1. The patient presented with intermittent right upper abdominal pain for 2 years with associated low grade fever. Imaging showed multiple hydatid cysts in the liver. 2. Hydatid cyst disease is caused by the larval stage of Echinococcus granulosus. Humans can become infected by contact with definitive hosts like dogs or ingesting contaminated food or water. 3. Treatment options include albendazole medication, puncturing and draining cysts using PAIR technique, or surgery to remove cysts depending on number and location.

1. HYDATID CYST DISEASE
OF LIVER
Dr Avijit Banerjee
South Eastern Railway
Hospital
Kolkata

2. CASE PRESENTATION
A lady aged 30 years presented with intermittent pain in the right
upper abdomen for past 2 years.
She had associated low grade fever
The pain was dull aching, persistent in nature, insidious in onset and
was not related to food intake or vomiting. The was no aggravating or
relieving factor
No h/o weight loss or loss of appetite
No h/o jaundice, hematemesis , melena
No h/o cough , haemoptysis , bone pain

3. PHYSICAL EXAMINATION
On general survey, patient’s nutrition was normal, not associated with
pallor, icterus or lymphadenopathy, pulse 80 per minute. No evidence
of dehydration.
On inspection , the shape of the abdomen was normal, umbilicus was
inverted, normal in position. The skin over the abdomen was normal.
No visible pulsations or scar mark.
On superficial palpation, the temperature of all quadrants were equal
and normal. Abdomen was soft and non tender.
On deep palpation liver was palpable , at about 4 fingers below the
costal margin. There was no lump in the abdomen. All other systemic
examinations were normal.

4. INVESTIGATIONS
USG – liver shows one echogenic SOL in the posterior segment of
right lobe of the liver. Huge cystic SOL with internal septations in
right sub hepatic region.
CECT – thin walled cystic lesion measuring 50x49 mm with wall
calcification is seen in segment 8. Another large lesion measuring
89x80mm involving right lobe of liver with an exophytic component.
The lesion shows mural calcification. Both lesion shows intrinsic
daughter cysts. Rest of hepatic parenchyma is normal. IHBR not
dilated. Intra-hepatic vascular structures appear normal. Cysts show
no post contrast enhancement.
IGG ECHINOCOCCUS – 6.0 mg/dl (HIGH)

10. HYDATID LIVER CYST
Echinococcosis (hydatid disease) is a zoonosis caused by the larval
stage of Echinococcus granulosus
Humans are accidental intermediate hosts, whereas animals can be
both intermediate and definitive hosts
The two main types of hydatid disease are caused by E. granulosus
and E. multilocularis

11. ETIOLOGY
The definitive host is usually a dog or some other carnivore
The adult worm of the parasite lives in the proximal small bowel of
the definitive host attached by hooklets to the mucosa.
Eggs are released into the host’s intestine and excreted in the feces
Sheep are the most common intermediate host, and these animals
ingest the ovum while grazing
The ovum loses the protective chitinous layer and is digested in the
duodenum. The released hexacanth embryo (oncosphere) passes
through the intestinal wall into the portal circulation and develops
into cysts within the liver. The definitive host eats the viscera of the
intermediate host to complete the cycle

12. Humans may become intermediate hosts through contact with the
definitive host (usually a dog) or by ingestion of contaminated water
or vegetables
Once in the liver, cysts grow to 1 cm in the first 6 months and 2–3
cm annually thereafter

14. PATHOLOGY
Majority are single cysts which occur in the right lobe of the liver and
half of them has daughter cysts and are multiloculated.
The typical hydatid cyst has a three-layer wall surrounding a fluid
cavity
Pericyst is the outer layer. It is thin ,indistinct fibrous tissue which is
adventitial reaction to the parasite infection. As the cyst grows the
blood vessels and bile ducts get incorporated in the structure leading
to hemorrhagic and biliary complications.over tym the pericyst
calcifies. It is the mechanical support and metabolic interface
between the host and parasite.

15. Ectocyst it is the outer layer , the laminated membrane made up of
cuticular chitinous structure without nuclei.0.5cm in thickness and
forms a barrier to bacteria and an ultrafilter for protein molecules
Endocyst it is the germinal membrane. responsible for the production
of clear hydatid fluid, the ectocyst, brood capsules, scoleces, and
daughter cysts.This germinal layer forms small cellular masses that
give rise to brood capsules, in which future worm heads develop.
They enlarge and develop into invaginated protoscoleces with four
suckers and a double row of hooks—a protoscolex

16. Hydatid sand = protoscoleces + brood capsudes + fluid +
calcareous bodies.
Hydatid sand is made up of around 400,000 scoleces per milliliter of
fluid. The protoscolex can differentiate in two directions. In the
definitive host, the scolex becomes an adult tapeworm. In the
intermediate host, including humans, each of the released
protoscoleces is capable of differentiating into a new hydatid cyst

17. Endogenic vesiculation = it is the formation of daughter cysts which a
defense reaction to the injury.
Ectogenic vesiculation = it is the crack in the germinal membrane
which leads to formation of satellite cysts, characteristic of
E.multilocularis.

18. DIAGNOSIS
Pain in the RUQ,hepatomegaly,fever, fatigue,nausea,dyspepsia.
Some may present with eosinophilia
Specific IgE antibodies are demonstrated with ELISA and
radioallergosorbent test (RAST) if active disease is present
Arc 5 antibody test is also there

19. RADIOLOGY

20. CT and MRI gives detailed images of the cysts
Endoscopic retrograde cholangiopancreatography (ERCP) may show
communication between the cysts and bile ducts and can be used to
drain the biliary tree before surgery. It is done by some routinely to
find out any silent communication between biliary ducts and cysts.

21. TREATMENT
DOC is albendazole which is given for atleast 1 month
PAIR technique stands for puncture of the cyst wall, aspiration of cyst
content, injection, and re-aspiration of a scolecoidal agent
modified PAIR technique was created to introduce concomitant
evacuation of cyst contents while infusing scolicidal agent via a
specially designed coaxial catheter system

22. Indications of PAIR is type 1 and type 2 cysts,and type 3,type 4 cysts
with drainable material,inoperable,pregnantor infected hydatid cysts.
C/I is in chillren less than 3 years of age, and ruptured cysts into
biliary tree or peritoneum
Type 5 cysts are meant for simple followup
Surgery remains the treatment of choice for uncomplicated hydatid
disease of the liver

23. SCOLICIDAL AGENTS
Formalin, hypertonic saline(20%), chlorhexidine,
cetrimide, hydrogen peroxide, polyvinylpyrrolidone-iodine,
silver nitrate, and ethyl alcohol

24. Open-Cyst Evacuation
Laparoscopic Cyst Evacuation
Pericystectomy
Liver Resection/Transplantation