Cyst with Fat-Fluid Level and Budd-Chiari Syndrome. 2001; 21(3-4): [225][226][227] Hepatic hydatid cyst is a parasitic infestation due to the development of the larval form of the tapeworm Echinococcus granulosus in the liver.1 Although compression of hepatic veins is commonly noticed on imaging studies, hepatic hydatidosis is a very rare cause of Budd-Chiari syndrome.2 Fat-fluid level in a hepatic hydatid cyst (HHC) was first reported in 1996 by Montero et al., 3 who documented three cases of the condition on CT and MRI, and explained it by its rupture into the biliary tree. Although no other cases have been published in the literature to our knowledge since then, there has been controversy on the significance of the presence of intraparasitic fat. Beric et al. feel that the fat-fluid level in a HHC is related to the degeneration of hydatid membranes rather than to biliocystic communication. 4 The purpose of this study was to report an exceptional case of large fat-fluid level in a hepatic hydatid cyst in the left lobe with no biliocystic communication, but associated with chronic Budd-Chiari syndrome due to compression of hepatic veins by multiple HHC of the right lobe.
Case ReportA 55-year-old female patient was admitted for epigastric pain and heartburn of a year's duration. On examination, no jaundice or fever was noted. Abdominal palpation revealed an enlarged liver with a bulging mass in the left lobe. Liver function tests were normal (total bilirubin, 15 μmol/L; unconjugate bilirubin, 8 μmol/L; direct bilirubin, 7 μmol/L, and alkaline phosphatase, 112 IU/L). Serological tests for hepatitis B and C were negative. Test for echinococcosis using IHA was negative. On abdominal ultrasound, the liver was dysmorphic, showing undulating outlines with severe enlargement of the left lobe and caudate lobe, which were suggestive of chronic liver disease. The right lobe of the liver exhibited four masses. A huge multiseptated cystic mass, 12 cm in diameter and suggestive of multivesicular hydatid cyst (type 3 of Gharbi), occupied the whole right lateral sector, encroaching upon the right medial sector and totally compressing the right and middle hepatic veins. Three masses of solid heterogeneous echogenicity were in the segments 5 and 8, showing well-defined outlines with slight enhancement of posterior echoes. These three masses contained long hypoechoic spirals highly suggestive of pseudotumoral hydatid cyst (type 4 of Gharbi). The gallbladder harbored a large stone, whereas the biliary ducts were normal. The left hepatic lobe exhibited two superficial anterior echogenic heterogeneous masses, the largest of which was in segment 2. It was 13 cm in its long axis, and displayed a horizontal level separating a lower hyperechoic layer and an upper hypoechoic layer. The second mass, 5 cm in diameter, was located in segment 3 and showed peripheral calcifications. Also, ultrasound noted mild ascitis as well as splenorenal collateral venous circulation near the lower pole of the spleen denoting portal hypertension. CT wit...