A 37-year-old man presented with abdominal pain and a mass in the right upper quadrant. Imaging showed a hepatic cyst suggestive of a hydatid cyst. Hydatid cysts are caused by the larval stage of the Echinococcus granulosus tapeworm. Most cysts are asymptomatic but can cause symptoms depending on location and size. Treatment involves albendazole combined with surgery or percutaneous aspiration.

1. Sesión Clínica CS Verge del Toro. Maó
15-6-2012
Varón con dolor abdominal y
bultoma en hipocondrio
derecho
Dr. Mateu Seguí Diaz
UBS Es Castell. Menorca

2. Varón de 37 años
 Varón de 37 años, sin hábitos tóxicos. Natural de
Marruecos
 Trabaja en la construcción
 Sobrepeso sin otros FRCV
 Acude por diversos problemas gástricos

3. Varón de 37 años
 05-2011 Acude a Urgencias por dolor abdominal de 3
días de evolución que no responde al tratamiento
(IBP).
 Facies de afectación por dolor. Ictericia de piel y
mucosas.
 Abdomen tenso y defensivo, especialmente en
epigastrio, con severo dolor a este nivel y defensa
involuntaria. Blumberg (+) débil.

4. Analítica
• Analítica :
 - leucocitosis (20.800), sin desv a la izqda.
 - eosinofilia (31%)
 - Bb total = 9, con directa = 5,7
 - amilasa = 3.513
 - discreta alteración de la coagulación

5. RX simple de abdomen
En Rx simple abdomen : asa centinela y
calcificación redondeada, central, a nivel de
epigastrio (¿vesícula calcificada?, ¿quiste
hidatídico?). No neumoperitoneo

6. Ecografía de abdomen

7. Ecografía de abdomen

8. Ecografía de abdomen

9. Ecografía de abdomen

10. Ecografía de abdomen

11. Ecografía de abdomen

12. Ecografía de abdomen

13. Ecografía de abdomen

14. Ecografía de abdomen

15. Ecografía de abdomen

16. TAC de abdomen
TAC
 Masa hepática
sugestiva de quiste
hidatídico.
 Discreta cantidad de
líquido libre
intraabdominal.
 Esplenomegalia

17. Varón de 37 años-Control
 Quiste hidatídico , con clínica de dolor en epigastrio y en
HD, con amilasemia probablemente secundaria a suelta de
hidátides
 Se practicó CPRE y papilotomía. Pancreatitis leve post-
CPRE.

18. Varón de 37 años-Control
• Albendazol
• Control de sangre Ac el día (cumplidos los 28 dias)
• Se comparan los títulos de AC antes y después del
tratamiento, para programar una eventual cirugía

19. TAC de abdomen
TAC 10-05-2012
 El estudio comparativo con
exploraciones previas, la
última del 14-04-2011, pone
de manifiesto persistencia sin
cambios significativos de la
masa en segmento IV
hepático, heterogénea, con
calcificaciones groseras
murales y lesiones quísticas
intralesionales de predominio
periférico.

20. El Quiste
Hidatídico

21. Quiste hidatídico- E. granulosus
Echinococcal disease is caused by infection with the
metacestode stage of the tapeworm
Echinococcus, which belongs to the family Taeniidae.
Four species of Echinococcus produce infection in humans; E.
granulosus and E. multilocularis are the most common,
causing cystic echinococcosis (CE) and alveolar
echinococcosis (AE).
2012 UpToDate, |Release: 20.5 - C20.7.

22. Quiste hidatídico-Ciclo
 Un huésped definitivo, el que posee, la tenia o gusano en estado adulto, y
un intermediario donde se desarrolla la tenia en estado de larva (quiste
hidático).
 Los huéspedes definitivos son mamíferos carnívoros, mientras que pueden
actuar como huéspedes intermediarios varias especies de herbívoros y
omnívoros, entre ellos el hombre.
2012 UpToDate, |Release: 20.5 - C20.7.

23. Quiste hidatídico-Clínica
 The initial phase of primary infection is
always asymptomatic.
 Latent periods of more than 50 years
before symptoms arise have been
reported.
 While approximately 50 percent of
detected cases occur in asymptomatic
patients, many more cases remain
undiagnosed or are found incidentally at
autopsy.
2012 UpToDate, |Release: 20.5 - C20.7.

