Hydatid Csyt Liver

8/9/2019 Hydatid Csyt Liver

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DAIGNOSTICS & MANAGEMENTDAIGNOSTICS & MANAGEMENT

OFOF HYDATID CYST LIVERHYDATID CYST LIVER

BY:BY:DR.NAVEED AHMEDDR.NAVEED AHMEDRESIDENT OF SURGERYRESIDENT OF SURGERYWARD # 26,JPMCWARD # 26,JPMC


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Introduction:Introduction:

The disease is caused by the helminthThe disease is caused by the helminthEchinococcus granulosusEchinococcus granulosus(dog(dogtapeworm).tapeworm).

Its definitive host is dog/wolfIts definitive host is dog/wolf

Intermediate host is sheep.Intermediate host is sheep.

Humans are accidental intermediate hosts.Humans are accidental intermediate hosts.

The adult worm lives in the intestines ofThe adult worm lives in the intestines ofthe definitive host (dog) for 5the definitive host (dog) for 5--20 months.20 months.

Releases the ova with the stools. IngestionReleases the ova with the stools. Ingestionof the ova (on polluted vegetables, grassof the ova (on polluted vegetables, grassor water) causes infection.or water) causes infection.

Ecchinococcus granulosa

ova


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LIFECYCLE OF PARASITELIFECYCLE OF PARASITE


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This disease can affect almost any organThis disease can affect almost any organ

but has more propensity towards (LLB)but has more propensity towards (LLB)

LL iveriver (Rt lobe in 70% cases)(Rt lobe in 70% cases)

LLungsungs

BB rainrain


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STRUCTURE OF HYDATID CYSTSTRUCTURE OF HYDATID CYST

Its usually a unilocular fluid filled cystIts usually a unilocular fluid filled cyst

Fluid inside this cyst is extremely allergic/toxicFluid inside this cyst is extremely allergic/toxicMembrane surrounding fluid consists of threeMembrane surrounding fluid consists of three

distinct layersdistinct layers

1.1. OuterOuter PericystPericyst (derived from hosts organ/tissue)(derived from hosts organ/tissue)

2.2. MiddleMiddle EctocystEctocyst(composed of hyaline matter)(composed of hyaline matter)

3.3. InnerInner EndocystEndocyst(germinal layer that continuously produce(germinal layer that continuously produce

scolices)scolices)


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MICROSCOPIC PICTURE OF HYDATID CYSTMICROSCOPIC PICTURE OF HYDATID CYST


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Clinical picture (in high risk pts)Clinical picture (in high risk pts)

Serological studySerological study

Microscopic study of aspirated fluidMicroscopic study of aspirated fluid

Radiological study (most specific)Radiological study (most specific)


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CLINICAL FEATURES:CLINICAL FEATURES:

Right upper abdominal painRight upper abdominal pain

Hepatic enlargement/massHepatic enlargement/massAnorexiaAnorexia

Nausea and vomitingNausea and vomitingweight lossweight loss

Fever and chillsFever and chills

JaundiceJaundice

Urticaria and anaphylaxisUrticaria and anaphylaxis


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A HIGH INDEX OF SUSPICION IN :A HIGH INDEX OF SUSPICION IN :

RuralRural

residents.residents.

FarmersFarmers

oror

Persons inPersons in

contact withcontact withdog/sheeps.dog/sheeps.


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Serologically by:Serologically by:

EosinophiliaEosinophilia

Detection of antibody by:Detection of antibody by:

ELISA ( Enzyme Linked Immuno Sorbent Assay )ELISA ( Enzyme Linked Immuno Sorbent Assay )have a high specificity and accuracy.have a high specificity and accuracy.

indirect hemagglutinin test 70% sensitiveindirect hemagglutinin test 70% sensitive

complement fixation test.complement fixation test.


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MicroscopyMicroscopy by:by:

Fluid aspirated from a hydatid cyst willFluid aspirated from a hydatid cyst will

shows multiple protoscolices.shows multiple protoscolices.


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Radiologically by:Radiologically by:

Plain XPlain X--rayray (shows calcified cyst)(shows calcified cyst)

UltrasoundUltrasound (unilocular cyst)(unilocular cyst)

CTCT (floating membrane within cyst)(floating membrane within cyst) MRI, MRCP, ERCPMRI, MRCP, ERCP (may be employed In(may be employed Incomplicated cases.complicated cases.))


