Hydatid Cysts Disease of the
Liver
Treatment Options
Surgical Vs. Percutaneous Drainage
Presented By:
Dr.Doaa Al-Qaidy
Hose officer
Contents:
• Case presentation.
• Introduction.
• Basic Information.
• Hydatid disease in human:
 Liver Hydatid disease:
Clinical presentation, management options and
complication.
• Conclusion.
Case
•
A twenty-five year old female presented with
intermitted upper abdominal pain for two years.
She is a villager and there was history of weight
loss and off/on history of fever. There was no
previous hospitalization and surgical
interventions. There was history of keeping
sheep at home. On clinical examination patient
was a fibrile vital were stable, systematic review
was normal.
•
Abdominal Examination: 4X4 cm mass firm in
consistency in Epigastric area moves with
respiration slight tenderness in epigastric area.
There were no visible pulsation or penstaltic
movements on it. US abdomen&CTAbdomen
were both in favor of Hydatid cyst involving left
lobe of Liver completely. According to clinical
history and image finding Hydatid cyst was
suspected.
Introduction:
• Hydatid disease is a worldwide zoonosis
produced by the larval stage of the
Echinococcus tapeworm .
• The two main types of hydatid disease are
caused by E granulosus and E multilocularis.
• E granulosus is commonly seen in the great
grazing regions of the world—particularly the
Mediterranean region, Africa, South America,
the Middle East, Australia, and New Zealand—
and is the most frequently encountered type of
hydatid disease in humans.
Life Cycle of E granulosus
Hydatid Cyst Structure
• The hydatid cyst has three layers:
(a) the outer pericyst, composed of
modified host cells that form a dense and
fibrous protective zone;
(b) the middle laminated membrane, which
is acellular and allows the passage of
nutrients;
(c) the inner germinal layer, where the
scolices (the larval stage of the parasite)
and the laminated membrane are
produced.
• Daughter vesicles (brood capsules) are
small spheres that contain the
protoscolices and are formed from rests
of the germinal layer. Before becoming
daughter cysts, these daughter vesicles
are attached by a pedicle to the germinal
layer of the mother cyst. At gross
examination, the vesicles resemble a
bunch of grapes.
Hydatid Disease in Humans
Hydatid disease involves the
liver in approximately 75% of
cases, the lung in 15%, and other
anatomic locations in 10%
Clinical presentation :
The clinical features are highly variable. The spectrum of
symptoms depends on the following:
• Involved organs
• Size of cysts and their sites within the affected organ or
organs
• Interaction between the expanding cysts and adjacent
organ structures, particularly bile ducts and the vascular
system of the liver
• Symptoms due to pressure usually take a long time to
manifest, except when they occur in the brain .
• Most symptomatic cysts are larger than 5 cm in diameter.
• Bacterial infection of cysts and spread of protoscolices
and larval material into bile ducts or blood vessels
• Immunologic reactions such as asthma, anaphylaxis, or
membranous nephropathy secondary to release of
antigenic material
Hepatic Disease
• The right lobe is the most
frequently involved portion of the
liver.
• Once in the human liver, cysts grow
to 1 cm during the first 6 months
and 2–3 cm annually thereafter,
depending on host tissue
resistance.
Clinical presentation of liver disease:
Work Up
• Generally, routine laboratory tests do not show
specific results.
• In patients with rupture of the cyst in the biliary
tree, marked and transient elevation of cholestatic
enzyme levels occurs, often in association with
hyperamylasemia and eosinophilia (as many as
60%).
• Indirect hemagglutination test and enzyme-linked
immunosorbent assay are the most widely used
methods for detection of anti-Echinococcus
antibodies (immunoglobulin G [IgG]).These tests
give false positive results in cases of
schistosomiasis and nematode infestations that is
why they are not specific for diagnosing
hydatidosis.
Imaging Studies:
•
•
•
•
Plain radiography
Ultrasound examination
CT scaning
MRI
Management Options
• Medical .
• Surgery.
• PAIR.
Medical therapy:
•
•
Indications: Chemotherapy is indicated in patients with
primary liver or lung cysts that are inoperable (because of
location or medical condition), patients with cysts in 2 or
more organs, and peritoneal cysts.
Chemotherapeutic agents: Two benzimidazoles are used,
albendazole and mebendazole. Albendazole is
administered in several 1-month oral doses (10-15
mg/kg/d) separated by 14-day intervals. The optimal
period of treatment ranges from 3-6 months, with no
further increase in the incidence of adverse effects if this
period is prolonged. Mebendazole is also administered for
3-6 months orally in dosages of 40-50 mg/kg/d.
