Hydatid Cyst of the liver, case presentation. KSA 2017

HYDATID CYST OF THE LIVER

Case Presentation KSA 2017

DR. MOHAMAD AL-GAILANI FRCS

الدكتور محمد الكيالني

CONSULTANT SURGEON

MEDICAL EDUCATION & TRAINING DIRECTOR

SUWAIDI

Riyadh

CASE PRESENTATION:55 YEAR OLD (YEMENI) MALE

• Presented to my clinic at Al Hammadi Hospital (AHH) Suwaidi with upper outer quadrant dull abdominal pain for months.

• No history of jaundice, nausea or vomiting.

• Previous Ultrasound (US) scans at AHH showing hydatic cyst (HC) right lobe liver.

• Recent Computerized Axial Tomography (CT) chest and abdomen confirming the diagnosis.

DR. MOHAMAD AL-GAILANI FRCS AHH SUWAIDI HYDATID CYST OF THE LIVER CASE PRESENTATION KSA 2017

PAST SURGICAL HISTORY:

• 1990: HC Liver Surgery

• October 2016: Open Cholecystectomy for Gall Stones (AHH).

• During operation daughter cysts seen extruding from liver gall bladder fossa.

• Post Operatively-Persistent HC debris extruding from a sinus in the Kocher wound.

• March 2017: Wound Sinus exploration.

• Post Operative Rx: Albendazole

PAST MEDICAL HISTORY:

• Ischaemic heart disease.

• Coronary Angio at King Khaled University Hospital (KKUH), Riyadh, KSA.

• Type 2 Diabetes

• Hypertension

• Rx: Zestril, Concor, Lipitor, Actos, Diamicrone, Glipta, Albendazole

CLINICAL EXAMINATION:

• Temp 36 C

• PR 104 bpm

• BP 127/75 mm HG

•Weight 88 Kg

• No Jaundice

• Abdomen Soft, No Organomegaly

INVESTIGATIONS:

• HB 12.9 g/dL

• WCC 11,800 cells/mcL, Eosinophils 0.4%

• Platelets 186,000/mcL

• AST 34 IU/L

• ALT 46 IU/L

• Bilirubin 0.5 mg/dL

• Alkaline Phosphatase 106 IU/L

ULTRASOUND (PRE CHOLECYSTECTOMY) JANUARY 2016

• Hydatid Cyst Liver 8x4.5

cm Right Lobe (Segment

• Gall Bladder Distended,

Multiple Stones 5-10 mm

• Thickened Oedematous

• CBD Normal

ULTRASOUND (POST CHOLECYSTECTOMY)MARCH 2017:

• Right Lobe Liver Cystic

Mass 7.5x6.5 cm.

• Normal CBD.

• Absent Gall Bladder

(Cholecystectomy)

• Dx: Hydatid Cyst Right

Lobe Liver.

PREVIOUS SURGERYHISTOLOGY REPORTS:

• October 2016 (Open Cholecystectomy):

Chronic Cholecystitis

Gall Bladder Fossa Biopsy: Hydatid Cyst Daughter Cysts

•March 2017 (Wound Sinus exploration):

Sub Hepatic Drainage Tube Effluent: Hydatid Cyst Daughter Cysts

CT scan (1)June 2017

• Hydatid Cyst liver

Right Lobe

• Water Lily sign

• Normal CBD

WATER LILY

WATER LILY SIGN

• Detachment of the Endocyst membrane which results in floating membranes within the Pericyst that mimic the appearance of a water lily.

• Chest X-ray, US, CT or MRI.

• Transitional stage between active and inactive disease.

• Decreased intra-cystic pressure, degeneration, host response, trauma or following therapy.

CT scan (2)

CT scan (3)

HYDATID

CT scan (4)

HYDATID CYST

OPERATION EXCISION HYDATID CYST LIVERJuly 2017

• INCISION: Through scar previous Kocher incision

• FINDINGS:

1) Frozen abdomen! Extensive Adhesions.

2) Main large HC at the dome of the right lobe liver under the diaphragm

3) Small (incidental) HC near gall bladder fossa. (Likely the same HC encountered in previous cholecystectomy).

OPERATIVE FINDINGS:

The smaller HC at Gall

Bladder fossa

DR. M. AL-GAILANI FRCS, AHH SUWAIDI

OPERATIVE PROCEDURE:

1. Packing all around HC.

2. Hypertonic Saline intra cystic injection.

3. Complete evacuation all endocyst and daughter cysts of both HCs avoiding any spillage.

4. Two corrugated drains: sub hepatic & intra cavity of the larger HC.

The smaller HC at Gall Bladder Fossa

FOLLOW UP

• Histology & Microbiology:

HC confirmed: HC wall enucleation, outer ectocyst, inner endocyst, germinal layer & daughter cysts.

