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Abdomen » Hepatobiliary
Hepatic Echinococcus Cyst
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Presentation A 72 year old Italian woman presents with urticaria and a history of vague pain in the right upper quadrant. On examination there is a palpable mass in the RUQ. Laboratory data: Eosinophilia
 
 
Caption: Transabdominal ultrasound right upper quadrant
Description: Transabdominal ultrasound shows a large cystic mass in the right lobe of the liver containing multiple daughter cysts separated by a matrix of mixed echogenicity. There is a hyperechoic calcified rim associated with part of the cyst wall.
 
 
Caption: CT Scan Abdomen
Description: CT scan shows daughter vesicles in a typical peripheral location within the mother cyst and the partial calcification of the pericyst.
 
 
 
Caption: WHO-IWGE Classification of Ultrasound Patterns of Echinococcosis Cysts
Description: Classification of ultrasound images in cystic echinococcosis proposed by the Informal Working Group on Echinococcosis of the World Health Organization. The lesion in this case is a CE2. Click the image for a larger version.
 
Differential Diagnosis •    Complex pyogenic abscess
•    Hemorrhagic cyst
•    Infected cyst
•    Cystic metastases
•    Biliary cystoadenocarcinoma
 
Final Diagnosis Hepatic Echinococcus Cyst
 
Discussion Hydatid disease is a severe and common parasitic disease caused by larval stage of Echinococcus granulosus.  It is endemic to the Mediterranean basin and other sheep-raising areas (Africa , South America, Australia, New Zealand).  Ultrasonography and computed tomography, the most important diagnostic tools, are helpful for determining the complications and planning treatment

Imaging findings in hepatic hydatid disease depend on the stage of cyst growth.  In 2003, the World Health Organization Informal Working Group on Echinococcosis (WHO-IWGE) proposed a standardized ultrasound classification based on the active-transitional-inactive status of the cyst as suggested by its sonographic appearance.   A graphic of this classification system is available as part of a .pdf file which may be downloaded from the WHO site at http://whqlibdoc.who.int/hq/2001/WHO_CDS_CSR_APH_2001.6.pdf   
The .pdf file is a paper entitled PAIR: Puncture, Aspiration, Injection, Re-Aspiration.  An option for the treatment of Cystic Echinococcosis. World Health Organization, Department of Communicable Disease, Surveillance and Response. WHO/CDS/CSR/APH/2001.6

TREATMENT

The modern treatment of hydatid cyst of the liver varies from surgical intervention to percutaneous drainage or medical therapy.
Surgery is still the treatment of choice and can be performed by the conventional or laparoscopic approach (segmentale or lobar hepatectomy).
Percutaneous drainage and treatment of the cyst with hypertonic saline or alcohol seems to be a good alternative to surgery in selected cases (see the above noted .pdf file for a detailed description of one treatment approach).
Medical Therapy: Albendazole ; Mebendazole



 
Case References
  1. Gharbi HA, Hassine W, Brauner MW, Dupuch K. Ultrasound examination of the hydatic liver. Radiology 1981; 139: 459-463
  2. Haddad M, Birjawi G, Khouzami R, Khoury N, El-Zein Y, Al-Kutoubi A.  Unilocular hepatic echinococcal cysts: sonography and computed tomography findings.  Clin.Radiol 2001; 56: 746-750
  3. Brunetti E.; Filice C. ; Echinococcosis Hydatid Cyst ; e-medicine.com ; Dicembre 4, 2006.
  4. WHO Informal Working Group on Echinococcosis: Guidelines for treatment of cystic and alveolar echinococcosis in humans. WHO Informal Working Group on Echinococcosis. Bull World Health Organ 1996; 74(3): 231-42
  5. Kumar et al. Hydatid cyst of liver; Postgrad Med J.2003; 79: 113-114
  6. Shah DS, Parikh H, Shah B, Banuprakash S, Shah J. Imaging appereances of hydatid cyst. Indian J Radiol Imaging [serial online] 2006 [cited 2008 May 28];
  7. Filice C, Pirola F, Brunetti E, Dughetti S, Strosselli M, Foglieni CS.  A new therapeutic approach for hydatid liver cysts. Aspiration and alcohol injection under sonographic guidance.  Gastroenterology 1990; 98: 1366-1368
  8. Anil T. Ahuja , et al. ; Diagnostic Imaging Ultrasound ; Amirsys Inc 2007
 
Technical Details This case provided courtesy Dr. Danilo Sirigu and the web site "EcoMovies".  To view a wide range of high-quality video cases please visit  http://www.ecomovies.it