Spontaneous rupture of a nonparasitic hepatic cyst...

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Spontaneous rupture of a nonparasitic hepatic cyst

associated with peritonitis

PATRWIA SI IIPLFY, BSC, BARRY BAYLIS, MD, N OEL H ERS! IFil:I D, MD, RORERT LUI, MD, NnRMAN C W W ONU, MD

P SH1PLEY, B BAYLIS, N HERSHFrELD, R LUI, NCW WONG. Spontaneous rupture of a nonparasitic hepatic cyst associated with peritonitis. Can J Gastroenterol 1991 ;5(5 ): 171-173. The first report of a nonparnsitic cyst complicated by rupture and peritonitis is given. A 63-year-old female fo und to have a O\mrarasitic h epatic cyst was discharged from hospital when her symptoms of ~harr intermittent pains in the right uprer quadrant resolved spontaneously. Hours later, she was re-admitted with rupture and peritonitis. After hepatic cystojcjunnstomy (Roux-cn -y) and T -tube placement in the common hilc duct, the patient remains asymptomatic two years later.

Key Words: Hepatic cyst , Nonparasitic, peritonitis, Rupture

Rupture spontanee d'un kyste hepatique d'origine non parasitaire et peritonite

RESUME: On rnpporre le premier cas de kyste non paras itaire complique d 'une rupture et d'une pcritonite. Une patience de 63 ans et chcz qui on ava il Jiagnostique un kyste hepatique avait pu regagncr son domic ile quand les Jouleurs vives ct intermittentcs qu'elle cprouvait a hauteur du quadrant :.upcrocxtcrnc droit avaient sponrancment cessc. Quelques heures plus rard, clle a etc Je nouveau hospitalisce souffrant <l'une rupture Je kyste ct d'une peritonite. La paticntc a subi une cystojcjunostomic (operation de Roux en y) avec pose d'un Jrnm de Kehr Jans la voic biliairc princ ipale. Elle est toujours asymptomatiquc Jcux ans plus card.

Dc/wrrmenc., of Medicine, Medirnl B1oc/1,:111im-y, and Surgery. Uni1•er.1iry of Calgan, Calgary, Alhcrw

Corrcs[>oncknce and re[>rinc.1: Dr Nomwn C\\'l \\'long, Faculty of Medicme, Uniwrnty of Calgary, 3330 l los(>Hal /)ri1•e N\\'I, Call(ary. A lherca T2N -fN I

Received for /n1hlica111m )11/y 15, 199 1. Acce()red Ocwher 7, 199 I

CAN J GASTROl·.NTbROI Vut 5 No 5 S i·l'Tl:l.11ll·R/()c1\ )!ILi( 1991

IN MOST INClnFNCES NONPARASITI( '

hepatic cysts arc uncomplicmcJ, but the author, have recently encount cH:d a case associareJ with spontanCl)US rupture leading to peritonitis. The occ urrence of nonpara,i tic hepatic cysts is very low, clearly demon.~trnteJ hy the results of a 15 year retrospective swdy at the Mayn C linic in which 10,000 abdominal opcrnt ilms were , urveycd and only 15 found to he due to a nonparasitic hepatic cyst ( 1,2). The finding of ,1 nonparasitic cys t complicat ed hy rupture and peritoni t b is ex treme ly rare, thus prompting the authors to

summarize their experience in th b

report .

CASE PRESENTATION A 63-ycar-11ld fcmnle was admitted

tn the Calgary Fonthi lls Genera l l Jospital compla ining of sharp intermitte nt pa in, in the right upper quadrant of the ahdomen wi t h rad iatinn w the right shoulde r and <1rm. Six months previously the patienr had experienced ep,~odes of recurrent fever, c hills ,mJ fatigue . The only ~ignificant finding at

171

Si 111'1 f) er o/

R

C

A B C

Figure I) C11mp111ed wn101.,roplty 1cw1 of o soUwn nonpcirmrtic cy~t (C) of rite /wer, before ( A ) w1d clrmng rn(Hrm· ( B ) of tltt' bron and after s11rgrral rrearmcnr (C) A Th(' lesion (C) rn th(' nghr lohe of the l,wr hefore rn/>11tre B Hupwrc of tlte cyst i11t11 r/1c ,11hcc1(mdm regwn. l:Ytrc11•1l1a11on of fluid from rh<.' C'Vlt mw rlw ,ubca/>1r1~1r 1/)(lce r., mdrrnted /,v r/w /{ CA mheq11e11t ~can performed /lt•e momh., followmg ,11rgen. J,.m,111,trming rltlll tlte lesum /1m nm rec1111·ed

the 11me Ill ;1Jm1ss1on \\'a,- ,1 tender glohulnr mass lucated in the righ t urrl-r qw1Jrant nf I he ahdumen, that moved with rcsp1rnt1on. Au,cultmion of the mass failed lU reveal a ruh o r hruit.

