomatous mass. The drug regimen was adopted in anticipation of the need for repeated courses; praziquental having the advantage of being a single dose therapy and less toxic, while niridazole may cause less fibrosis. In schistosomiasis the clinical picture depends on the host and parasite factors-. What effects immunosuppressive states have on the clinical manifestations of schistosomiasis have not been conclusively established. In Zambia, large bilharziomas do not appear to have increased in incidence, despite the
rapidly increasing prevalence of HIV infection in a population in whom schistosomiasis is common. The possibility that HIV infection might alter the balance of cellular and fibrogenic responses of the host to the eggs, with effects on clinical disease, has not been supported by any report of interaction of HIV disease and schistosomiasis". This is in marked contrast to tuberculosis, the clinical manifestations of which are dramatically affected by HIV infection. It therefore seems unlikely that HIV infection in our patient was a factor contributing to his development of large bilharzioma. In our fisherman we speculate a very heavy infection with schistosomes as the cause of the large bilharzioma. Further studies of HIV and schistosomal pathology are needed to look into the possible interaction between the two.
A rare presentation of hydatid disease of liver
CASE REPORT
Navneet K Chaudhry MBBS MSI, Rajeev Kapoor MBBS MS 1, Bharati Gupta MD DM 2 Departments of 'Surgery and 2Gastroenterology, Christian Medical College, Ludhiana-141008, India TROPICAL DOCTOR,
1992, 22, 188-189
Echinococcus granulosus has a world-wide distribution, and is still a problem of considerable medical and public health significance in developing countries like India. The patients affected with hydatid disease may remain asymptomatic for many years. Complications occur in a significant number of cases. In this paper we are presenting a case of hydatid disease of liver with complete destruction of right and left hepatic ducts and common hepatic duct.
REFERENCES
1 WHO. Weekly epidemiological record 20 July 1990;65:221-8 2 Sebastian L. Pathogenesis of schistosomiasis. Surgery 1988; 58:1395 3 Gilks CF, Ojoo SA. A practical approach to the clinical problems of the HIV infected adult in the tropics. Trop Doct 1991;21:90-7
A 30-year-old woman presented with a history of intermittent jaundice and right hypochondrial pain for 2 years. She had a total of 8 attacks of jaundice, fever and right hypochondrial pain in 2 years; each attack lasted for 10-14 days. On admission she was jaundiced, there was evidence of recent weight loss. The liver was palpable 12 em below the right costal margin, the upper margin being in the fifth intercostal space in the mid-clavicular line. Liver span was 25 em. The liver was tender, and its surface was irregular and firm. No bruit was heard over the liver. Ultrasound showed a mass of mixed texture in the right lobe of the liver, measuring 15 x 15 em. Intrahepatic biliary radicles were moderately dilated and the common bile duct could not be seen. The pancreas, gallbladder and kidneys were normal. Amoebic liver abscess was suspected. Bilirubin was 18.2 mg 0,70 (normal < 1.0) direct bilirubin 10.9 mg %, aspartate transaminase 90 units/I (slightly raised), alanine transminase 39 units/I (high normal), plasma proteins 8.4 g/dl, albumin 3.7 g/dl and alkaline phosphatase 395 units/I (very high).
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explored and the remaining daughter cysts were taken out. A T-tube was put in the common bile duct. Pericystojejunostomy was performed in the most dependent part of the hydatid cyst using 3/0 vicryl interrupted sutures. Jejunojejunostomy was done about 40 em distal to it in one layer using 3/0 silk. The postoperative period was uncomplicated. Liver function tests done one month after the surgery were within normal limits. The patient has now been followedup for one year and is healthy. DISCUSSION
Figure l, Endoscopic retrograde cho/angiopancreatico-duodenographyshowing hydatid cyst communicating with the common hepatic duct Amoebic serology was negative and HBsAg was also negative. Endoscopic retrograde cholangiopancreaticoduodenography confirmed the diagnosis of a hydatid cyst communicating with the common hepatic duct. There was gross dilatation of the common bile duct which contained multiple daughter cysts (Figure I). A laparotomy was done through a midline incision. A large cyst measuring 18 x 18em, with well defined host capsule was found in the right lobe of the liver, extending down to the porta hepatis. The gallbladder was pushed down between cyst and liver. There were no identifiable right and left hepatic ducts. The cyst contained about 250 ml of bile-stained purulent material. It also contained laminated membrane with multiple daughter cysts. There was complete destruction of both major bile ducts and of the common hepatic duct. Both right and left ducts were found to be opening separately into the upper part of the cyst and the common hepatic duct was opening into the lower part of the hydatid cyst. The three openings formed a triangle. Cetrimide I % was used as scolicidal agent. The cyst was cleared of all infected bile and the whole of the laminated membrane was taken out along with the daughter cysts. The common bile duct was
