HEPATIC HYDATID CYST

BY THEVA

CASE PRESENTATION

49 yo, Malay woman No known medical illness Presented with :

epigastric and RHC discomfort for 3 mo

loss of weight fever for 1 day No loa/ no jaundice/ no obstructive symptoms Non smoker/ not alcoholic No family history of malignancy

PHYSICAL EXAMINATION

Not jaundice, pink On abdominal examination hepatomegaly, non tender, irregular margin and firm

in consistency, no splenomegaly Respiratory and cardiovascular system was

unremarkable Lymph nodes not palpable No stigmata of liver disease Vital signs stable Afebrile

LAB INVESTIGATION

FBC RP/ LFT Coagulation profile Viral screeening Alpha fetoprotein

FBC RP LFT COAG PROFILE

HB :11.96 UREA : 3.4 TB : 14 PT : 10.5

WC : 7.1 CREAT : 65 ALP : 113 INR : 1.03

PLT : 305 NA : 136 ALT : 47 APTT : 33.5

K : 4.2

DIFFERENTIAL DIAGNOSIS

HCC Hepatic abcess

IMAGING

Usg HBS Huge heterogenous cystic mass in the right liver lobe measuring > 20.5cm X 12cm.Presence of gallstone in GB.IHD and CBD not dilatedImp : suggestive of hydatid cyst with diffrential of amoebic liver abcess

*** further history : h/o of multiple visits to egypt within past few years. Last visit was in feb 2013 whr she took local salad dish with grilled fish and snails delicacies

CT LIVER

INVESTIGATIONS (ODERED BY ID TEAM) Echinococcosis serology Amoebiasis serology Meliodosis serology Stool ova and cyst Blood c & s

MANAGEMENT

Was referred to ID team Started on iv metronidazole 750mg

TDS for 10 days Albendazole 400mg bd Referred to Hosp Selayang planned

for op on 28/6

INTRODUCTION

Hydatid disease tapeworm of genus echinococcus 4 types E. granulosus ( commonest)

E. multilocularis (most virulent) E.vogeli/ oligathrus ( rare)

Definitive host dog/ wolf

Intermediate host human/ sheep

EPIDEMIOLOGY

found worldwide E. granulosus in broad regions of Eurasia,

several South American countries, and Africa

E. multilocularis endemic in the central part of Europe, parts of the Near East, Russia, the Central Asian Republics, China, northern Japan, and Alaska.

E. vogeli humid tropical forests in central and northern South America.

THE DISEASE CAN EFFECT ALMOST ANY ORGAN BUT COMMONLY

Liver Lung Brain

STRUCTURE OF HYDATID CYST

Usually unilocular fluid filled cyst (fluid inside allergic/ toxic)

3 layers Pericyst Ectocyst Endocyst

DIAGNOSES

History and physical examination Laboratory Imaging

CLINICAL MANIFESTATION

Involved organs Size of cysts and their sites within the

affected organ Interaction between the expanding

cysts and adjacent organ structures, particularly bile ducts and the vascular system of the liver

LABORATORY Full blood count eosinophilia Indirect hemagglutination test and

enzyme-linked immunosorbent assay are the most widely used methods for detection of anti-Echinococcus antibodies

IMAGING

Plain AXR

USG CT MRI, ERCP, MRCP (complicated cases)

CLASSIFICATION OF HYDATID CYSTS BASED ON THE ULTRASOUND APPEARANCE.

CL Active; Single cysts. Cysts are developing and are fertile. Cyst wall not visible.

CE1 Active; simple cyst often full of hydatid sand (snow flake sign). Visible cyst wall.

CE2 Active; multiple, or multi loculated cysts. May appear honeycomb like with daughter cysts.

CE3 Transition; degenerating cysts but still contain viable protoscoleces. Often see floating membranes in fluid filled cysts

CE4 Inactive; degeneration is advanced. Cysts may be calcified. Not likely to be fertile. Heterogeneous appearance with few or no daughter cysts.

CE5 Inactive. Often calcified. Usually infertile.

MANAGEMENT

Medical / Pharmacological Surgical

MEDICAL/PHARMACOLOGICAL

Not curative Indication inoperable / surgery in

contraindicated Used as adjunct to surgery to kill

spilled scolices/ to avoid peritoneal contamination

Drugs albendazole,mebendazole, praziquantel

THE PRINCIPLES OF SURGERY

total removal of all infective components of the cysts

the avoidance of spillage of cyst contents at time of surgery

management of communication between cyst and adjacent structures

management of the residual cavity minimize risks of operation.

