Hydatid Cyst of the liver, case presentation. KSA 2017

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  1. 1. HYDATID CYST OF THE LIVER Case Presentation KSA 2017 DR. MOHAMAD AL-GAILANI FRCS CONSULTANT SURGEON MEDICAL EDUCATION & TRAINING DIRECTOR SUWAIDI Riyadh KSA
  2. 2. CASE PRESENTATION: 55 YEAR OLD (YEMENI) MALE Presented to my clinic at Al Hammadi Hospital (AHH) Suwaidi with upper outer quadrant dull abdominal pain for months. No history of jaundice, nausea or vomiting. Previous Ultrasound (US) scans at AHH showing hydatic cyst (HC) right lobe liver. Recent Computerized Axial Tomography (CT) chest and abdomen confirming the diagnosis. DR. MOHAMAD AL-GAILANI FRCS AHH SUWAIDI HYDATID CYST OF THE LIVER CASE PRESENTATION KSA 2017 2
  3. 3. PAST SURGICAL HISTORY: 1990: HC Liver Surgery October 2016: Open Cholecystectomy for Gall Stones (AHH). During operation daughter cysts seen extruding from liver gall bladder fossa. Post Operatively-Persistent HC debris extruding from a sinus in the Kocher wound. March 2017: Wound Sinus exploration. Post Operative Rx: Albendazole DR. MOHAMAD AL-GAILANI FRCS AHH SUWAIDI HYDATID CYST OF THE LIVER CASE PRESENTATION KSA 2017 3
  4. 4. PAST MEDICAL HISTORY: Ischaemic heart disease. Coronary Angio at King Khaled University Hospital (KKUH), Riyadh, KSA. Type 2 Diabetes Hypertension Rx: Zestril, Concor, Lipitor, Actos, Diamicrone, Glipta, Albendazole DR. MOHAMAD AL-GAILANI FRCS AHH SUWAIDI HYDATID CYST OF THE LIVER CASE PRESENTATION KSA 2017 4
  5. 5. CLINICAL EXAMINATION: Temp 36 C PR 104 bpm BP 127/75 mm HG Weight 88 Kg No Jaundice Abdomen Soft, No Organomegaly DR. MOHAMAD AL-GAILANI FRCS AHH SUWAIDI HYDATID CYST OF THE LIVER CASE PRESENTATION KSA 2017 5
  6. 6. INVESTIGATIONS: HB 12.9 g/dL WCC 11,800 cells/mcL, Eosinophils 0.4% Platelets 186,000/mcL AST 34 IU/L ALT 46 IU/L Bilirubin 0.5 mg/dL Alkaline Phosphatase 106 IU/L DR. MOHAMAD AL-GAILANI FRCS AHH SUWAIDI HYDATID CYST OF THE LIVER CASE PRESENTATION KSA 2017 6
  7. 7. ULTRASOUND (PRE CHOLECYSTECTOMY) JANUARY 2016 DR. MOHAMAD AL-GAILANI FRCS AHH SUWAIDI HYDATID CYST OF THE LIVER CASE PRESENTATION KSA 2017 7 Hydatid Cyst Liver 8x4.5 cm Right Lobe (Segment VIII) Gall Bladder Distended, Multiple Stones 5-10 mm Thickened Oedematous Wall. CBD Normal
  8. 8. ULTRASOUND (POST CHOLECYSTECTOMY) MARCH 2017: DR. MOHAMAD AL-GAILANI FRCS AHH SUWAIDI HYDATID CYST OF THE LIVER CASE PRESENTATION KSA 2017 8 Right Lobe Liver Cystic Mass 7.5x6.5 cm. Normal CBD. Absent Gall Bladder (Cholecystectomy) Dx: Hydatid Cyst Right Lobe Liver.
