Infected hepatic cyst: an unusual differential diagnosis of peptic perforation

Abstract

Perforated peptic ulcer has many presentations with most cases presenting with pneumoperitoneum and signs of peritonitis. Here we report a case where preoperative evaluation suggested the presence of cyst associated with liver which intraoperatively revealed localized abscess secondary to peptic perforation. A 40 year old male patient presented with a tender lump confined to epigastrium and right hypochondrium, episodic vomiting, intermittent fever along with yellowish discoloration of sclera and urine for 10 days. CECT abdomen showed cystic lesion in left lobe of liver communicating with a loculated cavity which was present in association with right lobe of liver. Among the various diagnoses suggested was an infected hepatic cyst or liver abscess. During surgery there was a cystic collection of about 2 liters of pus between under surface of liver and stomach forming a pseudocyst. After draining the cavity two pinpoint perforations were found on the first part of duodenum. Omental patch repair of the perforation was done after freshening of margins with an uneventful postoperative period. CT scanning with oral contrast is the most valuable imaging technique for making an immediate and correct diagnosis of GI tract perforation especially in cases with negative X-ray and USG. On CECT abdomen hepatic cyst has sharply demarcated wall and is non-enhancing while liver abscess shows well demarcated hypodense areas with peripheral enhancement which may contain gas. The findings of the case show that although peptic perforation in itself is very common but it can have such a peculiar presentation.