The document presents a comprehensive overview of hydatid cystic disease, focusing on a case of a 32-year-old woman diagnosed with a hydatid cyst in the liver caused by Echinococcus granulosus. It outlines the disease's etiology, clinical presentation, diagnostic workup, treatment options including medical, paired techniques, and surgical interventions, as well as prevention strategies. Key epidemiological details are provided, highlighting global prevalence and the importance of proper hygiene and veterinary measures to control the disease.

1. Presesented by:
Sosman shivan mohammad & Abdulaziz muslim shahbaz
Supervised by: dr. Mustafa shukri
Hydatid cystic
disease

2. Objectives
 Case presentation
 Overview
 Clinical presentation
 Workup
 Treatment and management
 Prevention
 References

3. Case presentation
A 32-years-old woman without any history of digestive or hepatic disease.
 The patient had been well until few hours before of her admission.
 She was admitted to hospital complaining of right upper quadrant and
epigastrium abdominal pain, and nausea.
 On routine physical examination an abdominal mass was discovered on
the right upper quadrant, and there was tenderness in the upper abdomen
 Hematologic and blood chemical tests were performed:
 Her haematocrit was 36.4%, with a MCV of 86.9 μm3 and a platelet count
of 162/mm3.
 White-cell count of 7.0/mm3, neutrophils 79.8%, lymphocytes 7.1%,
monocytes 6.4%,
 Liver tests were normal.
1

4. Case presentation
 MRI of the abdomen with contrast medium revealed a low-density cystic mass
measuring 11x11x10 cm in the right lobe, with a thick, irregular wall (Figure 1
)
 A cystectomy was performed by laproscopy, with the use of specific
precautions to prevent local spread of disease.
 Aspiration of the contents of the cyst yielded clear, colorless fluid.
 Hydatid sand containing a protoscolex of Echinococcus granulosus was seen o
n microscopical examination (unstained wet preparation, x40; Figure 2).
 Serological test to Echinococcus granulosus antibodies IgG were positive.
 Specific anti-parasitic treatment was given and after two months the patient is
asymptomatic.
2
Figure 1 Figure 2

