Disseminated Intra-abdominal Hydatid Disease

Hydatid disease is one of the commonest parasitic infections of the liver. It can cause a variety of complications in the liver. Rupture into the peritoneal cavity leading to secondary echinococcosis is a difficult problem to manage. Early diagnosis and optimal choice of surgical management reduces the morbidity and mortality associated with this disease. A case of disseminated intra abdominal hydatid disease is presented along with a review of diagnosis and various therapeutic modalities.

Introduction

Echinococcosis (hydatid disease) is a zoonosis caused by the larval stage of Taenia echinococcosis, where humans are the accidental intermediate host and animals are both intermediate and definitive hosts. This disease is a major cause of human morbidity and mortality in many parts of the world. A case of disseminated intraperitoneal hydatid disease or secondary echinococcosis is presented along with a brief review of literature pertaining to the management of such complicated cases.

Case Report

A 24 year old male, a butcher by occupation presented with a lump in the lower abdomen since 6 months. The lump had been gradually increasing over a period of time. There was no history of jaundice. Patient has persistent abdominal pain which was dull aching in nature localized to the lower abdomen. There was no alteration in the bowel and bladder habits. The patient had sought treatment from a local practitioner but did not get any relief nor was the diagnosis made.

Physical examination revealed a large mass arising from the pelvis measuring 20 cm x 20 cm x 15 cm rising upto the umbilicus with a dull note on percussion over it. There was hepatomegaly (8 cms below the costal margin). There was no evidence of free fluid in the peritoneal cavity. Laboratory investigations revealed neutrophilic leucocytosis. Alkaline phosphatase was 140lu, S. bilirubin (Total) 0.9 mg%, direct bilirubin : 0.3 mg%, SGOT: 36 lu/L and SGPT 65 lu/L.

Double contrast CT scan of the abdomen revealed multiple cystic lesions in the abdomen. The cysts were multi loculated with multiple internal septations suggestive of hydatid disease. There were totally 7 cysts in various parts of the abdomen. (Figs. 1, 2 and 3).

1. Posterosuperior surface of the right lobe adherent to the under surface of the right hemidiaphragm.

2. Inferior surface of the right lobe lateral to the gall bladder.

3. Postero inferiorly in the ® lobe extending upto the superior pole of the right kidney.

4. A large cyst in the pelvic cavity.

5. A cyst in the mesentery of the small intestine.

6. A cyst in the greater omentum.

7. A cyst in the meso colon of the ® colon.


Fig. 1 : CT scan plate shows a large hepatic hydatid cyst. (Multiloculated cyst with internal septations)

Exploratory laparotomy was performed through a midline incision. The technique of surgical management of hepatic hydatids differed from that of extra hepatic hydatids.

For hepatic hydatids a scolicidal solution (hypertonic saline) was injected into the cyst followed by aspiration. The pericyst was then incised. The glistening laminated membrane along with the germinal layer was slowly and carefully removed taking care to prevent spillage. All daughter cysts were removed from the cyst. The internal surface of the remaining cyst was examined for biliary leak. If present they were ligated with 3.0 vicryl sutures. The largest of the remnant cyst cavity was packed with omentum. The suprahepatic, sub diaphragmatic cyst was totally deroofed to release the diaphragm from the superior surface of the liver. For extra hepatic hydatids, since the pericyst was very thin and it was easy to dissect it from the surrounding structures. Hence, cystectomy was performed for all the extra hepatic hydatids.

A rigorous peritoneal lavage was given with normal saline. The peritoneal cavity mobbed dry. Multiple tube drains were kept in the peritoneal cavity namely subhepatic, sub diaphragmatic and in the pelvis, prior to closure of the peritoneal cavity. Postoperative recovery of the patient was uneventful. Patient was administered albendozole for 6 weeks after the surgery.

The patient has been following up for the last 4 months. Repeat USG and LFT have been performed at each follow up visit. As yet there is no evidence of recurrent disease.


	Fig. 2 : CT scan plate shows a multiple intraperitoneal hydatid cysts. (Secondary Echinococcosis).

	Fig. 3 : CT scan plate shows a large hydatid cyst arising out of the pelvis.

Discussion

Principles of surgical management of an hydatid cyst depend upon the basic structure of the hydatid cyst.¹ A typical hydatid cyst has three layers. The outer layer is the pericyst or ectocyst that is formed from host tissue as a result of a chronic inflammatory reaction to the parasite. The pericyst consists of a layer of fibrous tissue that gradually increases in thickness as the cyst expands. A thick pericyst is present in hydatids situated in the liver and spleen, but is extremely thin in peritoneal hydatid cyst. Hepatic vascular and ductal structures are incorporated into the pericyst as the surrounding liver parenchyma is gradually compressed by the expanding cyst. These structures are then subject to injury during resection of the pericyst. Dense calcifications are seen in senescent cysts. The parasite makes up the germinal layer and the laminated membrane. The innermost germinal layer is the living parasite which is one cell thick and is intimately attached to the laminated membrane. The terminal layer gives rise to a large number of protoscolices and brood’s capsules. The middle layer is the laminated membrane which is made up of chitinous material that is gelatinous and ruptures easily with manipulation. The cyst fluid is secreted by the germinal layer and is normally crystal clear. The high secretion pressure is responsible for the progressive enlargement of the cyst. Bile stained cyst fluid is an indicator of communication of the cyst with the biliary tract.