24. Quiste hidatídico- Crecimiento
 Cysts typically increase in diameter at a rate of one to five
centimeters per year.
 The liver is affected in approximately two-thirds of patients,
the lungs in approximately 25 percent, and other organs
including the brain, muscle, kidney, bone, heart, and
pancreas in a small proportion of patients.
2012 UpToDate, |Release: 20.5 - C20.7.

25. Q hidatídico- Afectación del hígado
 E. granulosus infection of the liver
frequently produces no symptoms.
 The right lobe is affected in 60 to 85
percent of cases.
 Significant symptoms are unusual
before the cyst has reached at least
10 cm in diameter.
 E. granulosus cysts can rupture into
the biliary tree and produce biliary
colic, obstructive jaundice,
cholangitis, or pancreatitis.
2012 UpToDate, |Release: 20.5 - C20.7.

26. Q. hidatídico- Afectación Pulmón
 Pulmonary involvement with E. granulosus can lead to a variety of
symptoms, including chronic cough (sometimes with accompanying
hemoptysis or evacuation of cyst material), chest pain, pleuritis or
dyspnea.
 Rupture of a cyst into a bronchus may lead to hemoptysis, respiratory
distress, and asthma-like symptoms.
Kern P, Bardonnet K, Renner E, et al. European echinococcosis registry: human alveolar echinococcosis, Europe, 1982-2000.

27. Q. hidatídico-Ruptura del quiste
 Cyst rupture — Fever and acute hypersensitivity reactions
including anaphylaxis, may be the principal manifestations
of cyst rupture. Hypersensitivity reactions are related to the
release of antigenic material and secondary immunologic
reactions
McManus DP, Zhang W, Li J, Bartley PB. Echinococcosis. Lancet 2003; 362:1295

28. Q. hidatídico- Evolución asintomática
 33 patients with asymptomatic liver
hydatid cysts
 . Fifteen percent of patients had
undergone surgery 10 to 12 years after the
initial diagnosis, while the remaining 85
percent had not.
 Seventy-five percent of the patients who
did not have an operation remained
asymptomatic
 57 percent did not show a change in the
size of the cyst by imaging.
Frider B, Larrieu E, Odriozola M. Long-term outcome of asymptomatic liver hydatidosis. J Hepatol 1999; 30:228.

29. Q, hidatídico-Calcificación
 Calcification, which usually
requires five to 10 years to
develop, occurs most
commonly with hepatic cysts
but rarely with pulmonary or
bone cysts.
 Total calcification of the cyst
wall suggests that the cyst
may be nonviable.
2012 UpToDate, |Release: 20.5 - C20.7.

30. Quiste hidatídico-Supervivencia
 If left untreated, more than 90 percent of patients will die
within 10 years of the onset of clinical symptoms.
 Since treatment with albendazole has been introduced, the
prognosis has improved considerably.
 Of 117 patients from France who underwent long term
 follow-up, the actuarial survival rate was 88 percent
2012 UpToDate, |Release: 20.5 - C20.7.

31. Q. hidatídico-Laboratorio
 Nonspecific leukopenia or thrombocytopenia, mild
eosinophilia, and nonspecific liver function abnormalities may
be detected, but are not diagnostic.
 Fewer than 15 percent of cases have eosinophilia, which
generally occurs only if there is leakage of antigenic material
McManus DP, Zhang W, Li J, Bartley PB. Echinococcosis. Lancet 2003; 362:1295

32. Q. hidatídico- Ecografía
 Ultrasound is employed most widely because it is easy to
perform and less expensive.
 Ultrasound has a sensitivity of approximately 90 to 95 percent
WHO Informal Working Group. International classification of ultrasound images in cystic echinococcosis for application in clinical

33. Q. hidatídico-TAC, RMN
 However, both CT and MRI may provide more detail and
greater specificity
 CT has a higher overall sensitivity than ultrasound, with
sensitivity rates of 95 to 100 percent
2012 UpToDate, |Release: 20.5 - C20.7.

