EC Clinical and Medical Case Reports

This is an interesting case of a 50-year-old female with no significant past medical history who presented to the ED with right upper quadrant abdominal pain and a distended abdomen. She was found to have two significant large hepatic cyst lesions measuring 20 cm and 12 cm, which were concerning for hydatid cysts. Serology was positive echinococcus antibodies and the patient was treated with albendazole for presumed hydatid cysts. Hepatobiliary surgery was consulted for definitive treatment and resection of large cysts. Intraoperatively, the larger cyst was found to be very adherent to the diaphragm and therefore, the surgeon decided to perform the PAIR (percutaneous puncture, aspiration, injection, and respiration) method. They aspirated the cyst and injected 20% hypertonic saline as a scolicidal agent. The hypertonic saline was left in the cyst for fifteen minutes. Immediately after irrigation, the patient’s sodium increased from 137 mmol/L to 171 mmol/L and her potassium dropped to 2.8 mmol/L in roughly 35 minutes. Rapid efforts to correct the hypernatremia and hypokalemia were made with free water and potassium repletion. Electrolyte corrections were continued with free water. Once electrolytes normalized, she was extubated on post-operative day 2 with no neurologic deficits. Pathology later revealed that this was not in fact echinococcal hydatid cysts but rather a neuroendocrine tumor. She was then treated with octreotide. This is a rare case of severe hypernatremia and hypokalemia after scolicidal irrigation with hypertonic saline for presumed hydatid cyst infections. Perioperatively, management should focus on both rapid hypernatremia correction, and or concomitant free water administration; as well as proactive potassium repletion to prevent potential life-threatening sequelae.

Keywords: Intraoperative Hypernatremia; Hypokalemia; Hepatic Hydatid Cyst Resection

1. Horacio J Adrogué., et al. “Hypernatremia”. The New England Journal of Medicine20 (2000): 1493-1499.
2. Joshua M Thurman and Tomas Berl. “Chapter 29 - Therapy of Dysnatremic Disorders”. In: Editor(s): Christopher S. Wilcox. Therapy in Nephrology and Hypertension (Third Edition), W.B. Saunders (2008): 337-352.
3. Albi A., et al. “Severe hypernatremia after hypertonic saline irrigation of hydatid cysts”. Anesthesia and Analgesia6 (2002): 1806-1808.
4. Nunnari G., et al. “Hepatic echinococcosis: clinical and therapeutic aspects”. World Journal of Gastroenterology13 (2012): 1448-1458.
5. Georgios K Georgiou., et al. “Surgical management of hydatid liver disease”. International Journal of Surgery 20 (2015): 118-122.
6. Balik AA., et al. “Surgical Treatment of Hydatid Disease of the Liver: Review of 304 Cases”. The Archives of Surgery2 (1999): 166-169.
7. Krige JE., et al. “Fatal hypernatraemia after hypertonic saline irrigation of hepatic hydatid cysts”. Pediatric Surgery International1 (2002): 64-65.
8. Zeng Rujun MD., et al. “The association of hypernatremia and hypertonic saline irrigation in hepatic hydatid cysts”. Medicine37 (2017): 7889.
9. Kuzmanovska B., et al. “Hypernatremia-induced Neurologic Complications After Hepatic Hydatid Cyst Surgery: Pretreat to Prevent”. Medical Archives5 (2019): 356-358.
10. Kinsuk Chauhan., et al. “Rate of Correction of Hypernatremia and Health Outcomes in Critically Ill Patients”. Clinical Journal of the American Society of Nephrology5 (2019): 656-663.
11. Alshayeb HM., et al. “Severe hypernatremia correction rate and mortality in hospitalized patients”. The American Journal of the Medical Sciences5 (2011): 356-360.
12. Kahn A., et al. “Controlled fall in natremia and risk of seizures in hypertonic dehydration”. Intensive Care Medicine1 (1979): 27-31.
13. Blum D., et al. “Safe oral rehydration of hypertonic dehydration”. Journal of Pediatric Gastroenterology and Nutrition2 (1986): 232-235.
14. Arambewela MH., et al. “Extreme hypernatremia as a probable cause of fatal arrhythmia: a case report”. Journal of Medical Case Reports1 (2016): 272.
15. Sur M and Mohiuddin SS. Potassium (2022).
16. Murthy K., et al. “Profound hypokalemia in diabetic ketoacidosis: a therapeutic challenge”. Endocrine Practice5 (2005): 331-334.