complaints are upper abdominal discomfort and pain , poor appetite and a mass in the abdomen which , in many cases , expressed by the patient himself . physical findings may include hepatomegaly , a mass palpated on the surface of the liver or other organs and abdominal distention in chronic patients ( 2 ) .
herein , we evaluated different emergency presentations of hydatid cyst disease and their treatment under emergency conditions .
we studied pre - operative laboratory findings of patients in emergency room who had hydatid disease , to identify any parameters to predict any hydatid cyst - biliary system communication .
in this retrospective study approved by a research ethics committee ( ankara numune trining and research hospital ethics committee/20.01.2016/e-16 - 733 ) , we retrospectively reviewed the files of patients who underwent surgery due to hydatid cysts between march 2010 and march 2014 in numune research and training hospital , which is a high volume reference hospital in an endemic region .
all liver hydatid cyst patients who admitted emergency room and underwent laparotomy accordingly are included in the study .
patients with history of trauma , or recent hydatid cyst surgery ( in last six months ) are excluded .
patients diagnosed with liver hydatid disease only , during emergency diagnostic laparotomy are also included in the study .
we collected information of demographics , cyst sizes , presence of perforation , type of the hydatid cysts ( 3 ) , imaging modalities , preferred treatment methods , complications , time between hospital arrival and diagnosis , time between hospital arrival and surgery and outcome of the disease .
intraoperative diagnosis of biliary communication of hydatid cysts and postoperative biliary leakage were regarded as confirmed presence of biliary system involvement .
only the patients whose cysts are proven unrelated with biliary system are grouped as biliary system not involved group .
patients hydatid cysts confirmed or suspected to have a biliary system communication were grouped as biliary involved group .
groups were compared regarding initial laboratory findings of the patients ( the blood tests made upon arrival in the emergency room ) ; using mann - whitney u test .
dissection of hospital database revealed 243 patients underwent surgery due to liver hydatid disease between mar 2010 and mar 2014 .
only twelve of these patients ( 3 females , 9 males ) underwent surgery following their admission to the emergency surgery department due to peritoneal irritation with acute abdomen findings and/or abdominal sepsis is included in this study ( 4.93% ) .
the median age was 42 yr ( 1884 yr ) . only in three patients ,
disease was somehow communicated with the biliary system . in six cases , cyst rupture into the biliary system
was identified in operation room , and t - tube drainage was performed in four of them , while choledochoduodenostomy was preferred in two .
biliary leakage was identified postoperatively in two cases and one particular case had only a bilioma due to prior hydatid cyst surgery .
biliary system involved group had significantly higher pre - operative gamma glutamine transferase ( ggt ) and alkaline phosphatase ( alp ) levels ( p=0.036 ) . in this group ,
median ggt level was 190 u / l and median alp level was 249 u / l , which are around , two - times the upper limits .
no significant difference was noted regarding other pre - operative laboratory findings ( table 1 ) .
n : number of patients , alt : alanine aminotransferase , alp : alkaline phosphatase , ggt : gamma glutamyl transferase detailed information about demographics , preferred treatment method and outcome of each patient is summarized in table 2 .
table 3 gives detailed information about the complaints of the patients on admittance , imaging modalites used , gharbi types of the cysts , cyst diameters , and the elapsed time between admittance and diagnosis / treatment .
demographic features , preferred treatment methods and disease outcome f : female , m : male , hc : hydatid cyst , ercp : endoscopic retrograde cholangiopancreatography patients complaints on admission , diagnostic methods , cyst characteristics and elapsed time between admission and diagnosis / treatment hc : hydatid cyst , xr : x - ray , usg : ultrasonography , ct : computerized tomography , mrcp : magnetic resonance cholangiopancreatography , ctgpd : compurerized tomography guided percutaneous drainage , ercp : endoscopic retrograde cholangiopancreatography , dpl : diagnostic peritoneal lavage in two of twelve cases , hydatid disease was diagnosed during laparotomies initially performed for exploration purposes because of peritoneal irritation .
he had a known history of subtotal gastrectomy due to peptic ulcers , in addition to hydatid cyst surgery and was on follow - up .
emergerncy endoscopic retrograde cholangiopancreatography ( ercp ) could not be performed because of a duodenal diverticulum .
patient s health status did not improve . during this period of decision - making ,
emergency laparotomy revealed an infected bilioma , probably due to prior hydatid cyst surgery and t - tube drainage was performed .
he was referred to the interventional radiology unit due to liver abscess and a percutaneous drainage catheter was placed in it . on the follow - up ,
meanwhile , the patient s vital signs worsened and he was moved to the surgical intensive care unit .
laparotomy revealed a superinfected hydatid cyst , which has a relation with the biliary system as well .
standard cystotomy , drainage , omentoplasty was performed and t - tube drainage was added .
unfortunately , biliary leakage was detected on the postoperative third day and sphincterotomy with ercp was performed .
