Rupture of a hydatid cyst of the liver into portal vein

Mzoughi Zeineb | Omrani Sahir | Bahi Hager | Talbi Ghofrane | Gharbi Lassaad | Mestiri Hafedh | Arfa Nafaa | Bayar Rached | Khalfallah Mohamed Taher |

La tunisie chirurgicale - 2017 ; Vol 2017

Resumé

Hydatid disease is a worldwide distributed zoonotic infection. It represents a health problem in endemic areas. The most common involved organs are liver and lung. Portal vein rupture of liver hydatid cyst (LHC) is uncommon [1, 2]. The aim of our three reports is to describe this rare complication and to expose problems in therapeutic management.

Mots Clés

Rupture, hydatid, cys, liver, portal vein

Introduction :

Hydatid disease is a worldwide distributed zoonotic infection. It represents a health problem in endemic areas. The most common involved organs are liver and lung. Portal vein rupture of liver hydatid cyst (LHC) is uncommon [1, 2]. The aim of our three reports is to describe this rare complication and to expose problems in therapeutic management.

Article

Case history:

Case 1:Fourty-three year old woman was complaining of abdominal pain and productive biliary cough. She has been four times operated for hydatid cysts of the liver. She underwent Lagrot procedure each time. Physical examination showed fever, jaundice and splenomegaly. Laboratory tests showed an anemia with no thrombocytopenia. Liver function tests showed cholestasis. Computed tomography (CT) of the thorax and the abdomen revealed a giant right LHC ruptured into the right chest and the biliary tract. Abdominal CT showed also a communication between the cyst and the portal vein with multiple hydatid vesicles in its lumen, portal hypertension and cavernoma. She underwent a right thoracotomy. The right lower pulmonary lobe was decorticated before oversewing the fistulous tract between the cyst and the diaphragm.

The cyst in the liver and the hydatid vesicles in the portal vein were not treated. The postoperative course was uneventful. She had albendazole as a treatment. She also had a vitamin K antagonist to avoid the extension of the thrombosis. She goes well and follow-up CT six months after did not show any abnormality.

Case 2: Thirty nine year old man with a long history of liver hydatid cyst complicated by acute pancreatitis and cholangitis, complained of abdominal pain. On physical examination there was a right upper quadrant mass. Laboratory tests revealed cholestasis and cytolysis. Abdominal CT showed multiple hydatid cysts of the liver and the presence of hydatic material inside the biliary tract and the portal system (Figure 1). There also were cavernoma and portal hypertension signs (Figure 1). The patient underwent an endoscopic sphincterotomy associated with the administration of albendazole and a vitamin K antagonist. The patient was seen on follow up, he goes well in spite of portal hypertension signs after 1 year.

Case 3: twenty six year old woman, who was operated three times for a liver hydatid cyst, consulted for an upper right abdominal pain with a generalized jaundice. Physical examination showed a splenomegaly with no other mass. Laboratory tests revealed cholestasis, anemia, and thrombocytopenia. The abdominal MRI showed multiples hydatid cysts of the liver with presence of hydatid material in the portal vein (Figure 2), cavernoma and an important collateral circulation. She had albendazole with a vitamin K antagonist. She goes well after 6 months.

Discussion:

The most common involved organs by hydatid cyst are the liver and lungs, with incidences of respectively 50%–80% and 10%–40% [3]. In one third of cases, the involvement concerns multiple organs [4]. Vascular complications are reported in about 0.8 % of cases [1]. This complication is most frequently represented by vascular compression. The rupture into the portal vein is uncommon. Only few cases have been reported [1, 2]. The cyst compresses, at first, the vein. The inflammatory phenomenon leads to a fistula between the cyst and the vessel. In this case, hydatid vesicles are found in the lumen of the vein [4]. Symptoms varies from abdominal pain and fever to portal hypertension signs as found in our cases. Anaphylactic reaction can be observed. Anaphylactic shock is due to leaking of antigenic material from the cyst [2, 5].

In most reported cases, patients had been previously operated for hydatid cysts. The development of thrombosis, portal cavernoma and portal hypertension, seen in our three cases, are not frequent [2].

Ultrasound and CT scan can identify hydatid cysts and cavernoma[1, 2]. MRI is the more effective. It shows the presence of multiple daughter vesicles filling the lumen of the portal vein and a communication between the residual cyst and the portal vein [2].

There is no clear therapeutic strategy about the management of these patients. In one case reported, the rupture of the cyst into the portal vein was discovered in the pre operative phase, such our patients [1].Conservative treatment by Albendazole and anti coagulant therapy was indicated [1]. Conservative treatment was indicated in our three cases towards the liver cyst opened into the portal vein. Complications are mainly due to hemorrhage caused by cavernomas[2].

Conclusion:

The management of Portal vein rupture of LHC is still difficult. The conservative treatment is the only solution. Liver transplantation and endovascular strategies may be an options and have to be studied.

 

Figures 1: Abdominal CT showing multiple hydatid cysts of the liver with a portal thrombosi, cavernoma and portal hypertension signs.

 

Figure 2: MRI showing the hydatic cyst with hydatic material into the portal vein.Reconstruction showing that the portal vein is full with hydatic vesicles.

 

Références

[1] Haoues N, Zairi S, Zaafouri H, Essaghaier S, NooemenR,Daghfous MH and al.  The rupture of liver hydatid cyst in the portal veins discovered in pre operativephase : contribution of imagery- J Afhepatolgastroenterol 2014; 8(1):45-48.

[2] ZubiaurreLizarralde L, Oyarzabal Pérez I, Ruiz Montesinos I, GuisasolaGorrotxategi E. Invasion of the portal vein by a hydatidcyst. Review of the literature. GastroenterolHepatol. 2006;29(7):405-8.

 [3] Yener A, Mine Ç, Ali Bilal U, Atila E. Transdiaphragmatic approach to liver and lung hydatid cysts. Turk J Med Sci 2012;42(Sup.2):1388-93.

[4]Gonzalez EP, Gil-Grande L, delArbol LR, delPozo D, Miquel J, Vazquez M et al. Portal hypertension secondary to portal invasive echinococcosis. J Clin Gastroenterology 2002;34 (1):103-4.

[5] BlascoNavalpotro MA, CorralesRodríguez de Tembleque M, Poza Jiménez A, Sánchez-Gómez Navarro J.  Anaphylacticshockcaused by spontaneous rupture of hepatchydatidcystintoinferiorvena cava RevClinEsp 1993;192(1):49-50.