Investigation And managementof : Investigation And managementof Hydatid Disease Presented by
Dalian Medical University
Intern ,WRH Investigations : : Investigations : # Blood count .
# Casoni’s Test
# Plain X-ray
# CT Scanning
# ERCP Blood count . : Blood count . Generally, routine laboratory tests do not show specific results. In patients with rupture of the cyst in the biliary tree, marked and transient elevation of cholestatic enzyme levels occurs, often in association with hyperamylasemia and eosinophilia (up to 60%).
In most cases, eosinophilia is limited (<15%) or absent. Serology : Serology For the detection of anti-echinococcus antibodies.
# Indirect Haemagglutination
# ELISA Indirect Hemagglutination test : Indirect Hemagglutination test A fixed amount of anti-echinococcus antibodies is mixed with fixed amount of red blood cells coated with antigens. A positive IHA test is indicated by formation of the a ‘mat’ or ‘carpet’ cells at the bottom of the well. Casoni’s Intra-dermal Test : Casoni’s Intra-dermal Test Casoni’s antigen (0.1 ml) is injected intra-dermally at a suitable site on the vein free volar surface of right forearm. A wheal measuring ≥ 24 mm in one direction or ≥ 22 mm in both the direction within 15-30 min of the test is considered positive. Senstivity : Senstivity IHA ----- 60-100 %
Casoni’s test 60 -80 %
Due to low sensitivity and specificity, Casoni’s test is not used now days. X-ray Features hydatid Disease : X-ray Features hydatid Disease Lung :::: E. multilocularis
- Multiple nodules varied in shape and size. E granolsus: : E granolsus: Well defined smoothly outlined
Well circumscribed homogenous opacity Bilateral Hydatid Cyst : Bilateral Hydatid Cyst When Cyst Ruptures : When Cyst Ruptures - If the cyst ruptures air around or within the cyst and the collapsed cyst results in variety of descriptive terms like
- Water lily sign
- Sign of rising sun
- serpent sign Water lily sign : Water lily sign CT Scan . : CT Scan . A hydatid cyst typically demonstrates a high-attenuation wall
Calcification of the cyst wall is easily detected
Daughter vesicles manifest as round structures located peripherally within the mother cyst. They usually contain fluid with a lower attenuation than that of the fluid in the mother cyst . Daughter vesicles in liver : Daughter vesicles in liver B/L Hydatid cyst of lungs : B/L Hydatid cyst of lungs Water lily sign : Water lily sign Detachment of the laminated membrane from the pericyst can be visualized as linear areas of increased attenuation within the cyst . Water lily sign in lungs : Water lily sign in lungs Water lily sign in lungs : Water lily sign in lungs Cerebral Hydatid cyst: a well-defined oval cystic mass with an attenuation : Cerebral Hydatid cyst: a well-defined oval cystic mass with an attenuation Ultrasonogram : Ultrasonogram Is the investigation of choice for daignostic.
The following features are helpful for sonographic diagnosis of hydatid cyst.
# When the mother cyst is filled with daughter cyst, the appearance of cyst inside the cyst or cart-wheel appearance is highly suggestive.
# The hydatid sand may appear as low level echoes within the cyst. Ultrasonogram : Ultrasonogram # Calcificaton of dead hepatic cyst produce bright echoes with distal shadowing.
# Irregularity of the cyst wall due to budding process from the germinal layer may be diagnostic. Hydatid cyst of liver : Hydatid cyst of liver Daughter cyst : Daughter cyst ERCP in biliary complication of hepatic hydatid cyst : ERCP in biliary complication of hepatic hydatid cyst # biliary fistula
# hydatid material within the bile duct
# bile duct stenosis
# hydatid membrane on the gall bladder
# extrnsic compression to bile duct Management of Hydatid cyst : Management of Hydatid cyst 1 . Conservative Treatment
Calcified cyst are dead cyst. They are left alone.
2. Symtomless, small cyst can be left alone. Once symptomatic or if the size is more than 5 cm they may be treated. Medical Treatment : Medical Treatment Indication of Medical Treatment
# Disseminated Hydatid Cyst
# Inaccessible for surgery ( deep seated, multiple, recurrent)
#patient unfit for surgery
#Contamination of peritoneal cavity at surgery.
# Pre-operative preparation of the patient to prevent peritoneal dissemination and reduce the risk of recurrence if spillage during surgery. Medical Treatment : Medical Treatment # Albendazole
Albendazole is better absorbed from the gut and is probably more effective than mebendazole. It is administered for 4 week cycles seperated by 2 weeks of drug free interval. Sugery : indication. : Sugery : indication. # Symptomatic cyst
# Asymtomatic patient with cyst > 5 cm, non calcified.
# Infected Cyst.
Types of surgical intervention
# Partial Pericystectomy with omentoplasty
# Hepatic Resection
#Capitonnage Puncture Aspiration Injection Reaspiration. : Puncture Aspiration Injection Reaspiration. # Puncture under US guidance with or without catheter
# Aspiration of cystic fluid (10-15 mL) for parasitological examination and biochemical evaluation
If protoscolices are present and are still viable ------ aspiration of hydatid fluid
If protoscolices are absent :a) If clinical and epidemiological data, and biochemical fluid data are positive proceed to next stepsb) If clinical and epidemiological data, and biochemical fluid data are negative stop procedure ( probably non-parasitic cyst ) (Non-parasitic cysts are treated with alcohol injection only when symptomatic)
Injection of 95 % Ethanol solution (1/3 of amount of aspirated fluid)
Reaspiration of alcohol solution after 15 minutes Pericystectomy with omentoplasty : Pericystectomy with omentoplasty Incision – Mid-line
# Fluid from the cyst is aspirated by the syringe
#Cystic cavity is filled with scolicidal solution and kept for 5 mins and aspirated back.
# cyst is excised in a plane outside pericyst.
# the laminated membrane is grasped by sponge holding forceps and is removed.all the daughter cyst are removed.
# if major biliary communication is found cystojejunostomy is required.
#if required greater omentum is packed into the cavity of the cyst. Scolicidal Agents : Scolicidal Agents Agents Side effects
Hypertonic saline Hypernatraemia
Alcohol (75-95% ) Cholangitis
Na Hypochlorite Hypernatraemia Hepatic Resection : Hepatic Resection If cyst are situated in the peripheral part of the liver and not too large. If there are multiple cyst in one lobe then a hepatic lobectomy may be considered.
Capitonnage- If omentum is not available for closing the cavity ,redundant cyst wall can be infolded into the cystic cavity and sutured. Reference : Reference Baileys and Love’ Short Practice of Surgery
Manipal manual of Surgery
Bedside Clinics in Surgery