Indian Pediatrics 1999;36:1048-1051
|Simmi K. Ratan, Shabnam Bhandari
Grover*, Rajiv Kulsreshtha and Vandana Puri*
the Departments of Pediatric Surgery and Radiology*, Safdarjung Hospital, New Delhi 110
|The liver is one of the most commonly injured
organ in abdominal trauma. Most often hepatic trauma results only in superficial
lacerations(1). Traumatic liver cysts are an unusual sequelae of hepatic trauma(2). Very
few cases of post traumatic liver cysts have been described in the literature. The authors
found only nine such cases reported in the pediatric age group(2-4). To the best of our
knowledge, this is the first case report of this entity from India. Though various
modalities of treatment have been described for dealing with such lesions, we highlight
our experience of successful treatment in patient by cyst excision followed by capitonnage
of the remainder cavity.
A 5 -year-old girl presented with a history of epigastric pain and increasing abdominal distension following abdominal trauma about two months back. Past history revealed that the child had sustained moderate trauma in the epigastric region while playing. After injury the child was relatively asymptomatic for a few days. Medical attention was sought only when she developed increasingly frequent episodes of epigastric pain, post-parandial fullness and vomiting. Abdominal examination revealed an epigastric fullness with prominent superficial veins over anterior abdominal wall. A 10 ´ 10 cm lump was palpable in the right hypo-chondrium extending to the epigastrium, not moving with respiration. The lump was mildly tender without overlying guarding or increasing prominence on knee-elbow position. A provisional diagnosis of post traumatic pseudo-cyst of pancreas was made. The laboratory analysis revealed mild increase in serum amylase level. Abdominal sonography revealed a cystic mass with an irregular wall and internal echoes overlying the body of the pancreas and extending into the liver parencyma. Contrast enhanced CT scan abdomen corroborated the ultrasound findings (Fig. 1).
Fig. 1. CECT scan at the upper abdomen reveals a large cyst overlying the body of pancreas and invaginating into the liver parenchyma.
Adominal explora-tion through right supraumbilical incision revealed a large 15 ´ 10 cm cyst embedded in the right lobe of the liver, near its anteroinferior surface. The duodenum was stretched and pushed inferomedially. The gall bladder and biliary tree were hidden beneath the cyst and were normal. The pancreas and the surrounding retroperitoneal structures were normal. The cyst was found to contain altered blood with some amount of bile. However, no communica-tion with biliary radicals could be detected. The compressed liver parenchyma was forming a part of the capsule of the cyst. With gentle blunt and sharp dissection, a plane could be develo-ped between the cyst and its capsule in the upper portion and the excision of the cyst was done. The remainder of the cavity was oblitera-ted by capitonnage method, i.e., multiple stit-ches were taken in layers starting from the depth of the cavity in order to appose the walls of the cyst. Histological examination of the cyst wall revealed chronic inflammatory cells and fibrous tissue. The post-operative recovery was un-eventful and the patient was discharged on the 7th postoperative day. The child has been well both clinically and radiologically on follow up after one year of surgery.
Traumatic cysts of liver are amongst the less frequently known sequelae of liver trauma. The incidence of this entity is very low and has been reported to be even less than 0.5 per cent (3). A review of the literature revealed only nine cases of traumatic liver cysts in pediatric age group(2-4). Abdominal pain, distension and hepatomegaly were the most common presen-ting features in the cases described in the literature. In many patients the diagnosis was made only at laparotomy performed due to complications of post traumatic hepatic cyst(2,3,5). These complications are obstructive jaundice, abscess formation, hemorrhagic shock or bile peritonitis due to cyst rupture(2,3,5). Our patient also presented with abdominal pain and distension. In addition, she had an epigastric mass which mimicked the presentation of a post traumatic pseudopancreatic cyst, both clinically and radiologically.
