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DAIGNOSTICS & MANAGEMENTDAIGNOSTICS & MANAGEMENT
OFOF HYDATID CYST LIVERHYDATID CYST LIVER
BY:BY:DR.NAVEED AHMEDDR.NAVEED AHMEDRESIDENT OF SURGERYRESIDENT OF SURGERYWARD # 26,JPMCWARD # 26,JPMC
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Introduction:Introduction:
The disease is caused by the helminthThe disease is caused by the helminthEchinococcus granulosusEchinococcus granulosus(dog(dogtapeworm).tapeworm).
Its definitive host is dog/wolfIts definitive host is dog/wolf
Intermediate host is sheep.Intermediate host is sheep.
Humans are accidental intermediate hosts.Humans are accidental intermediate hosts.
The adult worm lives in the intestines ofThe adult worm lives in the intestines ofthe definitive host (dog) for 5the definitive host (dog) for 5--20 months.20 months.
Releases the ova with the stools. IngestionReleases the ova with the stools. Ingestionof the ova (on polluted vegetables, grassof the ova (on polluted vegetables, grassor water) causes infection.or water) causes infection.
Ecchinococcus granulosa
ova
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LIFECYCLE OF PARASITELIFECYCLE OF PARASITE
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This disease can affect almost any organThis disease can affect almost any organ
but has more propensity towards (LLB)but has more propensity towards (LLB)
LL iveriver (Rt lobe in 70% cases)(Rt lobe in 70% cases)
LLungsungs
BB rainrain
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STRUCTURE OF HYDATID CYSTSTRUCTURE OF HYDATID CYST
Its usually a unilocular fluid filled cystIts usually a unilocular fluid filled cyst
Fluid inside this cyst is extremely allergic/toxicFluid inside this cyst is extremely allergic/toxicMembrane surrounding fluid consists of threeMembrane surrounding fluid consists of three
distinct layersdistinct layers
1.1. OuterOuter PericystPericyst (derived from hosts organ/tissue)(derived from hosts organ/tissue)
2.2. MiddleMiddle EctocystEctocyst(composed of hyaline matter)(composed of hyaline matter)
3.3. InnerInner EndocystEndocyst(germinal layer that continuously produce(germinal layer that continuously produce
scolices)scolices)
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MICROSCOPIC PICTURE OF HYDATID CYSTMICROSCOPIC PICTURE OF HYDATID CYST
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Clinical picture (in high risk pts)Clinical picture (in high risk pts)
Serological studySerological study
Microscopic study of aspirated fluidMicroscopic study of aspirated fluid
Radiological study (most specific)Radiological study (most specific)
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CLINICAL FEATURES:CLINICAL FEATURES:
Right upper abdominal painRight upper abdominal pain
Hepatic enlargement/massHepatic enlargement/massAnorexiaAnorexia
Nausea and vomitingNausea and vomitingweight lossweight loss
Fever and chillsFever and chills
JaundiceJaundice
Urticaria and anaphylaxisUrticaria and anaphylaxis
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A HIGH INDEX OF SUSPICION IN :A HIGH INDEX OF SUSPICION IN :
RuralRural
residents.residents.
FarmersFarmers
oror
Persons inPersons in
contact withcontact withdog/sheeps.dog/sheeps.
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Serologically by:Serologically by:
EosinophiliaEosinophilia
Detection of antibody by:Detection of antibody by:
ELISA ( Enzyme Linked Immuno Sorbent Assay )ELISA ( Enzyme Linked Immuno Sorbent Assay )have a high specificity and accuracy.have a high specificity and accuracy.
indirect hemagglutinin test 70% sensitiveindirect hemagglutinin test 70% sensitive
complement fixation test.complement fixation test.
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MicroscopyMicroscopy by:by:
Fluid aspirated from a hydatid cyst willFluid aspirated from a hydatid cyst will
shows multiple protoscolices.shows multiple protoscolices.
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Radiologically by:Radiologically by:
Plain XPlain X--rayray (shows calcified cyst)(shows calcified cyst)
UltrasoundUltrasound (unilocular cyst)(unilocular cyst)
CTCT (floating membrane within cyst)(floating membrane within cyst) MRI, MRCP, ERCPMRI, MRCP, ERCP (may be employed In(may be employed Incomplicated cases.complicated cases.))