Lahorat\lry inve~tigatiom ,h(lweJ 1h:tt whne hlo1xl ce ll cnunt (5.8xJ09/L), asrartale amint>Lrnnsf era,e ( 2 5 U/L) and to tal htltruhin ( 11 µmol/L) were all within normal limits. Potential etiologies for hepatic cy,r ~uch as amc:hiasb and echinococcu, were: excl uded hy negative serology. The only positive find ing w,l', an ultrasound study .,howing a homogeneous ,olitmy cyst ( I 3x 15 cm2)

nn thl' inferior ,urface of the right lnhe \lf the li ver. The: locmron and size of this le, ion was confirmed hy comruted tomugrarhy scan (figure IA ). The cour,e in hospital was unrc:markahlc. The patient\ symptn1rn, reslilved ,rontaneously, ,md 1 he patient was Jbcharged.

Within hnurs of discharge, a sudden change 111 the charau enstrc, of the pain promp1ed the pmrent to return to ho,p1 tal. This time, the abdominal parn w,1s .,C'verc: and generalize,!. Phys ical examination un re-admission :,howed t har the patient was 111 acute distress (hlood rressure 140/80 mmHg, pube 120 heats/min, and respiratory rnte 24/ m111). Ahdominal examination revealed a distended ahdomen and srgm of peritoni tis. S ignificant lahoratory findings included n whitl' hlood ce ll

172

cnum of I 5.6xJ 09/L wirh 871Y., pol ymorphonuclcm ce ll s. A flat plate x-rny of the abdomen had rhl' apr earnnce of ground glass, suggest mg the presence of fluid in the rcritoncal cnvity. Repeat computed rrnnogrnphy scan dt'mlmstrated that the cyst had ruptllred and broken through Cl isscn 's c;1psuk (Figure: IR). Medical management included mtravcnmrs fluids and an antibiotic, cc:foxicin (2 g every 4 h).

After the ratient's condition had stabilizc:J , she underwent hepatic cy,tojejunosto my (Roux-c:n-y) and T-tuhc placement in the common hile duct. A nalys is ornuid from the cyst revealed hoth hlood and hile, hut cultures of the: fluid were negat ive. A n intraor erative T -tuhe cholangiogrnm foilc:d to show communication of rhc: cyst with the: hiliary t ree. I listological rc:rom indicated that the cyst was lined hy low columnar errthelinl cc: lb of uniform thickness w11h no evidence: of malignancy. The patient's posmrerativc: course was unrenrnrkahle. No complic,11 ions or recurrence were: encountered during a hric:f fo llow-up pcnml (Figure IC), and the patient remains asymptommic two years fdlowing the rmcc:dure.

DISCUSSION In the rresc:nt rcr on the authors

have ,ummarized I he t·vents b iding up to the dragnos1s ;i nd management of a

nonparasiric lyst of tlw li ver. The h1srological finding of low columnar epithel i,tl ce lls indicates that the bton was a cnngen ita l d uctal cyst of the li ver (2). Cmgen it ,11 hcp,lliL cysts in thcahsencc nf polycystic kidney dbeasc arc very uncommon (2). T he incidence nf this d isease is highest in elderl y females (3) . The ~ingle feature of this case rresentation that sets it apart from others is the: spontaneous rupture of the cyst lc:aJing to pc:ritonitb.

Solitary congen ital hc:p,ttiL cyst,mc classified as heing either rarenchymal or duc1al (4,5). Conservative management is usually indicated for asymptomatic solitary part'nchymal or ductal cysts, hut comrlicntions mny occur. Parc:nchymal cysts arbc: from the tissue of mucous glands or frnm the terrs ligamcntum (6). Cysts of this nature give: rise to symptoms of ahdominal fullness anJ hi le trnct ohstruct ion wlwn they hccrnnc: fil led with trnnsudmive fluid ('3,7- 10). In contrast, ducrnl cyst, arise from th e: failure of rrovisional embryonic h ile ducts to undergo involution (1,5,7, 10). Dcspitcthcahsencenf comm unicati1m hc:rwcen d uctal cy,i, and major hile tracts (I, I I), hemorrhage and hil e leakage inlo thc: cyst arc known rnrnpli rntions (2,1, 10).