5. Overview
Background, pathophysiology, etiology and
epidemiology
3

6. Background
 Hydatid disease is a parasitic infestation by a tapeworm
of the genus Echinococcus.
 Zoonosis
 Humans are accidental intermediate hosts, whereas animals
can be both intermediate hosts and definitive hosts.
 In humans, 50–75% of the cysts occur in the liver,
 25% are located in the lungs, and
 5–10% distribute along the arterial system
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7. pathophysiology
There are four known species of Echinococcus
 Three of them are medical importance in humans:
1. E granulosus Cystic echinococcosis (CE)
2. E multilocularis Alveolar echinococcosis (AE)
3. E vogeli Polycystic Echinococcosis
 E granulosus is the most common of the three
 E multilocularis is rare but is the most virulent, and
 E vogeli is the most rare.
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8. Etiology
 The life cycle has three developmental stages:
1. The adult tapeworm in the definitive host
2. eggs in the environment
3. metacestode in the intermediate host
 Metacestodes are ingested by the definitive host.
 The metacestodes mature into the tapeworm in the definitive host and, in turn,
release eggs into the environment.
 The intermediate host ingests the eggs, which hatch into metacestodes, which
infest the liver, lungs, muscles, and other organs of the intermediate host.
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9.  Life cycle of
Echinococcus granulosus:
 Structure of
hydatid cyst:
A) pericyst membrane (infla
mmatory host reaction)
B) Laminated layer (parasite origin)
C) Germinal layer
D) and E). Daughter cyst.
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10. Epidemiology
 No sexual predilection is recognized for hydatid cysts.
 The parasite has the capability of infecting persons of all races equally
 The cysts grow slowly, and a cyst is rarely diagnosed during childhood or adol
escence unless the brain is affected.
 CE is a disease of younger adults, with an average age at diagnosis of 30-40
years
 Alveolar echinococcosis (AE) is a disease of older adults
 Echinococcosis is also unusual in northern Europe.
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11. Epidemiology
 The highly endemic areas are marked in red and include countries in the Mediterranean basin,
the Middle East, central Asia, sub-Saharan Africa, and South America.
 Note that this zoonosis is present worldwide, with only a few countries free of endemic case
s.
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12. Clinical presentation
History and physical examination
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13. History
The parasite load, the site, and the size of the cysts determi
ne the degree of symptoms.
 Many hydatid cysts remain asymptomatic
 history of living in or visiting an endemic area
symptoms can be produced by a mass effect or cyst complications
 Liver: symptoms of obstructive jaundice and abdominal pain.
 With biliary rupture, the classic triad of biliary colic, jaundice, and urticaria is
observed.
 Lungs: chronic cough, dyspnea, pleuritic chest pain, and hemoptysis.
 Brain: Headache, dizziness, and a decreased level of consciousness may sig
nify cerebral involvement.
 Specific neurologic deficits may occur depending on the location of the cyst in
the brain
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14. History
 Secondary complications: due to infection or leakage of the
cyst
 Minor leaks lead to increased pain and a mild allergic reaction characterized b
y flushing and urticaria.
 Major rupture leads to a full-blown anaphylactic reaction
 A rupture into the biliary tree can lead to obstruction by the daughter cysts,
producing cholangitis.
 Rupture into the bronchi can lead to expectoration of cyst fluid.
 Infection: primary or secondary mild fever to full-blown sepsi
s.
 Extremity pain with or without neurologic deficit is a sign of either bone or mus
cle involvement.
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15. Physical examination
Examination findings are nonspecific
 Skin: Jaundice due to biliary obstruction, Spider angiomas due to liver cirrhosi
s, Urticaria and erythema may be seen.
 Vital signs: fever due to primary or secondary infection or an allergic reaction
Hypotension is observed with anaphylaxis secondary to a cyst leak.
 Lungs: decreased breath sounds ,signs of airway obstruction ,consolidation o
f the affected segment, lobule, lobe, or the whole lung.
 Abdomen: abdominal tenderness most common, Hepatomegaly or a mass m
aybe felt.
 Tender hepatomegaly is a sign of secondary infection of the cyst,
 Ascites is rare,
 Splenomegaly either due to splenic echinococcosis or PHT.
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16. Physical examination
 Extremities:
 Bone involvement tenderness and, rarely, a palpable mass
.
 Muscle involvement usually a palpable mass.
 Peripheral nerve compression can occur, although extremely rarely.
It results in nerve-specific sensory and/or motor deficit.
 Brain: nonspecific findings on neurological examination
they range from very mild to full coma and cerebral herniation.
 Eyes: rare, abnormal findings include:
decreased visual acuity, blindness, and exophthalmos.
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17. workup
Lab, Imaging and procedures
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18. Laboratory studies
 Routine blood studies are non specific.
 Eosinophilia in 25% of all infected cases
 Hypogammaglobinemia in 30% of all infected cases
 Bilirubin and Alkaline phosphatase elevation in liver involvement .
 Indirect hemagglutination test and ELISA : for detection of Anti-Echinococcus I
gG antibodies, are initial screening test of choice
 Immunodiffusion and immunoelectophoresis demonstrate antibodies to antige
n 5 and provide specific confirmation of reactivity .
 ELISA is useful in follow up to detect recurrence .
 Casoni test : intradermal skin test , is now largely abandoned because of its lo
w sensitivity and potential for severe allergic reaction .
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19. Imaging studies
1-Plain x-ray film
 Nonspecific and non revealing
 Thin rim of calcification delineating a cyst is suggestive of hydatid cyst .
 Elevated diaphragm and concentric calcifications in the cyst wall on CHEST X RAYS
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20. Imaging studies
a 45-year-old woman who was coughing and had
abundant watery sputum 2 weeks previously.
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21. Imaging studies
2-Ultrasonography
 Specificity- approx 90%
 Internal structure,number,and location of the cysts
 Diagnostic when demonstrate daughter cyst and hydatid sand
 Accuracy remain operator-dependent
 Usual findings :
1. Solitary cyst
2. Water lily sign
3. Daughter cysts
Gharbi US classification
of cystic echinococcosis
Water lily sign
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22. Imaging studies
3-CT scan
 Has accuracy of 98%
 It is the best test for differentiation
of hydatid cyst from amebic and pyogenic cyst in liver
 specific information about the location
 depth of the cyst within the liver
 structural details of the hydatid cyst
 It shows cyst adequately but not superior to CT scan .
4-MRI
Calcified hydatid cyst
MRI of Hepatic hydatid cyst
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23. procedures
 ERCP
 Is both diagnostic and therapeutic in cases of intrabiliary rapt
ure of hydatid cyst in whom sphincterotomy can be preforme
d
• ERCP showing biliary
communication with
cyst and hydatid material in
common bile duct.
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24. Treatment
Medical, PAIR, Surgical and
prevention
22