  9. 9. PREVIOUS SURGERY HISTOLOGY REPORTS: October 2016 (Open Cholecystectomy): Chronic Cholecystitis Gall Bladder Fossa Biopsy: Hydatid Cyst Daughter Cysts March 2017 (Wound Sinus exploration): Sub Hepatic Drainage Tube Effluent: Hydatid Cyst Daughter Cysts DR. MOHAMAD AL-GAILANI FRCS AHH SUWAIDI HYDATID CYST OF THE LIVER CASE PRESENTATION KSA 2017 9
  10. 10. CT scan (1) June 2017 DR. MOHAMAD AL-GAILANI FRCS AHH SUWAIDI HYDATID CYST OF THE LIVER CASE PRESENTATION KSA 2017 10 Hydatid Cyst liver Right Lobe Water Lily sign Normal CBD WATER LILY SIGN
  11. 11. WATER LILY SIGN Detachment of the Endocyst membrane which results in floating membranes within the Pericyst that mimic the appearance of a water lily. Chest X-ray, US, CT or MRI. Transitional stage between active and inactive disease. Decreased intra-cystic pressure, degeneration, host response, trauma or following therapy. DR. MOHAMAD AL-GAILANI FRCS AHH SUWAIDI HYDATID CYST OF THE LIVER CASE PRESENTATION KSA 2017 11
  12. 12. CT scan (2) DR. MOHAMAD AL-GAILANI FRCS AHH SUWAIDI HYDATID CYST OF THE LIVER CASE PRESENTATION KSA 2017 12
  13. 13. CT scan (3) DR. MOHAMAD AL-GAILANI FRCS AHH SUWAIDI HYDATID CYST OF THE LIVER CASE PRESENTATION KSA 2017 13 HYDATID CYST
  14. 14. CT scan (4) DR. MOHAMAD AL-GAILANI FRCS AHH SUWAIDI HYDATID CYST OF THE LIVER CASE PRESENTATION KSA 2017 14 HYDATID CYST
  15. 15. OPERATION EXCISION HYDATID CYST LIVER July 2017 INCISION: Through scar previous Kocher incision FINDINGS: 1) Frozen abdomen! Extensive Adhesions. 2) Main large HC at the dome of the right lobe liver under the diaphragm 3) Small (incidental) HC near gall bladder fossa. (Likely the same HC encountered in previous cholecystectomy). DR. MOHAMAD AL-GAILANI FRCS AHH SUWAIDI HYDATID CYST OF THE LIVER CASE PRESENTATION KSA 2017 15
  16. 16. OPERATIVE FINDINGS: DR. MOHAMAD AL-GAILANI FRCS AHH SUWAIDI HYDATID CYST OF THE LIVER CASE PRESENTATION KSA 2017 16 The smaller HC at Gall Bladder fossa DR. M. AL-GAILANI FRCS, AHH SUWAIDI
  17. 17. OPERATIVE PROCEDURE: 1. Packing all around HC. 2. Hypertonic Saline intra cystic injection. 3. Complete evacuation all endocyst and daughter cysts of both HCs avoiding any spillage. 4. Two corrugated drains: sub hepatic & intra cavity of the larger HC. DR. MOHAMAD AL-GAILANI FRCS AHH SUWAIDI HYDATID CYST OF THE LIVER CASE PRESENTATION KSA 2017 17
  18. 18. The smaller HC at Gall Bladder Fossa DR. MOHAMAD AL-GAILANI FRCS AHH SUWAIDI HYDATID CYST OF THE LIVER CASE PRESENTATION KSA 2017 18
  19. 19. FOLLOW UP Histology & Microbiology: HC confirmed: HC wall enucleation, outer ectocyst, inner endocyst, germinal layer & daughter cysts. Uneventful postoperative recovery Drains removed 12th postoperative day Discharged well. DR. MOHAMAD AL-GAILANI FRCS AHH SUWAIDI HYDATID CYST OF THE LIVER CASE PRESENTATION KSA 2017 19
  20. 20. HYDATID CYST DISEASE DR. MOHAMAD AL-GAILANI FRCS AHH SUWAIDI HYDATID CYST OF THE LIVER CASE PRESENTATION KSA 2017 20
  21. 21. EPIDEMIOLOGY OF HC: DR. MOHAMAD AL-GAILANI FRCS AHH SUWAIDI HYDATID CYST OF THE LIVER CASE PRESENTATION KSA 2017 21 1. Human Hydatid Cyst is prevalent in the Middle East and North Africa. 2. Hyper endemic in Turkey, Iraq, Jordan, Morocco, Libya & Algeria. 3. Hydatid cysts are found in Sheep, Goats, Cattle & Camels. 4. Sheep-Dog spread is the most important Zoonotic transmission vehicle for Human Hydatic Cyst disease.
  22. 22. ECHINOCOCUS GRANULOSUS TAPE WORM DR. MOHAMAD AL-GAILANI FRCS AHH SUWAIDI HYDATID CYST OF THE LIVER CASE PRESENTATION KSA 2017 22 SCOLEX SHOWING HOOKS
  23. 23. HYDATID CYST INTERMEDIATE HOST (SHEEP) DR. MOHAMAD AL-GAILANI FRCS AHH SUWAIDI HYDATID CYST OF THE LIVER CASE PRESENTATION KSA 2017 23 Prevalence of HC in slaughtered sheep in Riyadh City around 1.06%. E. Almalki Et Al. Saudi Journal of Biological Sciences (2017)
  24. 24. MAJOR PUBLIC HEALTH HAZARD! DR. MOHAMAD AL-GAILANI FRCS AHH SUWAIDI HYDATID CYST OF THE LIVER CASE PRESENTATION KSA 2017 24 SHEEP OFFAL (HC) FED TO DOGS DOGS EXCRETA CONTAING OVA CONTAMINATE AGRICULTURE
  25. 25. ECHINOCOCUS GRANULOSUS OVUM INFECTIVE TO HUMANS DR. MOHAMAD AL-GAILANI FRCS AHH SUWAIDI HYDATID CYST OF THE LIVER CASE PRESENTATION KSA 2017 25 Resistant to all antiseptics including Permanganate antiseptic & even to Formalin!