• Contraindications: Early pregnancy, bone
marrow suppression, chronic hepatic disease,
large cysts with the risk of rupture, and inactive
or calcified cysts are contraindications. A
relative contraindication is bone cysts because
of the significantly decreased response.
• Outcome : Response rates in 1000 treated
patients were that 30% had cyst disappearance
(cure), 30-50% had a decrease in the size of the
cyst (improvement), and 20-40% had no
changes. Also, younger adults responded better
than older adults.
PAIR
•
This technique, performed using either
ultrasound or CT guidance, involves aspiration
of the contents via a special cannula, followed
by injection of a scolicidal agent for at least 15
minutes, and then reaspiration of the cystic
contents. The cyst is then filled with isotonic
sodium chloride solution. Perioperative
treatment with a benzimidazole is mandatory (4
d prior to the procedure and 1-3 mo after).
• The cysts should be larger than 5 cm in
diameter and type I or II according to the Gharbi
ultrasound classification of liver cysts
• Indications: Inoperable patients;
patients refusing surgery; multiple
cysts in segment I, II, and III of the
liver; and relapse after surgery or
chemotherapy are indications for
the PAIR technique.
• Contraindications: Early pregnancy,
lung cysts, inaccessible cysts,
superficially located cysts (risk of
spillage), type II honeycomb cysts,
type IV cysts, and cysts
communicating with the biliary tree
(risk of sclerosing cholangitis from
the scolecoidal agent).
• Outcome: The reduced cost and shorter hospital
stay associated with PAIR compared to surgery
make it desirable. The risk of spillage and
anaphylaxis is considerable, especially in
superficially located cysts, and transhepatic
puncture is recommended. Sclerosing
cholangitis (chemical) and biliary fistulas are
other risks. Experience is still limited.
Surgical Management
• Indications:
1-Large liver cysts with multiple daughter cysts;
superficially located single liver cysts that may
rupture (traumatically or spontaneously).
2-liver cysts with biliary tree communication or
pressure effects on vital organs or structures.
3-infected cysts .
4-cysts in lungs, brain, kidneys, eyes, bones .
Choice of surgical technique:
• 1-Radical surgery (total pericystectomy
or partial resection, if possible),
• 2-Conservative surgery (open
cystectomy), or simple tube drainage for
infected and communicating cysts are
choices for surgical technique. The more
radical the procedure, the lower the risk
of relapses but the higher the risk of
complications.
• Concomitant treatment with
benzimidazoles (albendazole or
mebendazole) has been reported to
reduce the risk of secondary
echinococcosis. Treatment is
started 4 days preoperatively and
lasts for 1 month.
•
Contraindications: General contraindications to
surgical procedures (eg, extremes of age,
pregnancy, severe preexisting medical
conditions); multiple cysts in multiple organs;
cysts that are difficult to access; dead cysts;
calcified cysts; and very small cysts are
contraindications.
Complications:
1-All the usual complications related to the surgical
procedure and anesthesia
2-Related to the parasite Recurrence
• Metastasis
• Infection
• Spillage and seeding (secondary echinococcosis) Allergic reaction or anaphylactic shock
3-Related to the medical treatment Hepatotoxicity
• Anemia
• Thrombocytopenia
• Alopecia
• Embryotoxicity
• Teratogenicity.
Complications , cont.
4-Related to PAIR
• Hemorrhage
• Mechanical damage to other tissue
• Infections
• Allergic reaction or anaphylactic shock
• Persistence of daughter cysts
• Sudden intracystic decompression leading to biliary
fistulas
5-Related to scolicidal agents - Chemical sclerosing
cholangitis
Conclusion:
•
Many hydatid cysts remain asymptomatic, even
into advanced age. Parasite load, the site, and
the size of the cysts determine the degree of
symptoms.
• The liver is the most common organ involved,
followed by the lungs. These 2 organs account
for 90% of cases of echinococcosis.
• Surgery remains the main Treatment of the
hydatied liver disease , PAIR technique still
promising.
• Patient education about the prevention of this
zoonotic infection .
References:
Articles:
• Hydatid Disease: Radiologic and Pathologic Features and
Complications , by Iván Pedrosa,
MD,Radiographics,2004.
• Surgical treatment of liver hydatid disease,by ali azer,
department of general surgery , Baskent university, Turky
2006.
• Surgical treatment of hydatid cysts of the liver,drainage
versus omentoplasty,annuls of hepatology , 2005.
• Percutaneous Treatment of hydatid liver diseases , 2009.
Web sites:
http://emedicine.medscape.com/articl
e/178648-followup#a2651 .