hydatid cyst liver

1. HYDATID CYST

2. HISTORYHISTORY
• Hydatid disease -Hydatid disease - one of the oldest diseasesone of the oldest diseases known to mankind, is aknown to mankind, is a
parasitic infestation caused by tapeworm of genus Echinococcusparasitic infestation caused by tapeworm of genus Echinococcus
• It was first described in the Talmud as a "It was first described in the Talmud as a "Bladder full of waterBladder full of water" ." .
• HippocratesHippocrates described the human hydatid disease more than twodescribed the human hydatid disease more than two
thousand years ago with a very interesting expression (thousand years ago with a very interesting expression (liver filledliver filled
with waterwith water) .) .

3. HydatidHydatid :: Greek for ‘drop of water’Greek for ‘drop of water’
EchinococcusEchinococcus ::
• ‘‘hedgehog berry’hedgehog berry’
• coined by Rudolphi in the first decade of the 19coined by Rudolphi in the first decade of the 19thth
centurycentury

4. Genus EchinococcusGenus Echinococcus - 4 species:- 4 species:
•E. granulosusE. granulosus - commonest -cystic echinococcosis (hydatid- commonest -cystic echinococcosis (hydatid
disease)disease)
•E. multilocularisE. multilocularis - alveolar echinococcosis - the most virulent.- alveolar echinococcosis - the most virulent.
•E. vogeli & E. oligarthusE. vogeli & E. oligarthus – polycystic echinococcosis– polycystic echinococcosis

5. EPIDEMIOLOGYEPIDEMIOLOGY
• E.granulosusE.granulosus is present virtually worldwide, more common in sheepis present virtually worldwide, more common in sheep
and cattle raising countriesand cattle raising countries
IndiaIndia- AP, Gujarat,Tamil Nadu,West Bengal,- AP, Gujarat,Tamil Nadu,West Bengal, Orissa, Bihar,Orissa, Bihar,
Punjab, Haryana, HP, UP,Punjab, Haryana, HP, UP, Kashmir, Delhi and Pondicherry.Kashmir, Delhi and Pondicherry.
• E.multilocularisE.multilocularis -Northern hemisphere, including central Europe and-Northern hemisphere, including central Europe and
the northern parts of Europe, Asia, and North America.the northern parts of Europe, Asia, and North America.
• E.vogeliE.vogeli andand E. oligarthusE. oligarthus -Central and South America.-Central and South America.

6. ECHINOCOCCUS GRANULOSUSECHINOCOCCUS GRANULOSUS
• Common Name:TapewormCommon Name:Tapeworm
• Also Called Hydatid WormAlso Called Hydatid Worm
• About 5mm longAbout 5mm long

7. • Definitive host:Definitive host: dog & other caninedog & other canine
• Intermediate host:Intermediate host: sheep, cattle, camel & humansheep, cattle, camel & human
• Infective stage:Infective stage: egg (gravid proglottid)egg (gravid proglottid)
• Sites of hydatid:Sites of hydatid: liver, lungs, abdominal cavity, spleen, kidneys, heart,liver, lungs, abdominal cavity, spleen, kidneys, heart,
bones, central nervous system etcbones, central nervous system etc
• Man is a dead end hostMan is a dead end host

9. TRANSMISSIONTRANSMISSION
• Ingestion from contaminated grass, usually for herbivoresIngestion from contaminated grass, usually for herbivores
• Contamination caused by poor hygiene, followed by transferContamination caused by poor hygiene, followed by transfer
to the mouthto the mouth
• Accidental ingestion of contaminated soil, berries orAccidental ingestion of contaminated soil, berries or
vegetablesvegetables

10. MORPHOLOGYMORPHOLOGY
Adult wormAdult worm:: 3-6 mm3-6 mm
• ScolexScolex- pyriform 300 µm, 4 suckers and a- pyriform 300 µm, 4 suckers and a
protrusible rostellum with two circular rows ofprotrusible rostellum with two circular rows of
hookletshooklets
• NeckNeck- short, thick- short, thick
• StrobilaStrobila- 3-4 proglottids usually (immature,- 3-4 proglottids usually (immature,
mature and gravid)mature and gravid)

12. Scolex With Hooks Protoscolices

13. PATHOGENICITYPATHOGENICITY
• Hydatid cystHydatid cyst represents larval formrepresents larval form
• Generally acquired duringGenerally acquired during childhoodchildhood..
• GradualGradual displacement of vital host tissuedisplacement of vital host tissue, vessels or parts of organs →, vessels or parts of organs →
damage and dysfunctiondamage and dysfunction
• The cyst wall is formed by:The cyst wall is formed by:
Pericyst-Pericyst-
• fibrous tissue laid down byfibrous tissue laid down by host fibroblastshost fibroblasts and new blood vessels.and new blood vessels.
• merges with surrounding normal tissue.merges with surrounding normal tissue.
• Nutrition derived through this layer.Nutrition derived through this layer.
• In old cysts, it may become sclerosed or calcified and parasite may dieIn old cysts, it may become sclerosed or calcified and parasite may die
within it.within it.
• Absent in lung, bone, muscle, sometimes brainAbsent in lung, bone, muscle, sometimes brain