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Plain XPlain X --ray abdomenray abdomenshowing Hydatid cystsshowing Hydatid cysts
in liver (3 cysts markedin liver (3 cysts marked
by arrows)by arrows)
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U/S Abdomen showing giant liverU/S Abdomen showing giant liver
cystcyst
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CT Abdomen showing giant liver cystCT Abdomen showing giant liver cyst
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WHO CLASSIFICATION OF HYDATIDWHO CLASSIFICATION OF HYDATID
CYSTCYST
HYDATID CYST
CLASS ONEOR
Active group
CLASS TWOOR
Transition group
CLASS THREE
OR
Inactive group
Class one and class two cyst of WHO classification
needs urgent management.
While class three cyst should be left in place
followed with observation by serial ultrasounds
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Management ???????Management ???????
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Management options areManagement options are
Medical or pharmacological treatmentMedical or pharmacological treatment
&&
Surgical treatmentSurgical treatment
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PHARMACOLOGICAL TREATMENTPHARMACOLOGICAL TREATMENT
Pharmacological treatment is not curative.Pharmacological treatment is not curative.
Indicated in cases which are inoperable (surgery isIndicated in cases which are inoperable (surgery iscontraindicated).contraindicated).
Used as an adjunct to surgery to kill spilledUsed as an adjunct to surgery to kill spilled
scolices & avoid peritoneal contamination.scolices & avoid peritoneal contamination.
Drug of choice areDrug of choice are
albendazole,albendazole,
mebendazolemebendazole
praziquantelpraziquantel
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Surgery is the most specific form ofSurgery is the most specific form of
curative treatment for echinococcosis.curative treatment for echinococcosis.
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SURGICAL TREATMENT:SURGICAL TREATMENT:
For uncomplicated hydatid cystsFor uncomplicated hydatid cysts
Open/Laparoscopic surgeryOpen/Laparoscopic surgery
Cystectomy (excision of cyst)Cystectomy (excision of cyst)
Simple tube drainageSimple tube drainage
PericystectomyPericystectomy
Hepatic segmentectomyHepatic segmentectomy
Marsupialization and Omentoplasty (not recommended anyMarsupialization and Omentoplasty (not recommended anymore)more)
Ultrasound guided percutanous aspirationUltrasound guided percutanous aspiration
Puncture, Aspiration, Injection & RePuncture, Aspiration, Injection & Re--aspiration (PAIR)aspiration (PAIR)
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CONTRACONTRA--INDICATIONS FOR SURGERYINDICATIONS FOR SURGERY
ARE:ARE:General contraindications to surgeryGeneral contraindications to surgery
Extremes of ageExtremes of age
PregnancyPregnancy
Preexisting medical conditionsPreexisting medical conditions
Multiple cysts in multiple organsMultiple cysts in multiple organs
Cysts are difficult to be accessedCysts are difficult to be accessed
Dead cystsDead cysts (WHO class 3)(WHO class 3)
Calcified cystsCalcified cysts (WHO class 3)(WHO class 3)
Very small cystsVery small cysts
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Contraindications for laparoscopicContraindications for laparoscopic
procedure:procedure:
Deep intraparenchymal cystsDeep intraparenchymal cysts
Posterior CystPosterior Cyst
More than 3 cystsMore than 3 cysts
Cysts with thick and calcified wallsCysts with thick and calcified walls
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COMPLICATIONS OF HYDATID CYSTCOMPLICATIONS OF HYDATID CYST
Intrabiliary rupture leading to:Intrabiliary rupture leading to:
Biliary colicBiliary colic obstructive jaundiceobstructive jaundice Intarperitoneal rupture leading to:Intarperitoneal rupture leading to: Acute abdomen (peritonitis)Acute abdomen (peritonitis)
Anaphylactic shockAnaphylactic shock
Intraplueral rupture leading to:Intraplueral rupture leading to:
DyspneaDyspnea Blood and bile stained sputumBlood and bile stained sputum
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SURGICAL MANAGEMENT INSURGICAL MANAGEMENT IN
COMPLICATED CASESCOMPLICATED CASES
ComplicationComplication Surgical procedureSurgical procedure
1. Intarperitoneal1. Intarperitoneal
rupturerupture
Laparotomy +Laparotomy +
peritoneal toilet +peritoneal toilet +PericystectomyPericystectomy
2. Intrabiliary rupture2. Intrabiliary rupture
Choledochotomy +Choledochotomy +
TT--tube placementtube placement
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POSTPOST--OP COMPLICATIONS:OP COMPLICATIONS:
Anaphylactic shockAnaphylactic shock
BleedingBleeding
PostPost--operative infection with creating ofoperative infection with creating ofperihepatic abscessesperihepatic abscesses
External biliary fistulaExternal biliary fistula
RecurrenceRecurrence
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