hydatid cysts.docx

7/28/2019 hydatid cysts.docx

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Surgery

Hydatid cyst diseaseCyst: is a pathological fluid filled sac bound by a wall .

In true cysts the sac bound by cells of epithelial origin.

They may be Congenital Or Acquired.

Hydatid Cyst (H.C) Disease : is a parasitic infection of

man caused by the adult & larval stages of the

Echinococcus cestodes mainly Echonococcus granulosis

species. Endemic in sheep rearing districts of many

countries like middle east ,Mediterranean ,Australia ,

newzeland.

Very ancient disease known to Hippocrates over 3000

years ago ,and AL-rhazes the Arab physician 900 years

AD. But the nature of the Echonococcus worm and themode of infection was only established by about the

middle of nineteenth century.

Life cycle & mode of infection of this parasite :-

Echonococcus adult worm develops & lives in the

intestine of the carnivorous animals such as dogs ,fox ,


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length of the worm is between 2.9 9 mm the eggs 30

38 micro m .the dogs are mediators of the hydatid to

man , in endemic areas 20- 100% of the dogs are

infected .

Adults worms have three segments

The immature,

mature ,

gravid segments

which produce thousands of ova voided in feces of the

dogs contaminating grass, vegetables , water ,man eat

contaminated food or have the infection by direct

contact with dogs .

Dog is the definitive host complete the cycle by eatinginfected offal's

The outer chitonic layers of the ova is dissolved by

gastric guise after ingestion of the ovum Releasing

embryo which penetrates the intestine and enter the

portal circulation to become lodged in the capillaries of

the liver,where cystic larval stage develop forming H.C

Embryo could pass into various sites in the body which

differs according to the series consulted , but E.G cysts

R found most commonly in the liver (52%) followed by

the lung (8.4%) Abdominal cavity (8%) kidneys(7%)


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CNS (0.2-2.4%)and Bone (1-2.5%)

Hydatid cyst consist of 3 layers

1-pseudo cyst (adventitia)which results from host

reaction to the parasite its outer gray fibrous layer

which intimately blended with the liver or host tissue

2-Ectocyst .(laminated membrane )is the middle

chitinous whitish elastic layer. And formed by parasite

itself it could peels from the outer pseudo cyst unless

there is infection.

3.Endocyst is the inner layers of germinal epithelium .

which is made of single layer .

Its the only living layer of the hydatid cyst.

It secret the ectocyst & internally it secrets the hydatid

fluid ,broad capsules, within brood capsules R thousands

of scoliosis which R the heads of future worms.

Clinical features

Many R asymptomatic & become discovered incidentally

at postmortem Or on investigations 4 other purposes

.clinical features of symptomatic cysts depend on the


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site of the cyst,pressure symptoms , presence of

complications.

In hepatic hydatid the most common presentation ispainful or painless hepatomegaly or abdominal mass

biliary colic ,sometimes associated with transient

jaundice & occasionally with cholangitis as signified by

rigors sweating &fever , in brain hydatids raised

intracranial pressure with focal neurological signs , in

bone pathological fractures of along bone , collapsedvertebra ,in pulmonary hydatids the most common

symptoms & fever , cough , expectoration , dyspnea ,

hemoptysis ,in renal hydatids lumber pain & very rarely

hydatidiuria occurs.

Complications includes:

Suppuration, due to secondary inf. Causing fever ,

increased pain & tenderness with all clinical

manifestations of the liver or pulmonary abscesses

when these organs R involved by hydatid cysts

Rupture of hydatid cyst according to site of rupture if it's

on peritoneal cavity which may present as emergency

with sign of acute abdominal pain & generalized

peritonitis . Anaphylactic phenomena ,notably

urtecaria R prone to occur . sometimes the rupture of

the cyst will lead to anaphylactic shock , urtecaria ,

bronchospasm , asthma , & even convulsion coma ,&

Death


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If the patient survive multiple daughter cysts could

occurs with ascitis & subsequent intestinal Obstruction .