T he lrt era1ure LOnl :tins nnly three documcnt..:d c;1sc:s of nonparas1t1c hepntiL cyst thm ruptured, nnne of which were associated with peritontt11

CAN J U1\STRl)fNTf-lH)I Vl)I 5 Nll 5 St l'Tl-~tllf·R/(X TOl11 R 1991

(2,l0, l2). The author~ haw documeme<l the present case a~ an example 1hat goe:, against the general hdie( chat rupture of a nonparnsitic hepatic cyst i, a benign condition. In light of this experience the nut ho rs suggest chm more aggressive management may be indicated in certain ca,es. For example, cysts that contain trnnsudmes 1rn1y be

REFERENCES I Sanfdippo P, Bearh, L), Wedaml L.

Cy,tic di,eaM: of the li ver. Ann Surg-1974;179:922-5.

l. I lormn R. G iant cyM of the livn complicated hy rupture. 11r J S urg 1954;41 :442-4.

1. Lnwin DEM, Tay l1>r BR, Lang-er B. Greig P. N onparn, itic cy,t, of the liver. The case for con,erv:ni ve , urg ical m,magem<'nt. Ann Surg 1987;205:45-8.

4. Clinkscale, N, Trigg L, Pok lcpov ic J. Ohstrucrive Jaundice ,econ dary 10 hcnign hepmic cy,t. Racliolugy 1985; 154:641.

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drnined with trrinsahdominal aspiration ( 4, I 3, 14 ). External drainage i, indicareJ for infected cysts. In conrrast, bilcnr blood-conrnining cyst, can be safely drained hy cystojejunostomy. Becriuse hepatic cyst rupture occurs most commonly in the elderly it is essential that early surgical interven tion be weighed aga inst the potential outcome dcscrih-

Gastroenter<il I 985;80:907- 11 . 6. Sood S, W,mon A. Solita ry cyst of the

li ve r present ing a, an ahdommal emergency. Postgnid Med J 1974;50:48-'iO.

7. Flag R, Robinson D. Soli tary nonparasitic hepatic cys1s. A rch S urg 1967;15:964-71.

8. I lemon S, Gray 11, Dockcrly M. Benign 1 umors of the liver. Surg Gynl'rnl Ohs1e1 1957; 103:607-9.

9. Davb C. Nonpara,u ic cysts pf liver. AmJ Surg 1937;35:590-4.

I 0. 1 lamli n E. C,1,e record., nl the M,issachw,crr, Gcncrnl l lnsp11 al. N Engl J Med 195 1 ;244:66-70.

11. Edwards J, Eck h au,cr F, Kno l J, S1rodcr W, Arrclm,111 H. Optimizin g surgical

CAN J G ASTROENTFRl l l Vl lL 5 Nt) 5 St:l'TEMlll'R/l \ 1\ 1111-- R 199 I

Peritonitis and nonparasitic hepatic cyst

eJ ahuve, as t h1s age grnup is kast

capahle uf tl1 lcrn1 ing sl'verc illnc,s. In conclusion, thl' ,1uthllrs haVl' re

ported a case of nonparas111c cys1 nl the liver tha t ruptured, leading to acute peritonitis. To their knowledge, this is the only reported c.1se in wh ich pcritonitb has occurred fnllrnving rupturl' or a nonparnsitic hepatic crt.

managcml'nl Df sympl Pm:ltic ,nlir:iry hepatic cysts. Am Surg 191'7;5 ,:5 10-4.

I Z. Akrivi.1dis EA, S1c1mkl 11 , Ralls I'. Redeker A. Sp,mtanenu, rupwrc ,,t nonpara,i1 kl y,1 of the li ver Uastrnenrcrnlogy 1989;97:2 I l 'i.

I 3. Cappel! MS. O hs1 rue m e J:tundicc from hcn1gn, n onparnS1t1c lwpa1ir ry,1: lden1 ificat ion of risk f:1c1ors :md percutaneous nsp1rn1 um fnr diagn,1sis and trc.nment. Am J GaMrocnreml I 988;83:93-6.

14. Rnemer C E, Ferrucci JT, Mueller PR. S1mcDne JF, v,m Sonncnhcrg E. W1frenhcrgJ. Hcpntic cyM: Diagno,is and therapy by ,on ogrnphic needle asp1ral!on . Am J Roentgcnol 1981;1 }6:1065-70.

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