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DAIGNOSTICS & MANAGEMENT

OF
HYDATID CYST LIVER

BY:
DR.NAVEED AHMED
RESIDENT OF SURGERY
WARD # 26,JPMC
Introduction:
► The disease is caused by the helminth
Echinococcus granulosus (dog
tapeworm).

► Its definitive host is dog/wolf


Ecchinococcus granulosa

► Intermediate host is sheep.

► Humans are accidental intermediate hosts.

► The adult worm lives in the intestines of


the definitive host (dog) for 5-20 months.

► Releases the ova with the stools. Ingestion


of the ova (on polluted vegetables, grass
or water) causes infection. ova
LIFECYCLE OF PARASITE
This disease can affect almost any organ
but has more propensity towards (LLB)

 Liver (Rt lobe in 70% cases)

 Lungs

 Brain
STRUCTURE OF HYDATID CYST

► It’s usually a unilocular fluid filled cyst


► Fluid inside this cyst is extremely allergic/toxic
► Membrane surrounding fluid consists of three
distinct layers

1. Outer Pericyst (derived from host’s organ/tissue)

2. Middle Ectocyst (composed of hyaline matter)

3. Inner Endocyst (germinal layer that continuously produce


scolices)
MICROSCOPIC PICTURE OF HYDATID CYST
HOW TO DIAGNOSE
??????????
► Clinical picture (in high risk pts)

► Serological study

► Microscopic study of aspirated fluid

► Radiological study (most specific)


CLINICAL FEATURES:
► Right upper abdominal pain
► Hepatic enlargement/mass
► Anorexia
► Nausea and vomiting
► weight loss
► Fever and chills
► Jaundice
► Urticaria and anaphylaxis
A HIGH INDEX OF SUSPICION IN :
 Rural
residents.

 Farmers
or
 Persons in
contact with
dog/sheeps.
Serologically by:
► Eosinophilia
► Detection of antibody by:

 ELISA ( Enzyme Linked Immuno Sorbent Assay )


have a high specificity and accuracy.

 indirect hemagglutinin test 70% sensitive

 complement fixation test.


Microscopy by:

Fluid aspirated from a hydatid cyst will


shows multiple protoscolices.
Radiologically by:

 Plain X-ray (shows calcified cyst)

 Ultrasound (unilocular cyst)

 CT (floating membrane within cyst)

 MRI, MRCP, ERCP (may be employed In


complicated cases.)
Plain X-ray abdomen
showing Hydatid cysts
in liver (3 cysts marked
by arrows)
U/S Abdomen showing giant liver
cyst
CT Abdomen showing giant liver cyst
WHO CLASSIFICATION OF HYDATID
CYST

HYDATID CYST

CLASS ONE CLASS TWO CLASS THREE


OR OR OR
Active group Transition group 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
Management ???????
Management options are

► Medical or pharmacological treatment

&

► Surgical treatment
PHARMACOLOGICAL TREATMENT
► Pharmacological treatment is not curative.
► Indicated in cases which are inoperable (surgery is
contraindicated).
► Used as an adjunct to surgery to kill spilled
scolices & avoid peritoneal contamination.
► Drug of choice are
 albendazole,
 mebendazole
 praziquantel
Surgery is the most specific form of
curative treatment for echinococcosis.
SURGICAL TREATMENT:
► For uncomplicated hydatid cysts
►Open/Laparoscopic surgery

 Cystectomy (excision of cyst)


 Simple tube drainage
 Pericystectomy
 Hepatic segmentectomy
 Marsupialization and Omentoplasty (not recommended any
more)

►Ultrasound guided percutanous aspiration


 Puncture, Aspiration, Injection & Re-aspiration (PAIR)
CONTRA-INDICATIONS FOR SURGERY
ARE:
► General contraindications to surgery
 Extremes of age
 Pregnancy
 Preexisting medical conditions

► Multiple cysts in multiple organs


► Cysts are difficult to be accessed
► Dead cysts (WHO class 3)
► Calcified cysts (WHO class 3)
► Very small cysts
Contraindications for laparoscopic
procedure:

► Deep intraparenchymal cysts


► Posterior Cyst
► More than 3 cysts
► Cysts with thick and calcified walls
COMPLICATIONS OF HYDATID CYST

► Intrabiliary rupture leading to:


 Biliary colic
 obstructive jaundice
► Intarperitoneal rupture leading to:
 Acute abdomen (peritonitis)
 Anaphylactic shock
► Intraplueral rupture leading to:
 Dyspnea
 Blood and bile stained sputum
SURGICAL MANAGEMENT IN
COMPLICATED CASES

Complication Surgical procedure

1. Intarperitoneal Laparotomy +
rupture peritoneal toilet +
Pericystectomy

Choledochotomy +
2. Intrabiliary rupture T-tube placement
POST-OP COMPLICATIONS:
► Anaphylactic shock

► Bleeding

► Post-operative infection with creating of


perihepatic abscesses

► External biliary fistula

► Recurrence