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Hydatid Disease of the Liver: Clinical Presentation and Complications
Abstract
The clinical presentation of hydatid disease of the liver depends on several factors which include location and the size of cyst, the stage of development and whether the cyst is alive or dead. The majority of patients with hydatid liver disease have indolent presentation in an otherwise healthy individual. Almost 75% of patients are asymptomatic, and hydatid cyst is detected as an accidental finding during a routine examination (Stephen et al. 1997). The cyst is usually more than 5 cm, when symptoms do occur. In symptomatic patients, the most common complaint is the dull aching pain in the right upper quadrant (80%) followed by dyspepsia and vomiting in 50% of patients. Diaphragmatic pain can be seen in cysts protruding from the superior surface of the liver.
... Abdominal ultrasonography is very useful, but sometimes insufficient for the monitoring of situations that involve several abdominal surgical procedures, as well as cases involving retroperitoneal CE. The post-surgical residual cavity, visible after more than 18 months, strengthens the possibility of recurrence, as has been documented previously in the literature [29,30]. Computed tomography scanning has many advantages for the diagnosis of multivisceral CE and postoperative surveillance [16,25]. ...
Cystic echinococcosis is an often-overlooked condition that otherwise negatively impacts both the individual and the community, prompting major public health concerns. Early diagnosis and treatment, as well as collaboration between specialties including surgery and parasitology, are essential for avoiding complications and disease relapse. To better illustrate this, we present the case of an elderly person with a rare localization of the disease at the muscular level. The patient underwent numerous surgical interventions, and received multiple courses of antiparasitic treatment over the course of 40 years as a result of the multivisceral dissemination of the parasite.
One hundred and fifty cases of hydatid cysts affecting different organs were studied and of these 78 cases were hepatic. Intrabiliary rupture is the commonest complication and was found in 32 cases.
The greatest incidence is at about 40 years of age. Males are affected more than females.
The clinical presentation of occult intrabiliary rupture with suppuration is described and the source of infection of the cyst is proved to be biliary in origin.
Jaundice which is obstructive might develop and a convenient term, “hydatid jaundice”, is suggested.
Evaluation of various surgical procedures for the management of such cases is discussed.
1. Publ Bibliogr. s. 126-146
Hydatid cysts of soft-tissue organs occur in five forms: univesicular, multivesicular, calcified (aborted), ruptured (into adjacent body cavities or host organ ducts), and infected. Each of these distinct forms requires an appropriate surgical approach. For uni- or multivesicular cysts uncontrolled spillage of fertile elements of the parasite is a major hazard. A new method using local freezing of the cyst's outer layer and 0.5% silver nitrate as a scolicidal agent effectively overcomes this problem. Calcified cysts can be left alone. Suppuration or rupture into adjacent body cavities or internal organ channels must be handled according to basic surgical principles and all of the parasitic material removed.
Sonographic and cholangiographic appearances of confirmed intrabiliary rupture of a hepatic hydatid cyst were studied in 15 cases. Sonographic findings included liver cyst in all cases; nonshadowing echogenic structures in the dilated biliary tree representing hydatid material, such as fragmented membranes, sand, matrix, and daughter vesicles, in eight cases; and loss of continuity of the cyst wall adjacent to the bile duct representing the site of communication in seven cases. Cholangiographic findings were as follows: filling defects of varying size and shapes in the dilated biliary tree in 13 cases, and changing shape and position of these filling defects in three of them; and leakage of contrast medium into the cyst cavity in 12 cases. Intrabiliary rupture of hepatic hydatid cyst was suggested by sonography in 10 cases (66.7%) and at cholangiography in 13 cases (86.6%). We conclude that a joint application of sonography and endoscopic cholangiography is mandatory for proper preoperative evaluation of this disorder.
The results of surgery in 48 patients with hepatic hydatid disease are described. In 26 out of 32 patients with uncomplicated cysts, conservative surgery with obliteration of the cyst cavity by omentoplasty gave satisfactory results. In contrast, 16 patients with cysts complicated by pyogenic infection or cholangitis required a variety of surgical procedures, including prolonged tube drainage, exploration of the common bile duct, sphincterotomy/plasty and hepatojejunostomy to achieve a satisfactory outcome. The group with complicated cysts also had a much longer postoperative stay (median 30 days) than those with uncomplicated cysts (median 14 days). Two patients died: in one, post-mortem examination revealed carcinoma in the wall of the cyst.
