Hydatid Cysts and Carcinoid Tumors: A Case Report
Melissa Jordan, MD and R. Victor Zhang, MD,
PhD
Department of Anesthesiology, University of Florida, Gainesville, Florida
Hydatid Disease is caused by infection with the helminth Ecchinococcus
granulosus. The liver is the most common organ involved. Cysts can be up to
20cm in diameter and can be fatal. The interior of a hydatid cyst is filled
with hundreds of protoscolices, each of which has the ability to grow into
an adult worm and, eventually, a new hydatid cyst. In addition to
disseminating infection, spilling of cyst fluid can trigger fatal
anaphylaxis.
Carcinoid tumors are neuroendocrine tumors that produce a variety of potent
hormones and chemicals which cause the symptoms known as carcinoid syndrome.
The most common primary site of carcinoid is the small intestine, and the
most common site of distal spread is to the liver. A carcinoid crisis can
accompany stress, physical stimulation, or manipulation of a carcinoid
tumor. Severe hypotension and bronchospasm that is refractory to treatment
may occur during a crisis. Epinephrine use can trigger or worsen carcinoid
crisis.
A 53 year old man from the Phillippines, who had also lived in the Middle
East, was diagnosed with recurrent hydatid disease, when he presented to his
primary care provider complaining of abdominal pain. Imaging revealed a
large multi-cystic lesion in the right lobe of his liver crossing the right
portal and hepatic veins and evidence for extrahepatic disease involving the
diaphragm and possibly the lung. Complete surgical resection was planned.
After induction of anesthesia, a 9 Fr introducer was placed in the right
internal jugular vein and an arterial line was placed in the left radial
artery.
The patient underwent a right hepatic lobectomy with resection of the
diaphragm and cholecystectomy. He was hemodynamically labile throughout the
resection despite appropriate fluid resuciation as gauged by central venous
pressure, stable hematocrit, and adequate urine output. A phenylephrine
infusion was started at 40mcg/min in an attempt to maintain mean arterial
pressures within 20% of preoperative levels. The infusion rate had to be
titrated upward to 100mcg/min as liver manipulation continued. Epinephrine
was administered to treat a presumed anaphylactic reaction to disseminated
cyst contents. Surprisingly, the pt’s blood pressure decreased markedly and
in a dose-dependent manner in response to epinephrine. Therefore, the
somatostatin analog octreotide (100mcg) was administered, resulting in
improved blood pressures control at a reduced infusion rate of phenylephrine.
The patient’s postoperative course was complicated by a hydropneumothorax,
requiring chest tube drainage. He was 12 days after surgery in good
condition.
This case report describes a patient with hydatid disease who developed
profound hypotension after administration of epinephrine, suggesting the
presence of a carcinoid tumor. The case demonstrates the merits of
entertaining a full differential diagnosis for an event such as hypotension
during liver resection, in order to be able to adapt the treatment plan to
the patient’s needs.
