Small bowel volvulus as a rare manifestation of a primary peritoneal hydatid cyst

A 73-year-old man presented to the emergency department with a diagnosis of acute obstructive syndrome resulting in vomiting, abdominal bloating, and pain. He had no history of previous surgeries or medical illness. On physical examination, he had normal vital signs, mild abdominal distension with no peritoneal signs. Blood tests showed a minimal inflammatory reaction with a white blood cell count of 11.4 K cells/mm³ and C-reactive protein of 12.08 mg/dL. Abdominal computed tomography (CT) showed dilatation of the small intestine with the presence of a “whirlwind sign” and a multilocular cystic lesion in the pelvis measuring 51 × 37 × 40 mm with a regular thick wall (Fig. 1, Fig. 2). Liver and spleen were normal. The patient underwent emergency surgery for a volvulus of the small intestine. Intraoperatively, the upstream intestinal loops filled with liquid became heavy and rotated due to the mass effect of the pelvic hydatid cyst. The cystic mass adherent to the small bowel blocked the intestine below and produced a volvulus of the connected intestine (Fig. 3). The small bowel appeared congested but not ischemic. The cyst then was separated from the intestine. Macroscopically, the section of the cyst showed several “daughter” cysts (Fig. 4).

Fig. 1.

Sagittal computed tomography scan showing the pelvic hydatid cyst (Red arrow) adherent to the small intestine with the presence of a “whirlwind sign” (White arrow).

Fig. 2.

Computed tomography of the multilocular cystic lesion in the pelvis (arrow) and dilated small bowel.

Fig. 3.

Intraoperative photograph of a pelvic cyst and adhesion band with the small bowel.

Fig. 4.

Daughter cysts.

Echinococcosis is a common zoonotic disease in the Mediterranean region caused by Echinococcus granulosus. Most common sites are liver (75%), lung (15%) and kidney (3%) [1]. A peritoneal hydatid cyst represents an unusual localization (6% of all abdominal hydatidosis) and is of two types primary and secondary. Primary peritoneal echinococcosis with no other intra-abdominal cysts is very rare occurring only in 2% of the cases. In these cases, the parasite reaches the peritoneal cavity via a hematogenic or lymphatic diffusion [2], [3]. There are no specific clinical manifestation and their symptomatology depends on their size and potential complications. A solitary pelvic hydatid cyst can present with a nonspecific mass of urinary and rectal compression. Most rarely, it can cause intestinal obstruction due to compression, traction on mesentery or adhesion band. In a literature review, we found two cases of hydatid cyst present with small bowel volvulus [4], [5]. Preoperative diagnosis is generally based on ultrasonography findings. Patients with small bowel volvulus can be identified on CT through detection of a whirl sign associated with multilocular anechoic cystic mass and wall calcification [3]. Emergency surgery is the most effective treatment. Surgical intervention based on resection if necrosis or perforation have occurred, total surgical removal of the hydatid cyst whenever is possible. During surgery, it is suggested to protect the peritoneal cavity with sponges soaked with scolicidal agents to avoid secondary contamination.

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Ethical approval

It is exemption from ethical approval because it is an observation report.

Consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

CRediT authorship contribution statement

MBK, MM, MG: Study concept, Data collection, MBK, KN: Writing – original draft. MBK, SH, AS: Writing – review & editing. MB: senior author and manuscript reviewer Review & editing.

Conflict of interest

We declare no financial support or relationships that may pose a conflict of interest.