SURGERY CURATIVE TREATMENT !!!

Uncomplicated hydatid cysts : Radical/ conservative surgery Radical procedures complete removal of the cyst with or

without hepatic resection.

greater intraoperative risks Cystectomy, pericystectomy, lobectomy and hepatectomy

Conservative procedures sterilization and evacuation of cyst content, including the hydatid membrane (hydatidectomy), and partial removal of the cyst . residual cavity remains, bearing the risk of secondary bacterial infection and abscess formation & Higher recurrence rate

Laparoscopic surgery offers a lower morbidity outcome and a shorter hospital laparoscopic procedure gives a better visual control of the cyst

cavity under magnification which allows a better detection of biliary fistula. This approach is possible only in selected cases.

The criteria to exclude laparoscopic treatment of hydatid cyst of liver are: Rupture of the cyst in biliary tract Central localization of the cyst Cysts dimension >15 cm Number of cysts > 3 Thickened or calcified walls opening of bile ducts that leak bile

disadvantage is the lack of precautionary measures to prevent spillage and allergic reactions are more common in laparoscopic interventions due to peritoneal spillage.

PAIR ULTRASOUND GUIDED PERCUTANOUS, ASPIRATION, INJECTION & REASPIRATION

percutaneous drainage of echinococcal cysts located in the abdomen

drainage is performed with a fine needle or a catheter killing of the protoscolices remaining in the cyst cavity by a protoscolicide agent.

If a catheter is temporarily left in the cyst PAIRD If numerous and large daughter cysts are

present, an alternative percutaneous technique “Percutaneous Puncture with Drainage and Curettage” (PPDC)” surgical settings, using specified materials.

COMPLICATIONS

Intrabiliary rupture leading to: Biliary colic Obstructive jaundice

Intraperitoneal rupture leading to: Acute abdomen (peritonitis) Anaphylactic shock

Intrapleural rupture leading to:DyspneaBlood and bile stained sputum

DISCUSSION

PAIR vs open surgery??

Semago conducted a meta-analysis comparing 769 patients with echinococcosis hepatic cysts managed with PAIR method and compared it with era matched 952 patients managed surgically.

PAIR was either combined with albendazole or with out albendazole.

Cases of hepatic ecchinococcus diagnosed and included in analysis on basis of clinical,radiological, cytologic and serologic

Exclusion criteria: pregnant/infected cyst

Surgical interventation consist of both radical & conservative

PAIR meets almost all the goals open surgery of in activation of the cestode parasite,evacuation of the cyst, removal of germinal layer, and obliteration of the remaining cavity

Anaphylaxis, cyst infection, intra abdominal abscess, sepsis, and biliary fistula occurred in 7.9 % and 25.1 % of PAIR treated and surgical control subjects respectively

Fever and allergic reactions were ecountered more frequently in PAIR group(5.5 % and 2.5%) respectively Minor reactions occurred more commonly among surgical groups then PAIR, 13.1% and 33 %

No peritoneal dissemination in PAIR group. Clinical and parasitologic cure occurred in 95.8 % in PAIR and 89.8 % in surgery Incomplete response occurred in 2.0 % and 3.2 % respectively Disease recurrence occurred in 1.6 and 6.3

% respectively One procedure related death in PAIR due to

anaphylaxis compared to 0.7% ( 7 deaths) among surgical controls.Causes of mortality includes pulmonary complications,liver failure myocardial infarction, generalised peritonitis and anaphylaxis

PAIR greater clinical efficacy low rates of major and minor complications, mortality, recurrence rate and short hospitalization days.

LIMITATIONS OF THIS STUDY

Shorter followup period for patients underwent PAIR (20.5 mo) than surgical control subjects (32 mo)

It is not clear what type of patients have gone

to surgery

SOURCES

1. PAIR: Puncture, Aspiration, Injection, Re-Aspiration.An option for the treatment of Cystic echinococcosis.http://www.who.int/emc

2. http//www.dpd.cdc.gov/dpdx3. Raymond A. Smego et al. Percutaneous Aspiration-injection-

Reaaspiration plus albendazole or mebendazole for hepatic cystic echinococcososis: A meta-analysis.The infectious diseases society of

America 2003.4. http://emedicine.medscape.com5. http://

wwwnc.cdc.gov/travel/yellowbook/2012/chapter-3-infectious-diseases-related-to-travel/echinococcosis

6. Falih mohsin ali et al.Laparoscopic vs open management in hydatid cysts liver.World journal of laparasopic surgery jan-april 2011.7-11