14. Ectocyst:Ectocyst:
• SecretedSecreted by embryoby embryo
• Tough, acellular, laminated ,elastic hyaline membrane, 1 mmTough, acellular, laminated ,elastic hyaline membrane, 1 mm
• Resembles white of a hard boiled eggResembles white of a hard boiled egg
• Protects the cyst from host enzymes, bile & bacteriaProtects the cyst from host enzymes, bile & bacteria
• Non- infectiveNon- infective
Endocyst:Endocyst:
• Germinal layer, living component of the parasiteGerminal layer, living component of the parasite
• Consists of number of nuclei embedded in a protoplasmicConsists of number of nuclei embedded in a protoplasmic
mass.mass.
• Gives rise to ectocyst, brood capsules and scolicesGives rise to ectocyst, brood capsules and scolices
• SecretesSecretes hydatid fluid.hydatid fluid.

16. Daughter cyst
Granddaugher cyst
Protoscolex
Brood capsule
Cuticle layer
Germinal layer
Brood capsule

17. Daughter cysts

21. ORGANS AFFECTEDORGANS AFFECTED
The parasite can colonise virtuallyThe parasite can colonise virtually every organevery organ in the bodyin the body
• Liver- 52-77% (¾ right liver)Liver- 52-77% (¾ right liver)
• Lung- 8.5-44%Lung- 8.5-44%
• Abdominal cavity- 8%Abdominal cavity- 8%
• Kidney- 7%Kidney- 7%
• Central nervous system- 0.2-2.4%Central nervous system- 0.2-2.4%
• Bone- 1-2.5%Bone- 1-2.5%
• Less common- spleen,Less common- spleen,
bladder, thyroid, prostate , heart, eye, adrenal gland, cervix,bladder, thyroid, prostate , heart, eye, adrenal gland, cervix,
fallopian tube, ovaries, breast, pancreas, subcutaneous tissuesfallopian tube, ovaries, breast, pancreas, subcutaneous tissues..

23. WORK UPWORK UP
• Generally, routine laboratory tests do not show specific results.Generally, routine laboratory tests do not show specific results.
• In patients with rupture of the cyst in the biliary tree,In patients with rupture of the cyst in the biliary tree,
marked andmarked and transient elevation of cholestatic enzymetransient elevation of cholestatic enzyme
levelslevels occurs, often in association withoccurs, often in association with
hyperamylasemiahyperamylasemia andand eosinophiliaeosinophilia (as many as 60%).(as many as 60%).
• Indirect hemagglutination test and enzyme-linkedIndirect hemagglutination test and enzyme-linked
immunosorbent assay are the most widely usedimmunosorbent assay are the most widely used
methods for detection of anti-Echinococcus antibodiesmethods for detection of anti-Echinococcus antibodies
(immunoglobulin G [IgG]).These tests give false(immunoglobulin G [IgG]).These tests give false
positive results in cases of schistosomiasis andpositive results in cases of schistosomiasis and
nematode infestations that is why they are not specificnematode infestations that is why they are not specific
for diagnosing hydatidosis.for diagnosing hydatidosis.

24. MAN'S ARM SHOWING POSITIVE SKIN TEST FORMAN'S ARM SHOWING POSITIVE SKIN TEST FOR
HYDATID DISEASEHYDATID DISEASE

25. IMAGING STUDIES:IMAGING STUDIES:
• Plain radiographyPlain radiography
• Ultrasound examinationUltrasound examination
• CT scaningCT scaning
• MRIMRI

26. B-ultrasound, liver
CT, brain
CT, liver X-ray, lung

28. MANAGEMENT OPTIONSMANAGEMENT OPTIONS
• Medical .Medical .
• Surgery.Surgery.
• PAIR.PAIR.

30. • Contraindications:Contraindications: Early pregnancyEarly pregnancy,, bone marrow suppressionbone marrow suppression,,
chronic hepatic diseasechronic hepatic disease,, large cysts with the risk of rupturelarge cysts with the risk of rupture,,
andand inactive or calcified cysts are contraindicationsinactive or calcified cysts are contraindications. A relative. A relative
contraindication is bone cysts because of the significantlycontraindication is bone cysts because of the significantly
decreased response.decreased response.
• Outcome : Response rates in 1000 treated patients were thatOutcome : Response rates in 1000 treated patients were that
30%30% had cyst disappearance (had cyst disappearance (curecure),), 30-50%30-50% had a decrease inhad a decrease in
the size of the cyst (the size of the cyst (improvementimprovement), and), and 20-40% had no20-40% had no
changeschanges. Also, younger adults responded better than older. Also, younger adults responded better than older
adults.adults.