34. Q. hidatídico-Serología
• Immunodiagnosis is useful for
primary diagnosis and for
follow-up after treatment .
• Detection of circulating E.
granulosus antigens in serum is
less sensitive than antibody
detection, which remains the
method of choice.
• Serologic testing produces
both many false positive and
false negative results.
2012 UpToDate, |Release: 20.5 - C20.7.

35. Quiste hidatídico-Serología
• Indirect hemagglutination (IHA)
• Indirect immunofluorescence
• Latex agglutination
• Double diffusion immunoelectrophoresis
• Counter-current immunoelectrophoresis (CIEP)
• Radioimmunoassay (RIA)
• Enzyme-linked immunosorbent assay (ELISA)
• Enzyme-linked immunoelectrotransfer blots (EITB)
• Enzyme-linked immunoelectrodiffusion assay
(ELIEDA)
• Time-resolved fluoroimmunoassay (TR-FLA)
• Immunoblot
2012 UpToDate, |Release: 20.5 - C20.7.

36. Q. hidatídico-Aspiración y biopsia
 Percutaneous aspiration or
biopsy may be required to
confirm the diagnosis
 This method of diagnosis is
reserved for situations when
other diagnostic methods are
inconclusive
 Potential anaphylaxis and
secondary spread of the
infection
2012 UpToDate, |Release: 20.5 - C20.7.

37. Q. hidatídico-Tratamiento médico (1)
 In the past, open surgery was the
only option
 Some asymptomatic cysts,
particularly if heavily, may be able
to be monitored without specific
therapy
 Active hydatid liver disease,
treatment with albendazole, in
combination with either surgery or
the PAIR procedure
(Percutaneous Aspiration,
Introduction of a protoscolicidal
agent, and Reaspiration)
2012 UpToDate, |Release: 20.5 - C20.7.

38. Q. hidatídico-Tratamiento médico (2)
 Albendazole generally is given
at a dosage of 10 to 15 mg/kg
per day in two divided doses.
 Absorption is improved by
taking albendazole with a fatty
meal.
 It comes in 400 mg tablets, and
the usual dose is 800 mg daily.
 Therapy most often is indicated
for a minimum of three to six
months
2012 UpToDate, |Release: 20.5 - C20.7.

39. Q. hidatídico-Tratamiento Quirúrgico
 Single liver cysts situated superficially that may rupture spontaneously
 Open surgery should be considered if percutaneous treatment is not
available
 As an alternative to percutaneous therapy for cysts communicating with
the biliary tree
 Management of cysts exerting pressure on adjacent vital organs.
2012 UpToDate, |Release: 20.5 - C20.7
WHO informal working group panel.

40. Quiste hidatídico-Prevención
 Avoiding close contact with dogs.
 Careful washing of vegetables and contaminated fresh produce can also
reduce infection.
 Prohibition of home-slaughter of sheep will prevent dogs from consuming
infected viscera, thus disrupting the life cycle of the parasite.
 Vaccination is also a prospect for prevention of echinococcosis
2012 UpToDate, |Release: 20.5 - C20.7.

41. Quiste hidatídico-Ideas clave (1)
 La infección por E granulosis es generalmente asintomática
durante muchos años
 Las complicaciones dependen del sitio donde se asiente el
gusano y del tamaño del quiste
 2/3 de los quiste se asientan en el hígado y un 1/3 en los
pulmones
 Los síntomas con hepatomegalia, ictericia y pérdida de peso
 Con síntomas y sin tratamiento la mortalidad es del 100%
 El diagnóstico es generalmente por ecografía
 Confirmado por serología ELISA
 La aspiración-biopsia solo se utiliza cuando los otros test no
son concluyentes
2012 UpToDate, |Release: 20.5 - C20.7.

42. Quiste hidatídico-Ideas clave (2)
 En individuos asintomáticos monitorizar la evolución
 Calcificación es sinónimo de no viable
 Albendazol + PAIR (Percutaneous Aspiration, Introduction of a
protoscolicidal agent, and Reaspiration)
 Tratamiento quirúrgico en grandes quistes con múltiples
vesiculas, superficiales y si pueden romperse con facilidad
 Y sin el tratamiento percutáneo no es posible o ejerce presión
sobre organos vitales.
 Evitar el contacto con perros, y no alimentar a estos con
visceras contaminadas
 Lavar las verduras
2012 UpToDate, |Release: 20.5 - C20.7.