• Uneventful postoperative recovery

• Drains removed 12th postoperative day

• Discharged well.

HYDATID CYST DISEASE

DR. MOHAMAD AL-GAILANI FRCS AHH SUWAIDI HYDATID CYST OF THE LIVER

CASE PRESENTATION KSA 2017

EPIDEMIOLOGY OF HC:

1. Human Hydatid Cyst is

prevalent in the Middle

East and North Africa.

2. Hyper endemic in Turkey,

Iraq, Jordan, Morocco,

Libya & Algeria.

3. Hydatid cysts are found in

Sheep, Goats, Cattle &

Camels.

4. Sheep-Dog spread is the

most important Zoonotic

transmission vehicle for

Human Hydatic Cyst

disease.

ECHINOCOCUS GRANULOSUSTAPE WORM

SCOLEX SHOWING HOOKS

HYDATID CYST INTERMEDIATE HOST (SHEEP)

Prevalence of HC in

slaughtered sheep in

Riyadh City around 1.06%.

E. Almalki Et Al.

Saudi Journal of Biological

Sciences (2017)

MAJOR PUBLIC HEALTH HAZARD!

SHEEP OFFAL

(HC) FED TO

DOGS EXCRETA CONTAING OVA CONTAMINATE

AGRICULTURE

ECHINOCOCUS GRANULOSUS OVUMINFECTIVE TO HUMANS

Resistant to all

antiseptics

including

Permanganate

antiseptic & even

to Formalin!

HC Ova deposited in Soil Can stay viable for up to a Year!

SALADHC OVA INFESTED LETTUCE

HYDATID CYST ACCIDENTAL INTERMEDIATE HOST (HUMANS)

HYDATID CYST ANATOMY

ECTOCYST (HOST)

DAUGHTER CYSTS

ENDOCYST (HC)

GERMINAL LAYER

HC CAN AFFECT ANY ORGAN!

LIVER 65%

LUNG 25%

• Brain 1%

• Spleen 1%

• Bone 3%

• Kidney 2%

• Eyes

• Thyroid Gland

• Breast

CLINICAL FEATURES:

•Depends On The Organ Affected

•High Index Of Suspicion In Endemic Areas

•Pressure Symptoms: Brain, Bone

•Lump: Thyroid, Skin, Breast, Skin

• Intra Biliary Rupture > Obstructive Jaundice

•Abscess: Liver, Lung

DIFFERENTIAL DIAGNOSIS:

• Biliary Cirrhosis

• Biliary Colic

• Biliary Obstruction

• Budd-Chiari Syndrome

• Cystic Teratoma

DIFFERENTIAL DIAGNOSIS:

• Cysticercosis

• Hepatic Cysts

• Liver Abscess

• Primary Hepatic Carcinoma

• Pyogenic Hepatic Abscesses

INVESTIGATIONS:

• Eosinophilia is present in 25%

• ELISA: Enzyme-Linked Immuno Sorbent Assay Sensitivity 80%

• Casoni Test: intradermal skin test Sensitivity 70%

• Plain X-ray: A thin rim of calcification delineating a cyst is suggestive

• US: Cyst Wall, Daughter Cysts, Water Lily Sign

• CT

• MRI

MANAGEMENT:

1. SURGERY: Remains the primary treatment and the only hope for complete cure.

2. MEDICAL:

Inoperable because of location or multiple organs

Unfit for General Anaesthesia

Disseminated Peritoneal disease.

a. Albendazole (10-15 mg/kg/day) orally for 3-6 months

b. Mebendazole (40-50 mg/kg/day) orally for 3-6 months

SURGICAL TECHNIQUE:

1. Isolation: surrounding tissues are protected by covering them with cetrimide-soaked pads

2. Intra Cystic Injection Scolicidal Agents: Hypertonic saline 20%, Chlorhexidine 10%, Absolute alcohol 95%, Hydrogen Peroxide 3% or Cetrimide 1.5%.

3. Cyst aspiration and evacuation: Spillage Free

4. Remaining cavity:

1) Close after closure of any biliary communications

2) Omental packing

3) Marsupialization

4) Drainage

PUBLIC HEALTH & PREVENTION:

• Breaking down the life cycle by stray dog control

• Preventing sheep offal from being fed to stray dogs

• Thorough washing of all vegetables especially lettuce with soap and running water

• Soaking of vegetables in Potasium Permangate or any other antiseptic is ineffective!

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