33. SURGICAL MANAGEMENTSURGICAL MANAGEMENT
• Indications:Indications:
1-Large liver cysts with multiple daughter cysts; superficially1-Large liver cysts with multiple daughter cysts; superficially
located single liver cysts that may rupture (traumatically orlocated single liver cysts that may rupture (traumatically or
spontaneously).spontaneously).
2-liver cysts with biliary tree communication or pressure effects2-liver cysts with biliary tree communication or pressure effects
on vital organs or structures.on vital organs or structures.
3-infected cysts .3-infected cysts .
4-cysts in lungs, brain, kidneys, eyes, bones .4-cysts in lungs, brain, kidneys, eyes, bones .

34. CHOICE OF SURGICALCHOICE OF SURGICAL
TECHNIQUETECHNIQUE::
• 1-Radical surgery (total pericystectomy or1-Radical surgery (total pericystectomy or
partial resection, if possible),partial resection, if possible),
• 2-Conservative surgery (open cystectomy), or2-Conservative surgery (open cystectomy), or
simple tube drainage for infected andsimple tube drainage for infected and
communicating cysts are choices for surgicalcommunicating cysts are choices for surgical
technique.The more radical the procedure, thetechnique.The more radical the procedure, the
lower the risk of relapses but the higher the risklower the risk of relapses but the higher the risk
of complications.of complications.

36. • Concomitant treatment with benzimidazoles (albendazole orConcomitant treatment with benzimidazoles (albendazole or
mebendazole) has been reported to reduce the risk ofmebendazole) has been reported to reduce the risk of
secondary echinococcosissecondary echinococcosis.Treatment is started 4 days.Treatment is started 4 days
preoperatively and lasts for 1 month.preoperatively and lasts for 1 month.

37. COMPLICATIONS:COMPLICATIONS:
1-All the usual complications related to the surgical procedure and anesthesia1-All the usual complications related to the surgical procedure and anesthesia
2-Related to the parasite Recurrence2-Related to the parasite Recurrence
•MetastasisMetastasis
•InfectionInfection
•Spillage and seeding (secondary echinococcosis) - Allergic reaction or anaphylactic shockSpillage and seeding (secondary echinococcosis) - Allergic reaction or anaphylactic shock
3-Related to the medical treatment Hepatotoxicity3-Related to the medical treatment Hepatotoxicity
•AnemiaAnemia
•ThrombocytopeniaThrombocytopenia
•AlopeciaAlopecia
•EmbryotoxicityEmbryotoxicity
•TeratogenicityTeratogenicity..

38. COMPLICATIONS , CONT.COMPLICATIONS , CONT.
4-Related to PAIR4-Related to PAIR
• HemorrhageHemorrhage
•Mechanical damage to other tissueMechanical damage to other tissue
•InfectionsInfections
•Allergic reaction or anaphylactic shockAllergic reaction or anaphylactic shock
•Persistence of daughter cystsPersistence of daughter cysts
•Sudden intracystic decompression leading to biliary fistulasSudden intracystic decompression leading to biliary fistulas
5-Related to scolicidal agents - Chemical sclerosing cholangitis5-Related to scolicidal agents - Chemical sclerosing cholangitis

39. PREVENTIONPREVENTION
• The best way to keep dogsThe best way to keep dogs
from being infected is tofrom being infected is to
prevent them from eatingprevent them from eating
infected feces, orinfected feces, or
contaminated meatcontaminated meat
• The best way to avoidThe best way to avoid
human infection is to avoidhuman infection is to avoid
ingesting food or otheringesting food or other
substances contaminatedsubstances contaminated
with dog feceswith dog feces

40. PREVENTION (CONT’D)PREVENTION (CONT’D)
• The best method is to disrupt the lifecycleThe best method is to disrupt the lifecycle
• Basic hygiene practicesBasic hygiene practices
• Avoid feeding raw offal (internal organs of butchered animals) toAvoid feeding raw offal (internal organs of butchered animals) to
dogsdogs
• By doing this hydatids have been virtually eliminated in New ZealandBy doing this hydatids have been virtually eliminated in New Zealand
(a once common place for this parasite)(a once common place for this parasite)

41. CONCLUSION:CONCLUSION:
• Many hydatid cysts remain asymptomatic, even into advancedMany hydatid cysts remain asymptomatic, even into advanced
age. Parasite load, the site, and the size of the cysts determine theage. Parasite load, the site, and the size of the cysts determine the
degree of symptoms.degree of symptoms.
• The liver is the most common organ involved, followed by theThe liver is the most common organ involved, followed by the
lungs.These 2 organs account for 90% of cases of echinococcosis.lungs.These 2 organs account for 90% of cases of echinococcosis.
• Surgery remains the main Treatment of the hydatied liver diseaseSurgery remains the main Treatment of the hydatied liver disease
, PAIR technique still promising., PAIR technique still promising.
• Patient education about the prevention of this zoonotic infection .Patient education about the prevention of this zoonotic infection .

42. QUESTIONSQUESTIONS