The cyst can rupture into the stomach, duodenum, small intestine or into the general peritoneal cavity. Intraperitoneal rupture is a grave complication of liver hydatids. The release of brood’s capsules, scolices and even daughter cysts from a ruptured hydatid cyst into the peritoneal cavity leads to multiple cysts in the peritoneal cavity. This phenomenon is called secondary echinococcosis.²

In secondary echinococcosis, scolices, broods capsules implant and develop independently from the hepatic hydatid cyst. This cycle takes several years.

Pain is the commonest symptom of hydatid disease. Pain may be of acute onset if the cyst ruptures but latter on becomes continuous dull aching in nature. Fever supervenes if there is secondary infection. Jaundice develops if there is intrabiliary rupture of the cyst.³ occasionally intra peritoneal rupture can lead to severe allergic reactions.⁴

A double contrast CT Scan is 90-100% accurate for diagnosing hydatid cysts.⁵ It provides superior visualization in 3 dimensions of the extent of the cystic disease, is useful in planning an operative approach and is superior to USG in identifying additional extrahepatic intra abdominal cysts.⁶ In jaundiced patients with hepatic hydatid disease, ERCP should be carried out to confirm the cause of jaundice.⁷

The role of medical treatment in hydatid disease is limited.⁸ It is used predominantly as an adjuvant therapy for extensive hepatic or extrahepatic hydatid disease.⁹ Albendazole is the drug of choice.^10,11 Long term use of this drug is not advised in view of its hepatotoxicity.¹⁰

Surgery therefore remains the mainstay of treatment for hydatid disease of the liver and is indicated in all patients with symptomatic disease.^8,9 The goals of surgery for heaptic hydatid disease is to remove all the parasite, to prevent spillage of parasitic daughter cyst and protoscolices and to preserve as much of liver function.10 Care has to be taken to detect any cyst biliary communication at the time of surgery.

The pericyst in hepatic hydatids is thick and contains vessels and biliary channels. An attempt to dissect this layer will cause widespread damage leading to bleeding and biliary leak which needs to be avoided. The pericyst does not contain any infective material. The infective material is in the germinal layer which can easily be removed as it comes out easily with the laminated membrane after incising the pericyst. The standard surgical option is to inject a scolicidal solution (e.g. hypertonic saline freshly prepared cetrimide solution or silver nitrate solution) into the cyst followed by aspiration of the contents. The pericyst is then incised. The laminated membrane alongwith the germinal layers are then slowly removed. The cyst is then deroofed. If the residual cavity is large it should be packed with omentum. If there are any cyst biliary communications as evidenced by bile leak intraoperatively these should be underrun with absorbable suture material. Adequate drainage should be kept in and around the cyst. If there is intrabiliary rupture of the cyst characterized by jaundice and confirmed preoperatively by ERCP, then CBD exploration is mandatory to clear the biliary tract of all macroscopic parasitic disease. Either a T tube or a choledochoduodenostomy should be performed to drain residual parasitic disease.3

In extrahepatic hydatids the pericyst is very thin and therefore a plane of dissection can always be found and developed between the cyst and the surrounding tissues. Hence the cyst is dissected and excised fully along with the pericyst.⁹

The recurrence rate of hydatid disease after surgical treatment is a controversial issue.¹² The recurrence rate is approximately 2%. However the recurrence rate after extra hepatic hydatid disease is very high as it is impossible to identify small residual seedings. Only grossly visible disease can be removed. A postoperative long term follow up regimen is essential. Early postoperative imaging provides a baseline for late comparisons. Repeated imaging every 6 weeks is essential.

Acknowledgement

We thank the Medical Superintendent of Rajawadi Municipal General Hospital, Ghatkopar, Mumbai - 77 for allowing us to publish this case report.

References

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8. Cohen Z, Stone RM, Langer B. Surgical treatment of hydatid disease of the liver. Can J Surg 1976; 19 : 416.

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12. Mottaghian H, Saidi F. Postoperative recurrence of hydatid disease. British J Surg 1978; 65 : 257.

IN PAKISTAN, ONE IN THREE PEOPLE ARE ANXIOUS OR DEPRESSED

Socioeconomic adversity and relationship problems are major risk factors for anxiety and depressive disorders in Pakistan. In a review of 20 studies, Mirza and Jenkins found that the prevalence of anxiety and depression in Pakistan was 33%. Being anxious or depressed was associated with female sex, middle age, low level of education, difficulties with finances, being a housewife, and relationship problems; a supportive family and friends may be of help. The authors were concerned with the methodological quality of the studies, and results should be interpreted with caution.

BMJ, 2004; 328 : 794.