Hydatid cyst theva

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  • 1. 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
  • 2. 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
  • 3. LAB INVESTIGATION  FBC  RP/ LFT  Coagulation profile  Viral screeening  Alpha fetoprotein
  • 4. 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
  • 5. DIFFERENTIAL DIAGNOSIS  HCC  Hepatic abcess
  • 6. 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
  • 7. CT LIVER
  • 8. INVESTIGATIONS (ODERED BY ID TEAM)  Echinococcosis serology  Amoebiasis serology  Meliodosis serology  Stool ova and cyst  Blood c & s
  • 9. 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
  • 10. 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
  • 11. 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.
  • 12. THE DISEASE CAN EFFECT ALMOST ANY ORGAN BUT COMMONLY  Liver  Lung  Brain
  • 13. STRUCTURE OF HYDATID CYST  Usually unilocular fluid filled cyst (fluid inside  allergic/ toxic)  3 layers  Pericyst  Ectocyst  Endocyst
  • 14. DIAGNOSES  History and physical examination  Laboratory  Imaging
  • 15. 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
  • 16. 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
  • 17. IMAGING  Plain AXR  USG  CT  MRI, ERCP, MRCP (complicated cases)
  • 18. 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.
  • 19. MANAGEMENT  Medical / Pharmacological  Surgical
  • 20. 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
  • 21. 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.
  • 22. 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
  • 23.  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.
  • 24. 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.
  • 25. 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
  • 26. DISCUSSION  PAIR vs open surgery??
  • 27.  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
  • 28.  Surgical interventation consist of both radical & conservative
  • 29.  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
  • 30.  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 %
  • 31.  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
  • 32. PAIR  greater clinical efficacy  low rates of major and minor complications, mortality, recurrence rate and short hospitalization days.
  • 33. 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
  • 34. 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