Christopher(1) has classified traumatic liver rupture into three types - central, subcapsular and rupture of liver tissue with its capsule. Intrahepatic rupture of liver tissue causes oozing of blood and bile that usually results in the formation of a traumatic liver cyst(1). The bleeding may stop, while flow of bile may continue and hence the cyst continues to grow. Therefore, there is usually a delay of several days to several months, or even years after the hepatic trauma, before the patient becomes symptomatic(2,4,5). However, patients beco-ming symptomatic within a few hours of injury have also been observed(2).
Most authors(2,6) are of the view that moderately severe trauma is a prerequisite to the formation of a hepatic pseudocyst as the rupture of bile ducts or hemorrhage must occur to cause it. However, other workers(3,5) do not find any relation between the severity of trauma and cyst formation.
Many workers who described post traumatic hepatic pseudocysts, did so in the pre imaging era. It was Sugimoto et al. in 1982 who emphasized the role of CT scan for the diagnosis of hepatic injuries(3). They also highlighted the importance of serial CT examinations. We believe, that the diagnosis of hepatic injury in the present era should be easier if the following imaging signs are looked for in a patient with abdominal injury: (i) a raised diaphragmatic dome on X-ray, (ii) altered hepatic echotexture on ultrasound, and (iii) altered liver attenuation at CT scan.
The differential diagnosis of a post-traumatic liver cyst clinically and at imaging includes a solitary unilocular cyst or hydatid cyst of liver, a pseudopancreatic cyst and loculated ascites especially due to tubercu-losis(7). Diagnosis is established by the nature and location of the mass at surgery. In a post traumatic cyst, altered blood and bile are the chief constitutents(2) while simple unilocular hepatic cyst contains thin clear fluid and hydatid cyst contains scolices(7). Definitive diagnosis at histopathology is based on recognizing a true epithelial lining in a unilocular hepatic cyst(7) while a post traumatic cyst does not have a true epithelial lining(2).
The modalities of treatment employed in the past for these cysts included simple drainage, intermittent irrigation and drainage by means of a tube, marsupilisation of the cyst to the abdominal wall and repeated packings(2-4). In a few cases, partial hepatectomy was resorted to(3). Recently, Chuang and Huang(4) treated their patients of post traumatic hepatic cyst by decortication of cyst wall and omentoplasty. Generally, the results of treatment by any of the described methods were found to be satisfactory. However, a few cases of traumatic hepatic cysts with spontaneous resolution have also been recorded(3).
In the present case, we excised the cyst and the capitonnage of the remaining cavity was done using mutliple stitches from compressed liver parenchyma. This method of treatment, though classically used for hydatid cysts of the liver(8), has not been described for dealing with traumatic liver cysts. Our patient had an uneventful post operative period and a shorter hospital stay as compared to the other described cases(3,5) and did well on follow up even after one year of surgical treatment.
Through this presentation, we reiterate the importance to institute a vigilant
follow-up by serial clinical and imaging examinations to document hepatic injury and its
rare sequel of post-traumatic cyst formation. This entity should be kept in differential
diagnosis of post traumatic pseudopancreatic cyst. Treatment of capitonnage may be
resorted to in cases of large cysts.
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3. Sugimoto T, Yoshioko T, Sawada Y, Sugimoto H, Maemura K. Post traumatic cyst of the liver found on CT scan-A new concept. J Trauma 1982; 22: 797-800.
4. Chuang JH, Huang SC. Post traumatic hepatic cyst- an unusual sequel of liver injury in the era of imaging. J Pediatr Surg 1996; 31: 272-274.
5. Jones HV, Harley HR. Traumatic cyst of the liver. Br J Surg 1970; 57: 468-470.
6. Walt AJ. Cyst and benign tumors of the liver. Surg Clin North Am 1977; 57: 449-464.
7. Peltokallio V. Non parasitic cysts of the liver-A clinical study of 117 cases. Ann Chir Gynecol Fenn 1970; 59 (Suppl 174): 1-63.
8. Wu X, Tan JZ, Shi TH, Zhou SN. Open method versus capsulorraphy without drainage in the treatment of children with hepatic hydatid disease. Br J Surg 1992; 79: 1184-1186.