2. 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
3. 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
7. 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 dilated
Imp : 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
13. INVESTIGATIONS (ODERED BY ID TEAM)
Echinococcosis serology
Amoebiasis serology
Meliodosis serology
Stool ova and cyst
Blood c & s
14. 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
15. 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
16.
17.
18. 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.
19. THE DISEASE CAN EFFECT ALMOST ANY ORGAN
BUT COMMONLY
Liver
Lung
Brain
22. 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
23. 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
26. 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.
29. 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
30. 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.
31. 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
32. 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.
33. 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.
34.
35.
36.
37. COMPLICATIONS
Intrabiliary rupture leading to:
Biliary colic
Obstructive jaundice
Intraperitoneal rupture leading to:
Acute abdomen (peritonitis)
Anaphylactic shock
Intrapleural rupture leading to:
Dyspnea
Blood and bile stained sputum
39. 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
41. 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
42. 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 %
43. 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
44. PAIR greater clinical efficacy
low rates of major and minor
complications, mortality, recurrence rate
and short hospitalization days.
45. 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
46. 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/dpdx
3. 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.
1. http://emedicine.medscape.com
2. http://wwwnc.cdc.gov/travel/yellowbook/2012/chapter-3-infectious-
diseases-related-to-travel/echinococcosis
3. Falih mohsin ali et al.Laparoscopic vs open management in hydatid
cysts liver.World journal of laparasopic surgery jan-april 2011.7-11