type 4 hydatid cyst was detected in the liver of case 11 , and its relation to the choledoch was unclear .
an unlucky iatrogenic choledoch injury has occurred during dissection of biliary structures from hydatic cyst wall .
he had a history of subtotal gastrectomy with billroth ii gastrojejunostomy , due to gastric ulcer .
patient was deceased due to hemodynamic instability and respiratory failure , in the intensive care unit , on the day of surgery . out of twelve patients ,
imaging modalities used , cyst diameters , elapsed time before diagnosis and surgery are also presented in table 2 .
cyst rupture into the peritoneal cavity or the biliary system is also rare ; however , these complications may cause severe complications such as anaphylaxis and may even threaten life ( 46 ) . as we observed in our sample ,
abdominal pain is the common cause for emergency room admittance in complicated hydatid cyst cases .
nonetheless , the emergency clinicians may not consider hydatid disease as the primary cause of abdominal pain , reasonably due to rarity ; even when the patient has a history of treated hydatid disease .
totally , 66.7% of 15 confirmed intrabiliary rupture of hydatid cysts could have been suggested by ultrasonography , preoperatively ( 7 ) .
emergency physicians are likely to get indeterminate reports from the radiologists , therefore , they need to rely more on the patient s physical examination and laboratory findings in such cases .
twenty - four patients with confirmed cyst - biliary communication out of a total of 116 hydatid cyst patients were studied and pre - operative history of vomiting , preoperative elevated alp , total bilirubin levels and cyst sizes greater than 10.5 cm were related with intrabiliary rupture ( 8) .
moreover , greater cyst size , elevated eosinophil count , alp , ggt , alanine aminotransferase , aspartate aminotransferase and bilirubin levels are associated with biliary leakage after hydatid cyst surgery ( 9 ) . nevertheless , none of these reports evaluated predictive potential of preoperative findings .
several cases of spontaneous hydatid cyst ruptures are reported , and these_ruptures may cause peritoneal irritation and even subsequent anaphlylaxis ( 4 , 10 ) . in turkey , rate of intraperitoneal rupture has been reported to be 7.8 ( 11 ) . however , in our database , no patients with intraperitoneal rupture of hydatid cyst could be found in a four yr period . on the other hand
, we saw that twelve out of 243 liver hydatid cyst surgeries in our hospital were performed in emergency conditions because of acute abdomen and/or abdominal sepsis ; and in nine of them biliary system was somehow involved . in our study ,
preoperative ggt and alp levels were higher in the patients with confirmed or suspected biliary system involvement .
although , this study was conducted in a high volume hospital in an endemic region , sample size was not adequate . as the sample size is tiny ,
we used mann whitney u test to see if we would be able to demonstrate any differences between groups .
it is not surprising to fail to demonstrate any difference in such analyses with low power .
however , our analyses succeeded in demonstrating higher ggt and alp levels in biliary system involved group . due to the limitations of our sample size , it is not possible to draw any definite conclusions .
however , this result is compatible with previous studies on electively managed hydatid cyst patients .
t - tube drainage is a safe method for treating intrabiliary ruptures of hydatid cysts ( 12 , 13 ) . in our study group ,
all emergency room patients who underwent t - tube drainage recovered perfectly . we think that t - tube drainage is a safe and relatively minimalistic surgical option in patients with hydatid cyst - biliary system communication , even in emergency conditions
there is very limited information about surgical emergencies of the patients who have hydatid cyst due to the limited sample sizes .
we think that preoperatively elevated alp and ggt levels may be considered as a warning sign for biliary involvement of the hydatid cyst in these patients .
 background : vast majority of complaints and physical examination findings of hydatid disease are common in emergency room patients . 
 different emergency presentations of hydatid cyst disease and their treatment are evaluated . 
 we studied preoperative laboratory findings of these patients to identify any parameters to predict hydatid cyst - biliary system communication.methods:we reviewed the files of patients who underwent emergency surgery due to liver hydatid cysts and related conditions between march 2010 and march 2014 in ankara numune research and training hospital , turkey , retrospectively . 
 patients were grouped , regarding to the presence of biliary system involvement.results:twelve patients ( 9 males , 3 females ) were included . 
 we identified two groups . 
 biliary system involved group ( n=9 ) had significantly higher pre - operative gamma glutamine transferase and alkaline phosphatase levels ( p=0.036 ) . 
 no significant difference was noted regarding other pre - operative laboratory findings . 
 mortality rate was 17%.conclusion : medical literature lacks sufficient information about hydatid disease related non - traumatic emergency surgeries . 
 preoperative elevated gamma glutamyl transferase and alkaline phosphatase levels may be questioned as a warning about cyst - biliary communication in hydatid cyst patients with abdominal pain in the emergency room . 
 future studies with larger sample sizes are needed . 
 in addition , prolongation of the time before diagnosis in these patients may result in life threatening complications . 
Introduction
Materials and Methods
Results
Discussion
Conclusion