25. Treatment
1-Medical treatment
 Two benzimidazoles
1-Albendazole: ( 10-15 mg/kg/d , 14 days intervals , for 3-6 months )
2-mebendazole: ( 40-50mg/kg/d , 3-6 months )
 Praziquentel: ( 400mg/kg/week )
• Is isoquinoloine derivative It has poor effect on germinal layer so it is of
choice for prophylaxis in pre and post operative period in order to prevent
secondary implantation of spilled protoscoleces.
 Indications:
1-primary liver or lung cysts that are inoperable
2-cysts in 2 or more organs
3-peritoneal cysts
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26. Treatment
 Contraindications for medical Rx:
1-Early pregnancy
2-chronic hepatic disease
3-large cyst with risk of rapture
4-inactive or calcified cyst ( relative contraindication in cases of bone cyst
because it has very low response )
5-bone marrow suppression
 Monitoring :
 CBC and liver enzymes adverse effects of drugs , every 2 weeks
for 3 months then every 4 weeks .
 Imaging studies follow-up on the morphologic status of the cy
st.
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27. Treatment
2-PAIR(puncture,aspiration,injection,reaspiration):
 Either under US or CT scan guidance
 Perioperative treatment with a benzimidazole is mandatory
(4 d prior to the procedure and for 1-3 mo after).
 Steps
1-puncture with parasitological examination if available
2-aspiration of cystic fluid ( take 10-15 cc and examine for bilirubin,
if present stop procedure and if not present aspirate whole fluid)
3-injection of 95% ethanol solution or hypertonic saline ( 1/3 of aspirated fluid )
4-reaspiration of protoscolicide solution after 15 minutes)
 This is repeated until the return is clear.
 The cyst is then filled with isotonic sodium chloride solution.
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28. Treatment
PAIR
 FREQUENTLY USED P
ROTOSCOLICIDAL AG
ENTS:
 15–20% Saline
 95% Ethanol
 A combination Of 30%
saline and 95% Ethanol
 Mebendazole Solution
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29. Treatment
 The PAIR technique can be performed on liver, bone, and kidney
 The cysts should be larger than 5 cm in diameter
 Type I or II according to the Gharbi ultrasound classification of liver cysts
 Performed on type III cysts as long as it is not a honeycomb cyst.
 Indications:
 1-inoperable patient
 2-patient refusing surgery
 3-relapse after surgery or chemotherapy
PAIR
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30. Treatment
PAIR
 Contraindications :
1-lung and brain cyst
2-inaccessible cyst
3-superficially located cyst
4-cyst communicating with biliary tre
5-types 3,4,5 cysts
6-early pregnancy
 Complications:
1-spillage and anaphylaxis
2- Sclerosing cholangitis
3-biliary fistulas
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31. treatment
3-surgery:
 Indications:
1-Large cyst with multiple daughter cyst
2-superficially located single liver cyst
3-liver cyst with biliary communication
4-cyst in lung , brain , kidney , bone , eyes or any other organs .
5-infected cyst
 Contraindications:
1-general contraindications to surgery ( extreme age , severe preexisting medica
condition )
2-multiple cyst in multiple organs
3-dead , very small cyst
4-Cyst difficult to access
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32. Treatment
 Preparation for surgery:
 Give 4-6 week of albendazole tablet before surgery (800mg/day in
divided doses) in adult
 Pre operative visualization of biliary tract by ERCP.
 Anaesthesist warned of sudden anaphylactic shock in case of spillage.
 Laparoscopic pericystectomy + aumentopexy
 Open surgery paricystectomy + aumentopexy
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33. prevention
 Because human infection with Echinococcus results from fecal-
oral contamination, prevention requires the following step
s:
•Education on proper hygiene
•Regular treatment of infected dogs to reduce worm load
•Prevention of dogs from eating viscera organs of intermediate
hosts (shep….etc)
•Avoidance of unnecessary contact with infected dogs
•Regulation of livestock butchering
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35. References
 https://emedicine.medscape.com/article/178648-overview
 https://www.researchgate.net/figure/Scheme-of-a-hydatid-cyst-A-pericyst-m
embrane-inflammatory-host-reaction-B-laminated_fig2_41849410
 https://www.hindawi.com/journals/vmi/2020/8859116/
 https://pubs.rsna.org/doi/full/10.1148/rg.2017160172
 Dr . Sabah Ahmed Doski