A 16-Year-Old Girl With Severe Abdominal Pain After a Hug

Elena Zafirova, MD; Milcho Panovski, MD, PhD

Disclosures

October 14, 2019

Surgery is the traditional treatment of choice for hydatid cysts, but numerous cysts are now treated with percutaneous aspiration, infusion of scolicidal agents, and reaspiration (PAIR). PAIR may be a reasonable approach for treating patients with inoperable disease, and it is typically performed while patients are on antihelminthic therapy to decrease the risk for cyst dissemination. Ultrasonographic staging is used to determine the ideal method of treatment.

The success of the surgical approach depends on the location and size of the cyst and the potential for injury to surrounding structures. PAIR is contraindicated for superficially located cysts, cysts communicating with the biliary tree, and cysts with multiple internal septal divisions. Surgery is still preferred for complicated cysts under these conditions. Care must be made to remove cysts without contaminating the surrounding tissues, as anaphylaxis and dissemination of infectious protoscoleces may result. In cases of intraperitoneal rupture, the peritoneal cavity should be searched for any hydatid elements and very thoroughly lavaged with large quantities of saline.

Albendazole and mebendazole are used for the medical treatment of echinococcosis in patients with contraindications for surgery. Albendazole is the preferred agent because of its greater absorption from the gastrointestinal tract, which results in higher serum levels. Multiple factors can be used to predict the patient response to treatment. These drugs may also be used for perioperative prophylaxis. A systemic review and meta-analysis concluded that treatment outcomes are better when surgery or PAIR is combined with benzimidazole drugs administered either preoperatively or postoperatively.[6] This study also found that combined treatment with albendazole plus praziquantel resulted in higher scolicidal and anti-cyst activity and was more likely to result in cure or improvement, compared with use of albendazole alone.

This patient was admitted to the surgery department and surgically treated the same night. The intraoperative findings included intraperitoneal and intrabiliary rupture of a hepatic hydatid cyst. Evacuation of the cyst fluid and its elements, as well as sterilization with hypertonic saline solution, was performed. Cholecystectomy was performed and a T-tube was inserted. In the postoperative period, she was treated with albendazole and discharged to home after approximately 2 weeks. She was instructed to continue on the albendazole for 3 months. At a 1-month postoperative follow-up visit, she was doing well and was without complications.

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