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Plain XPlain X --ray abdomenray abdomenshowing Hydatid cystsshowing Hydatid cysts

in liver (3 cysts markedin liver (3 cysts marked

by arrows)by arrows)


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U/S Abdomen showing giant liverU/S Abdomen showing giant liver

cystcyst


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CT Abdomen showing giant liver cystCT Abdomen showing giant liver cyst


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WHO CLASSIFICATION OF HYDATIDWHO CLASSIFICATION OF HYDATID

CYSTCYST

HYDATID CYST

CLASS ONEOR

Active group

CLASS TWOOR

Transition group

CLASS THREE

OR

Inactive group

Class one and class two cyst of WHO classification

needs urgent management.

While class three cyst should be left in place

followed with observation by serial ultrasounds


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Management ???????Management ???????


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Management options areManagement options are

Medical or pharmacological treatmentMedical or pharmacological treatment

&&

Surgical treatmentSurgical treatment


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PHARMACOLOGICAL TREATMENTPHARMACOLOGICAL TREATMENT

Pharmacological treatment is not curative.Pharmacological treatment is not curative.

Indicated in cases which are inoperable (surgery isIndicated in cases which are inoperable (surgery iscontraindicated).contraindicated).

Used as an adjunct to surgery to kill spilledUsed as an adjunct to surgery to kill spilled

scolices & avoid peritoneal contamination.scolices & avoid peritoneal contamination.

Drug of choice areDrug of choice are

albendazole,albendazole,

mebendazolemebendazole

praziquantelpraziquantel


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Surgery is the most specific form ofSurgery is the most specific form of

curative treatment for echinococcosis.curative treatment for echinococcosis.


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SURGICAL TREATMENT:SURGICAL TREATMENT:

For uncomplicated hydatid cystsFor uncomplicated hydatid cysts

Open/Laparoscopic surgeryOpen/Laparoscopic surgery

Cystectomy (excision of cyst)Cystectomy (excision of cyst)

Simple tube drainageSimple tube drainage

PericystectomyPericystectomy

Hepatic segmentectomyHepatic segmentectomy

Marsupialization and Omentoplasty (not recommended anyMarsupialization and Omentoplasty (not recommended anymore)more)

Ultrasound guided percutanous aspirationUltrasound guided percutanous aspiration

Puncture, Aspiration, Injection & RePuncture, Aspiration, Injection & Re--aspiration (PAIR)aspiration (PAIR)


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CONTRACONTRA--INDICATIONS FOR SURGERYINDICATIONS FOR SURGERY

ARE:ARE:General contraindications to surgeryGeneral contraindications to surgery

Extremes of ageExtremes of age

PregnancyPregnancy

Preexisting medical conditionsPreexisting medical conditions

Multiple cysts in multiple organsMultiple cysts in multiple organs

Cysts are difficult to be accessedCysts are difficult to be accessed

Dead cystsDead cysts (WHO class 3)(WHO class 3)

Calcified cystsCalcified cysts (WHO class 3)(WHO class 3)

Very small cystsVery small cysts


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Contraindications for laparoscopicContraindications for laparoscopic

procedure:procedure:

Deep intraparenchymal cystsDeep intraparenchymal cysts

Posterior CystPosterior Cyst

More than 3 cystsMore than 3 cysts

Cysts with thick and calcified wallsCysts with thick and calcified walls


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COMPLICATIONS OF HYDATID CYSTCOMPLICATIONS OF HYDATID CYST

Intrabiliary rupture leading to:Intrabiliary rupture leading to:

Biliary colicBiliary colic obstructive jaundiceobstructive jaundice Intarperitoneal rupture leading to:Intarperitoneal rupture leading to: Acute abdomen (peritonitis)Acute abdomen (peritonitis)

Anaphylactic shockAnaphylactic shock

Intraplueral rupture leading to:Intraplueral rupture leading to:

DyspneaDyspnea Blood and bile stained sputumBlood and bile stained sputum


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SURGICAL MANAGEMENT INSURGICAL MANAGEMENT IN

COMPLICATED CASESCOMPLICATED CASES

ComplicationComplication Surgical procedureSurgical procedure

1. Intarperitoneal1. Intarperitoneal

rupturerupture

Laparotomy +Laparotomy +

peritoneal toilet +peritoneal toilet +PericystectomyPericystectomy

2. Intrabiliary rupture2. Intrabiliary rupture

Choledochotomy +Choledochotomy +

TT--tube placementtube placement


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POSTPOST--OP COMPLICATIONS:OP COMPLICATIONS:

Anaphylactic shockAnaphylactic shock

BleedingBleeding

PostPost--operative infection with creating ofoperative infection with creating ofperihepatic abscessesperihepatic abscesses

External biliary fistulaExternal biliary fistula

RecurrenceRecurrence


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Hydatid Csyt Liver