What is the treatment for a ruptured cyst?

Treatment for Ruptured Cysts

The treatment for ruptured cysts depends on the location, severity, and complications, with immediate intervention required for ruptured cysts causing hemodynamic instability, infection, or peritonitis, while uncomplicated ruptures may be managed conservatively. 1

Emergency Assessment and Management

Initial Evaluation

• Determine hemodynamic stability (vital signs, signs of shock)
• Assess for signs of infection (fever, elevated white blood cell count)
• Evaluate for peritonitis (rebound tenderness, guarding)

Management Algorithm

For Hemodynamically Unstable Patients (Emergency):

1. Immediate resuscitation with IV fluids and blood products as needed
2. Urgent surgical intervention for hemorrhagic shock or sepsis
3. Continuous monitoring for at least 24 hours with clinical and biological observation for 3-5 days minimum 1

For Infected Cyst Rupture:

1. Broad-spectrum antibiotics (fluoroquinolones or third-generation cephalosporins)
2. Drainage for:
   • Cysts >5 cm in diameter
   • Non-response to antibiotics
   • Recurrent infections 1

For Uncomplicated Cyst Rupture:

1. Conservative management with pain control and monitoring
2. Follow-up imaging to assess resolution 2

Organ-Specific Management

Liver Cyst Rupture

• Most simple hepatic cyst ruptures can be managed conservatively with resuscitation and transfusion therapy if needed 2
• Consider percutaneous sclerotherapy as first-line treatment for symptomatic hepatic cysts (76-100% volume reduction) 1
• Laparoscopic fenestration/deroofing as second-line treatment when sclerotherapy fails 1

Pulmonary Hydatid Cyst Rupture

• Requires specialist management in dedicated centers
• Surgical excision is the primary treatment, conserving as much lung tissue as feasible
• Praziquantel pre- and post-operatively, with albendazole post-operatively 3
• Note: Significant eosinophilia (>1×10⁹/L) is common following hydatid cyst rupture 3

Ovarian Cyst Rupture

• Often self-limiting, especially with physiological cysts
• Laparoscopy indicated when diagnosis is uncertain or with hemodynamic compromise
• Prevention of recurrent rupture with ovulation suppression (combined oral contraceptives) 4

Follow-Up Care

• Wait at least 6 months before considering reintervention after any procedure, as volume reduction is slow 1
• Patient education regarding symptoms that would warrant reassessment
• Regular imaging follow-up (ultrasound every 3-4 months for hepatic cysts) 1

Special Considerations

• For patients with polycystic liver disease (PLD), ruptured cysts may require more intensive monitoring due to risk of complications 3
• In pregnancy, ruptured endometriotic ovarian cysts require special attention and may necessitate emergency intervention 5
• For patients on anticoagulants, reversal of anticoagulation may be necessary to control bleeding from ruptured cysts 2

Pitfalls and Caveats

• Do not delay surgical intervention in hemodynamically unstable patients
• Avoid percutaneous aspiration, injection of scolecidal agents, and re-aspiration (PAIR) for pulmonary hydatid cysts as this is contraindicated 3
• Clinical features of cyst rupture are often nonspecific; maintain high index of suspicion in patients with known cysts presenting with acute pain 4
• Recurrent cyst rupture should prompt evaluation for underlying conditions and preventive strategies