Hepatic hydatid disease can present in different ways. Rupture of the hydatid cyst of liver into the biliary system is the commonest complication 1• Whereas cystobiliary communications with the minor ducts are quite common, complete destruction of the major bile ducts is a rare complication of hepatic hydatid disease. It results in the passage of laminated membranes and daughter cysts into the common bile duct leading to jaundice. Pressure of hydatid cysts on major bile ducts can also lead to jaundice-. Ultrasonography and CT scan are useful methods of investigation', although in this patient ultrasound did not provide us with the correct diagnosis, which wearrived at by ERCP. A CT scan could not be done. Urgent operation is the only method of successful treatment'. We used 1070 cetrimide as a scolicidal agent. In some studies the use of scolicidal agents is not recommended because of the fear of sclerosing cholangitis>. When a hepatic hydatid cyst is complicated by cystobiliary fistula involving major bile ducts, we recommend pericystojejunostomy (either 'loop' or 'Roux-en-Y'). We have found this to be a simple, safe and an effective operation. T-tube drainage of the common bile duct in such cases is also recommended. In cystobiliary fistula involving only the minor ducts, the residual cavity is managed by omentoplasty. This works provided there is no distal biliary obstruction I. REFERENCES
2 3 4 5
Dawson JL, Stamatakis JD, Stringer MD, et al. Surgical treatment of hepatic hydatid disease. Br J Surg 1988; 75:946-50 Siatta E, Caullaro G. Obstructive jaundice caused by hydatid disease of liver. Chir Gastroenterol 1973;7:297-300 Murty TVM, Sood KC, Fawzi Salem Rakas, Biliary obstruction due to ruptured hydatid cyst. J Pediatr Surg 1989;24:401-3 Ovnat A, Peiser J, Avinoah E, et al. Acute cholangitis caused by ruptured hydatid cyst. Surgery 1984;95:495-500 Polo JR, Garcia-Sabrido JL. Sclerosing cholangitis associated with hydatid (letter). Arch Surg 1989;124:637
188
In our patient in spite of histological proof of schistosomal granuloma on the colonic mucosal biopsy and the fact that the patient was a fisherman, the diagnosis of non-Hodgkin's lymphoma was wrongly made on the basis of the patient's HIV status. We submit that a mass in the abdomen is not necessarily malignant just because a patient has HIV disease, unless the diagnosis of malignancy can be confirmed histologically. Another point of interest was that in spite of the HIV status of our patient, the bilharzioma responded dramatically well to anti-schistosomal chemotherapy, probably because there was little irreversible fibrosis in the granulomatous mass. The drug regimen was adopted in anticipation of the need for repeated courses; praziquental having the advantage of being a single dose therapy and less toxic, while niridazole may cause less fibrosis. In schistosomiasis the clinical picture depends on the host and parasite factors-. What effects immunosuppressive states have on the clinical manifestations of schistosomiasis have not been conclusively established. In Zambia, large bilharziomas do not appear to have increased in incidence, despite the
rapidly increasing prevalence of HIV infection in a population in whom schistosomiasis is common. The possibility that HIV infection might alter the balance of cellular and fibrogenic responses of the host to the eggs, with effects on clinical disease, has not been supported by any report of interaction of HIV disease and schistosomiasis". This is in marked contrast to tuberculosis, the clinical manifestations of which are dramatically affected by HIV infection. It therefore seems unlikely that HIV infection in our patient was a factor contributing to his development of large bilharzioma. In our fisherman we speculate a very heavy infection with schistosomes as the cause of the large bilharzioma. Further studies of HIV and schistosomal pathology are needed to look into the possible interaction between the two.
A rare presentation of hydatid disease of liver
CASE REPORT
Navneet K Chaudhry MBBS MSI, Rajeev Kapoor MBBS MS 1, Bharati Gupta MD DM 2 Departments of 'Surgery and 2Gastroenterology, Christian Medical College, Ludhiana-141008, India TROPICAL DOCTOR,
1992, 22, 188-189
Echinococcus granulosus has a world-wide distribution, and is still a problem of considerable medical and public health significance in developing countries like India. The patients affected with hydatid disease may remain asymptomatic for many years. Complications occur in a significant number of cases. In this paper we are presenting a case of hydatid disease of liver with complete destruction of right and left hepatic ducts and common hepatic duct.