If the rupture into alimentary tract causing a fistula

If it is into biliary channels :into an intra hepatic radicals

,gall bladder , C.B.D

With passage of daughter cysts causing intermittent

biliary colic , chills &fever , bouts of jaundice &

occasionally urinary .

If into the pleural cavity ,leading to pleural effusion with

fever & S.O.B .

Diagnosis

Imaging techniques including:

Ultrasonography , computed sonography ,plain

radiography , radionuclide scanning using agent like

technetium

Immunological diagnosis like :-

Immunoelctrophoresis this investigation depend on itspositivity ,upon formation of specific of respiration

(called arc5) produced by the interaction of the serum

from the patient with the antigen . this useful not only in

primary diagnosis but also in post surgical follow up . the

test revert to negative 2-3 years after successful


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operation & its a good indicator about the recurrences

of the disease .

This investigation is at present the one of choice inprimary diagnosis and follow up among the other tests

which includes :-

A- Indirect haemagglutination test (IHT)

B- Latex test(LT)

C- Complement fixation test (CFT)

D- ELISA

Treatment of H.C

Surgical treatment : surgery offers the only effective

treatment 4 living abdominal H.C , & is recommended 4both symptomatic & asymptomatic cases . Effective

surgical treatment includes :

1- Evacuation of the cyst content :hydatid fluid

,proscolises ,& hydatid sand R evacuated .

Even with the ultra most care spillage of the contentmight occur with the risk of disseminating the disease .

there R many chemicals that can destroy the cyst

content within 3-5 minutes including 20% hypertonic

saline ,0.5% silver nitrate , absolute alcohol . there is no

place 4 formaldehyde nowadays . scolicial agents

coming into contact with biliary tree may cause


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sclerosing cholangitis . scolicidal agents couldn't kill

daughter cysts so they should be regarded as potentially

infective & removed meticulously .

2. removal of the ectocyst (laminated membrane )with

the end cyst & daughter cysts.

3. treatment of the residual cavity . after inspecting the

cavity & cleaned with scolicidal agents the remaining

cavity dealt with either by:

Primary closure in small cyst , with placement ofnearby drains

Saucerasation :in bigger cyst especially if infectionpresent. It's done by excision of the extra hepatic

adventitia of the cyst & doing meticulous

hemostasis Omental patching or grafting in big cavities other

surgical procedures may be used in special

circumstances

i. Excision into including the pseudo cyst inpedunculated cysts.

ii. Removal of part or the whole of the organ involved. this is possible in the liver , spleen , kidney .

For uncomplicated simpler liver cyst, percutaneous

therapy by puncture , aspiration , injection & respiration

(PAIR) , combined with Albendazole treatment is used

widely now , there is no generally agreed standard


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method 4 laparoscopic treatment of hepatic hydatid

cysts .

Medical treatment : primary chemotherapy as analternative to surgery is still controversial as cure rate

with Albendazole R not yet available .

Indication & contraindications:

If hydatid disease is inoperable because of site ,multiple cysts disseminated peritoneal diseaseother disease making operation & anesthesia

hazardous

Adjuvant therapy in either preoperative or postoperative period should be considered to reduce

the risk of recurrence from unavoidable spillage of

infective material during surgery . the risk ofrecurrent disease in uncomplicated disease is

approximately 10%

Pregnancy & lactation R contraindicated to medicaltreatment also complicated cysts with cystobiliary

communications, infection ,rupture will not

benefited from the treatment

Albendazole is currently the choice 4 medicaltherapy of cyst not prophylactic ).10mg\kg B.W

daily in 2 doses 4 a month

Prazequantel is the best prophylactic agent 4preventing implantation of spilled protoscoleses


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& dose of 50mg \kg per day is required 4 pre or post

operative prophylaxis 1 month of Albendazole

treatment or even 2 weeks of prazequantelis

probably length of treatment there is too much

debate about the time needed 4 treatment or

prophylaxis in H.C medical treatment but follow up

the treatment using US or immunological assay used

in assessment of the benefits of the treatment .

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