Respiratory distress may follow due to aspiration of fluid elsewhere in the lungs

(c) Jaundice due to pressure on the bile ducts. (d) Severe systemic reaction following rupture into peritoneal cavity, gut itself or pleural cavity. (e) Cholangitis from rupture into biliary tree. 2. LUNG - Pulmonary hydatid cyst can present as - (a) Solitary or at times multiple cysts, on plain radiograph. (b) Shortness of breath or chest pain if cyst is large. (c) Haemoptysis following ulceration into a bronchus. (d) Expectoration of watery. fluid and daughter cysts ( grape skin' expectoration) following rupture into the bronchial tree. Respiratory distress may follow due to aspiration of fluid elsewhere in the lungs, and may be associated with urticaria and anaphylactic shock. (e) Fever, cough and purulent sputum, if secondary pyogenic infection occurs. 3. OTHER ORGANS - Presence of cysts in - (a) Brain - Epilepsy or hemiplegia. (b) Long bones - Pathological fractures. (c) Spleen -Splenomegaly. (d) Kidneys - Hematuria. (e) Spinal cord - Seizures or signs of increased intracranial pressure of subacute onset and progressive course. Root pains-and motor or sensory deficits. (f) Thyroid - Goitre (g) Behind the eye - Exophthalmos (h) Abdomen - Pseudocycesis from rapidly growing cysts. Diagnosis - 1. DEMONSTRATION OF HYDATID CYSTS - (a) Chest radiograph - various signs are - (a) Classical appearance of a circular shadow sharply defined with no reaction in surrounding lung parenchyma. The cyst may change shape on maximum inspiration an expiration (Escudero nimerove sign). (b) Crescent sign or pulmonary meniscus sign - If the cyst communicates with a bronchus, a cap of air may be seen above the cyst (also seen in lung abscess partially filled with ins pisated pus or blood clot, tuberculous cavity containing a Rasmussen aneurysm, and in intracavitary fungal ball). (c) Double arch (Cumbo's) sign - As more sir enters between pericyst and endocyst, the shrinking cyst ruptures with resultant air fluid level within the endocyst capped with crescent of air between pericyst and endocyst. (d) Water lilly sign - With further separation of endocyst and evacuation of fluid, a wavy endocyst membrane floats on top of remaining abscess exudates and seen microscopically on wet mount. (b) Adult worm - Remnants of adult worm cuticle surrounded by granulomatous tissue or calcification may be seen in surgical specimens from deep tissues. (c) Serological tests - EL ISA can detect antibodies in patients with cryptic or prepatent infections. Management - Minor surgical enlargement and firm massage along the tract of the worm can facilitate removal of emerging worms. The worm is wound on a rod, few centimeters each day, avoiding excessive tension. Septic abscesses and anaphylaxis require appropriate therapy. 20. TROPICAL SPRUE Definition -It is an alimentary dysfunction characterised by deficiency in gastric secretion and inability to absorb adequately fat, glucose, calcium and certain other food constituents and characterised by morning diarrhoea, bulky gaseous stools, sore tongue, megalocytic anemia and wasting. Etiology - Age - usually middle age. Sex - more in females especially when pregnant. Geographical distribution - Tropics and subtropics and mainly in hot, damp coastal climates. Season - Onset usually after rains. Race - mostly amongst Europeans Other predisposing causes - Prolonged residence in endemic area and hills, chronic dysentery, mucous colitis or hill diarrhoea Cause- An alimentary dysfunction in which a series of interlocking pathophysiologic events occur. Clinical features and Diagnosis - See Malabsorption syndromes. Course - Sprue relapses are uncommon after adequate treatment (unlike idiopathic steatorrhoea) and where they do occur, ultimately respond to treatment. Fatal cases are rare Differential Diagnosis - 1. Other megaloblastic anemias. 2. Idiopathic steatorrhoea- Long history. In sprue onset and course often more rapid, diarrhoea almost invariable, anemia tends to be more severe and is commonly normochromic or hypochromic. Hypocalcemia and cramps uncommon, stomatitis more marked, anorexia and abdominal pain more common. No specific response to folic acid or antibiotics 3. Chronic pancreatitis- Faeces contain high percentage of neutral fat but split fat content. low, the reverse is true in sprue 4 Giardiasis - may cause steatorrhoea. Diagnosis made by finding cysts of the parasite in formed stools and vegetative forms in fluid stools. 5. Intestinal strictures - e.g. due to TB Management - Aims - (i) Rest to alimentary canal by dietary regime (ii) Correction of anemia and gross deficiency conditions. 1. Diet - High protein, low carbohydrate and low fat - (a) Milk diet -Skimmed milk or proprietary dried milk; or protein hydrolysates and concentrates, 2 hourly feeds. Fruits and glucose. (b) Mixed diet - Skimmed milk, eggs, meat, bread, green vegetables, fresh fruits, and milk pudding. 2. Folic acid - Effect most marked in cases with prominent megaloblastic anemia. 30 mg. day p.o. or 15 mg I M for 3 weeks controls diarrhoea and causes improvement in stomatitis and glossitis. Maintenance dose of 5 mg b d The effect on fat absorption defect is minimal 3 Antibiotics - Short course treatment with broad spectrum antibiotics such as oxytetracycline 250 mg. q. d.s. by mouth can be effective. 4. Corticosteroids- if folic acid therapy fails. Prednisolone 50 mg. /day for 7 days, dose gradually reduced to 15