REFERENCES
1 WHO. Weekly epidemiological record 20 July 1990;65:221-8 2 Sebastian L. Pathogenesis of schistosomiasis. Surgery 1988; 58:1395 3 Gilks CF, Ojoo SA. A practical approach to the clinical problems of the HIV infected adult in the tropics. Trop Doct 1991;21:90-7
A 30-year-old woman presented with a history of intermittent jaundice and right hypochondrial pain for 2 years. She had a total of 8 attacks of jaundice, fever and right hypochondrial pain in 2 years; each attack lasted for 10-14 days. On admission she was jaundiced, there was evidence of recent weight loss. The liver was palpable 12 em below the right costal margin, the upper margin being in the fifth intercostal space in the mid-clavicular line. Liver span was 25 em. The liver was tender, and its surface was irregular and firm. No bruit was heard over the liver. Ultrasound showed a mass of mixed texture in the right lobe of the liver, measuring 15 x 15 em. Intrahepatic biliary radicles were moderately dilated and the common bile duct could not be seen. The pancreas, gallbladder and kidneys were normal. Amoebic liver abscess was suspected. Bilirubin was 18.2 mg 0,70 (normal < 1.0) direct bilirubin 10.9 mg %, aspartate transaminase 90 units/I (slightly raised), alanine transminase 39 units/I (high normal), plasma proteins 8.4 g/dl, albumin 3.7 g/dl and alkaline phosphatase 395 units/I (very high).
189
Tropical Doctor, October /992
explored and the remaining daughter cysts were taken out. A T-tube was put in the common bile duct. Pericystojejunostomy was performed in the most dependent part of the hydatid cyst using 3/0 vicryl interrupted sutures. Jejunojejunostomy was done about 40 em distal to it in one layer using 3/0 silk. The postoperative period was uncomplicated. Liver function tests done one month after the surgery were within normal limits. The patient has now been followedup for one year and is healthy. DISCUSSION
Figure l, Endoscopic retrograde cho/angiopancreatico-duodenographyshowing hydatid cyst communicating with the common hepatic duct Amoebic serology was negative and HBsAg was also negative. Endoscopic retrograde cholangiopancreaticoduodenography confirmed the diagnosis of a hydatid cyst communicating with the common hepatic duct. There was gross dilatation of the common bile duct which contained multiple daughter cysts (Figure I). A laparotomy was done through a midline incision. A large cyst measuring 18 x 18em, with well defined host capsule was found in the right lobe of the liver, extending down to the porta hepatis. The gallbladder was pushed down between cyst and liver. There were no identifiable right and left hepatic ducts. The cyst contained about 250 ml of bile-stained purulent material. It also contained laminated membrane with multiple daughter cysts. There was complete destruction of both major bile ducts and of the common hepatic duct. Both right and left ducts were found to be opening separately into the upper part of the cyst and the common hepatic duct was opening into the lower part of the hydatid cyst. The three openings formed a triangle. Cetrimide I % was used as scolicidal agent. The cyst was cleared of all infected bile and the whole of the laminated membrane was taken out along with the daughter cysts. The common bile duct was
Hepatic hydatid disease can present in different ways. Rupture of the hydatid cyst of liver into the biliary system is the commonest complication 1• Whereas cystobiliary communications with the minor ducts are quite common, complete destruction of the major bile ducts is a rare complication of hepatic hydatid disease. It results in the passage of laminated membranes and daughter cysts into the common bile duct leading to jaundice. Pressure of hydatid cysts on major bile ducts can also lead to jaundice-. Ultrasonography and CT scan are useful methods of investigation', although in this patient ultrasound did not provide us with the correct diagnosis, which wearrived at by ERCP. A CT scan could not be done. Urgent operation is the only method of successful treatment'. We used 1070 cetrimide as a scolicidal agent. In some studies the use of scolicidal agents is not recommended because of the fear of sclerosing cholangitis>. When a hepatic hydatid cyst is complicated by cystobiliary fistula involving major bile ducts, we recommend pericystojejunostomy (either 'loop' or 'Roux-en-Y'). We have found this to be a simple, safe and an effective operation. T-tube drainage of the common bile duct in such cases is also recommended. In cystobiliary fistula involving only the minor ducts, the residual cavity is managed by omentoplasty. This works provided there is no distal biliary obstruction I. REFERENCES
2 3 4 5
Dawson JL, Stamatakis JD, Stringer MD, et al. Surgical treatment of hepatic hydatid disease. Br J Surg 1988; 75:946-50 Siatta E, Caullaro G. Obstructive jaundice caused by hydatid disease of liver. Chir Gastroenterol 1973;7:297-300 Murty TVM, Sood KC, Fawzi Salem Rakas, Biliary obstruction due to ruptured hydatid cyst. J Pediatr Surg 1989;24:401-3 Ovnat A, Peiser J, Avinoah E, et al. Acute cholangitis caused by ruptured hydatid cyst. Surgery 1984;95:495-500 Polo JR, Garcia-Sabrido JL. Sclerosing cholangitis associated with hydatid (letter). Arch Surg 1989;124:637