Dans l'infection a E. granulosus l'action de l'aldendazole est probablement due a la liaison de la subuline des parasites a l'interieur des microtubules. Cependant les benzimidazoles peuvent se lier a la tubuline de l'hote et ceci est probablement responsable des anomalies hepatocellulaires observees. Cette toxicite justifie la suveillance soigneuse de la fonction hepatique avant et pendant le traitement. La fonction hepatique de tous les malades a recupere rapidement a l'arret de l'albendazole
The authors review 143 consecutive, surgically treated cases of hydatid disease of the liver seen over the past 10 years. Of the 208 cysts found, 82 (39.4%) were complicated; the remainder were simple. The complications included rupture into the biliary system (16.3%), suppuration (11.0%), partial calcification of the pericyst (5.8%), intraperitoneal rupture (4.8%), bronchobiliary fistula (0.9%) and cystocutaneous fistula (0.5%). External capitonnage was the most commonly used surgical technique (63.0%), followed by cystectomy (17.8%), omentoplasty (10.6%), tube drainage (7.7%) and cystojejunostomy (0.9%). Capitonnage was carried out with or without tube drainage. The complications of surgery were higher with drainage than without. The main complications of surgery were infection in the residual cavity and biliary fistula. The patients who underwent external capitonnage without drainage or omentoplasty had good results with minimal complication rates (3.5% and 4.5% respectively). For the patients in whom the cystectomy was established, the complication rate was 8.1%.
We performed a retrospective study of 19 patients who had been operated on for hepatic hydatid disease with diaphragmatic or transdiaphragmatic (D-TD) thoracic involvement chosen from a total of 444 patients who underwent operations for hepatic hydatid disease. In all cases D-TD involvement was confirmed by ultrasonography, CT, or MRI scan. We propose a new classification (grades 1-5) based on the degree of development of D-TD involvement. Before 1984 exposure was obtained by thoracophrenolaparotomy (nine cases) and later by right subcostal incision. Only four patients required atypical pulmonary resection. In 13 cases the diaphragm was repaired, and all 24 hepatic cysts were treated with total (16 cases) or partial (8 cases) cystopericystectomy. There was no operative mortality, and the most serious morbidity consisted of a biliary fistula and a biliobronchial fistula. For treatment of these patients we recommended right subcostal incision and total or near-total cystopericystectomy as a first choice of surgical technique.
Rupture and the sequellae of rupture are more important than the mass effect of hydatid cysts, except in the brain where the mass effect by itself has severe consequences. The biology of hydatid disease, including the complex interaction between primary and secondary hosts, is reviewed. The hydatid cyst always starts as a fluid-filled, cyst-like structure (Type I) which may proceed to a Type II lesion if daughter cysts and/or matrix develop. In some instances the Type II lesion becomes hypermature and due to starvation dies to become a mummified, inert calcified Type III lesion. Type I and II lesions may undergo three types of rupture: contained, communicating and direct. Contained rupture is clinically silent, but communicating rupture may cause biliary obstruction and evacuation or infection of the cyst. Direct rupture has the greatest clinical consequences which include anaphylaxis, dissemination of hydatid disease (secondary hydatosis) within the host, and bacterial infection of the pericyst cavity. The clinical implications of the hydatid disease at different stages are discussed. A plea is made for the development of an international medical hydatid registry employing uniform nomenclature and consistent reporting in order to allow more rational comparisons of different types of management.
Most of the abdominal hydatid cysts occur in liver. Extrahepatic hydatid cyst is usually secondary to rupture (operative and non-operative) of the hepatic hydatid cyst. Primary extrahepatic hydatid cysts are rare and only a few sporadic cases have been reported.
One hundred and eighty-three patients with abdominal hydatid cysts managed surgically from January 1998 to December 2003 were evaluated retrospectively. Twelve (6.5%) patients had only extrahepatic abdominal involvement.
The cysts were present in spleen (2.2%), pancreas (1.1%), peritoneum and pelvis (1.6%), gallbladder (0.6%), mesocolon (0.6%) and adrenal (0.6%).
It is difficult to diagnose extrahepatic echinococcosis as it usually is not suspected. Symptoms are related to size, location or ensuing complication of the cyst. It should be strongly suspected in differential diagnosis of all abdominal cysts especially in an endemic area.
A case of right sided transdiaphragmatic rupture of hepatic hydatid cyst into the right hemithorax is presented. Computed Tomography (CT) scan showed a large hydatid cyst replacing the right lobe of liver and causing complete collapse of right lung secondary to the transdiaphragmatic rupture. Per-operatively, a bronchopleural fistula was also identified and repaired.
Surgical management of hydatid disease. London: Butterworths
- El Mufti
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Problems and surgical treatment of broncho-biliary fistulas due to hydatid cyst of the liver. Second Panhellenic Congress of Surgery
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Maingot’s abdominal Operations. Liver abscess and hydatid cyst disease
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Intrabiliary rupture of hepatic hydatid cyst: multidetector-row CT demonstration
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