  26. 26. HC Ova deposited in Soil Can stay viable for up to a Year! DR. MOHAMAD AL-GAILANI FRCS AHH SUWAIDI HYDATID CYST OF THE LIVER CASE PRESENTATION KSA 2017 26 OVA SALADHC OVA INFESTED LETTUCE
  27. 27. HYDATID CYST ACCIDENTAL INTERMEDIATE HOST (HUMANS) DR. MOHAMAD AL-GAILANI FRCS AHH SUWAIDI HYDATID CYST OF THE LIVER CASE PRESENTATION KSA 2017 27
  28. 28. HYDATID CYST ANATOMY DR. MOHAMAD AL-GAILANI FRCS AHH SUWAIDI HYDATID CYST OF THE LIVER CASE PRESENTATION KSA 2017 28 ECTOCYST (HOST) DAUGHTER CYSTS ENDOCYST (HC) GERMINAL LAYER
  29. 29. HC CAN AFFECT ANY ORGAN! DR. MOHAMAD AL-GAILANI FRCS AHH SUWAIDI HYDATID CYST OF THE LIVER CASE PRESENTATION KSA 2017 29 LIVER 65% LUNG 25% Brain 1% Spleen 1% Bone 3% Kidney 2% Eyes Thyroid Gland Breast
  30. 30. CLINICAL FEATURES: Depends On The Organ Affected High Index Of Suspicion In Endemic Areas Pressure Symptoms: Brain, Bone Lump: Thyroid, Skin, Breast, Skin Intra Biliary Rupture > Obstructive Jaundice Abscess: Liver, Lung DR. MOHAMAD AL-GAILANI FRCS AHH SUWAIDI HYDATID CYST OF THE LIVER CASE PRESENTATION KSA 2017 30
  31. 31. DIFFERENTIAL DIAGNOSIS: DIFFERENTIAL DIAGNOSIS: Biliary Cirrhosis Biliary Colic Biliary Obstruction Budd-Chiari Syndrome Cystic Teratoma DIFFERENTIAL DIAGNOSIS: Cysticercosis Hepatic Cysts Liver Abscess Primary Hepatic Carcinoma Pyogenic Hepatic Abscesses DR. MOHAMAD AL-GAILANI FRCS AHH SUWAIDI HYDATID CYST OF THE LIVER CASE PRESENTATION KSA 2017 31
  32. 32. INVESTIGATIONS: Eosinophilia is present in 25% ELISA: Enzyme-Linked Immuno Sorbent Assay Sensitivity 80% Casoni Test: intradermal skin test Sensitivity 70% Plain X-ray: A thin rim of calcification delineating a cyst is suggestive US: Cyst Wall, Daughter Cysts, Water Lily Sign CT MRI DR. MOHAMAD AL-GAILANI FRCS AHH SUWAIDI HYDATID CYST OF THE LIVER CASE PRESENTATION KSA 2017 32
  33. 33. MANAGEMENT: 1. SURGERY: Remains the primary treatment and the only hope for complete cure. 2. MEDICAL: Inoperable because of location or multiple organs Unfit for General Anaesthesia Disseminated Peritoneal disease. a. Albendazole (10-15 mg/kg/day) orally for 3-6 months b. Mebendazole (40-50 mg/kg/day) orally for 3-6 months DR. MOHAMAD AL-GAILANI FRCS AHH SUWAIDI HYDATID CYST OF THE LIVER CASE PRESENTATION KSA 2017 33
  34. 34. SURGICAL TECHNIQUE: 1. Isolation: surrounding tissues are protected by covering them with cetrimide-soaked pads 2. Intra Cystic Injection Scolicidal Agents: Hypertonic saline 20%, Chlorhexidine 10%, Absolute alcohol 95%, Hydrogen Peroxide 3% or Cetrimide 1.5%. 3. Cyst aspiration and evacuation: Spillage Free 4. Remaining cavity: 1) Close after closure of any biliary communications 2) Omental packing 3) Marsupialization 4) Drainage DR. MOHAMAD AL-GAILANI FRCS AHH SUWAIDI HYDATID CYST OF THE LIVER CASE PRESENTATION KSA 2017 34
  35. 35. PUBLIC HEALTH & PREVENTION: Breaking down the life cycle by stray dog control Preventing sheep