This case report describes a 49-year-old woman who presented with abdominal pain and weight loss. Imaging revealed a large cystic mass in her liver consistent with a hydatid cyst. She was treated with albendazole and referred for surgery. Hydatid disease is caused by the tapeworm Echinococcus and commonly involves the liver or lungs. Diagnosis involves history, imaging, and serology. Treatment options include medical therapy with albendazole or surgery to remove the cyst. Percutaneous aspiration, injection and re-aspiration (PAIR) is a minimally invasive alternative to surgery but has a higher risk of allergic reactions.

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

4. LAB INVESTIGATION
 FBC
 RP/ LFT
 Coagulation profile
 Viral screeening
 Alpha fetoprotein

5. 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

6. DIFFERENTIAL DIAGNOSIS
 HCC
 Hepatic abcess

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

8. CT LIVER

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

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

20. STRUCTURE OF HYDATID CYST
 Usually unilocular fluid filled cyst (fluid inside
 allergic/ toxic)
 3 layers
 Pericyst
 Ectocyst
 Endocyst

21. DIAGNOSES
 History and physical examination
 Laboratory
 Imaging

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

24. IMAGING
 Plain AXR
 USG
 CT
 MRI, ERCP, MRCP (complicated cases)

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.

28. MANAGEMENT
 Medical / Pharmacological
 Surgical

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.

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

38. DISCUSSION
 PAIR vs open surgery??

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

40.  Surgical interventation consist of both radical
& conservative

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