hydated disease ,investigations and management

1. DR.MEHMOOD-UR-REHMAN
PG-WARD 26 JPMC
HYDATED DISEASE
(Echinococcoses)

2. Layout
 History
 Genus
 Epedemiology
 Organs affected
 Hosts of parasite
 E.granulosa morphology,life cycle and pathogenecity
 Clinical feature
 Investigations
 Managemant
 prevention

3. HISTORY
 Hydated means “drop of water”
 Echinococcus: “hedgehog” .it was coined by Rudholphi in
early 19s.
Hydated disease (one of the oldest disease) know to
mainkind,is a parasitic infestation caused by tapeworm of
genus Echinococcus.
It was first described in th talmud as a “Bladder full of water”.
Hippocrates described the hydated disease more then two
thousand years ago with a very intresting expression
“Liver filled with water”

4. Genus Echinococcus
4 species
 E.granulosus-The most commonest cuases “cystic”
hydated diseaase.
 E.multilocularis-most virulant causes alveolar disease.
 E.vogeli & oligarthus-the polycystic echinococcosis.

5. EPIDEMIOLOGY
 E.granulosa is present worldwide (more common in
sheep and cattle raising countries) including
Pakistan and India.
 E.multilocularis the alveolar form common in central
and northern Europe, north America and Asia
 E.vogeli and oligarthus in central and south America.

6. Affectees and Death
 Approximately 1.4 million are affected annually.
 In 1990 ,2000 deaths were reported
 2010, 1200 deaths reported.

7. Organs affected
 Liver:52-75%
 Lungs:10-30%
 Abd cavity:8%
 Kidneys:7%
 CNS: less then 2%
 Bones:1-2%
 Unusual sites :spleen,heart,adrenals glands,salivary
glands,eye,ovaries,pancreas and thyroid.

8. Hosts
Organism Definitive host Intermediate host
E.Granulosus Dogs and other canidae Sheep,gaot,cattle,camel,b
uffalos,kangroos and
other wild herbivores
E.Multilocularis
(Small fox
echinococcosis)
Foxes,dogs and cats Small rodents
(Mice,rats
,squirrals,rabbits.)
E.Vogeli and oligarthus Bush Dogs and dogs Small rodents

9. E.Granulosus
 Most common,causes cystic disease in almost any
organ the most common being liver 75% followed by
lungs 10-30%.
 Also called as Hydated worm , dog tapeworm
 About 3-6mm long.
 Definitive host is dog.Sheep and cattle being
intermediate host.
 Human is incidental and usually dead end host.

10. Morphology
 Adult worm :3-6mm long.
 SCOLEX: pyriform with 4 suckers and a rostellum
with 2 circular rows of hooklets.
 NECK:thick and short.
 STROBILA: 3-4 proglottids
usually(immature,mature and gravid).

11. Morphology

13. Life cycle

15. Life cycle
 Adult warm resides in the small intestine of
definitive host,eggs are produced by the gravid
proglottids which are released in feces,being ingested
by intermediate host or incidental host like
human.the egg hatches in small intestine and
releases oncosphere (embryo with 6 suckers) which
penetrate intestinal wall and reach diff organs like
liver through blood stream and develops into cyst.
 The cyst enlarges creating many protoscolices and
daughter cyst within cyst.

16. Life cycle
 The cyst containing organs are then ingested by the
definitive host and and the cycle restarts.
 In case of human the eggs are ingested accidently in
vegetables berries and soil.

17. Pathogenicity
 Hydated cyst represents LARVAL FORM.
 Acquired during childhood.
 Cyst displaces the vital host tissues , demages and
causes dysfunction.
 Cyst can survive in the organs for many years.
 Cyst wall is formed by
Pericyst
Ectocyst
Endocyst

19. Clinical features
 Can affect almost any organ most commonly liver and
lung.
 in case of liver hydated cyst it can be asymptomatic or
patient can present with abdominal
pain,dyspepsia,vomiting,fever and jaundice.
 Frequent sign is hepatomegaly/palpable mass.
 Bacterial superinfection can cause pyogenic abscess.
 Rupture can occur into billiary tree.
 Free rupture into body either spontanously or during
surgery can cause fatal anaphylactic
reaction,fever,pruritis,oedema,dyspnea and stridor.
 Incase of lung it can cause cough,SOB and chest pain and
mass effect.

20. workup
 Routine workup is of little value.
 In patient with ruptured cyst there can be transient
elevation of liver enzymes,Amylase and
eosinophilia(60%).
 Indirect hemagglutination test and ELISA are most
widely used to detect antibodies but they can give
false positive result in case of schistosomiasis and
namatodes that is why they are not specific in
diagnosing hydatidosis.

21. Imaging studies
 Plan radiograph,Usg,CT,MRI,MRCP,ERCP.
 Plan radiograph can show liver,lung calcified cyst.
 Usg is the most important and initial imaging study
for diagnosis , which can be supplemented by CT and
MRI.
 CT is the study of choice which can be further
confirmed by MRI
 In polycystic disease same imaging can show the
cyst.

32. WHO Classification
 In 2003 WHO IWGE proposed USG classification
based on the status of activity of cyst.
 GROUP 1: Active group-cyst larger then 2cm and
often fertile.
 GROUP 2: Transition group -cyst starting to
degenrate and entering a transition stage because of
host resistance or treatment.
 GROUP 3: Inactive group -degenerated partially or
totally calcified cyst,unlikely to contain viable
protoscolices.

33. Management options
 Medical.
 Surgical
 PAIR.

34. Medical management
 INDICATIONS
Primary liver and lung cyst that are inoperable
because of location or some other medical reason.
Cyst in 2 or more organs.
Peritoneal cyst.

35. Medical management
 Albendazole 10-15mg/kg/day or 400mg twise daily
for adults.given in cycles of 28 days with 2 weeks
treatment free period.
Schedules
1. Inoperable cases- 3 cycles
2. Pre operative cases- 6 weeks continues to reduce
risk of recurrance
3. Post operative cases- 3 cycles to reduce recurrance
incase of intra operative spillaeg of cyst contents.

36. Contraindications of medical treatment
 Early pregnancy
 Bone marrow suppression
 CLD
 Large cyst with risk of rupture
 Inactive or calcified cyst.
 Bone Cyst (relative contraindication)
30% patients have complete recovery after medical
treatment.

37. SURGICAL MANAGEMENT
Usually managed in a tertiary care unit by a
multidisciplinary team of surgeon , physician and
interventional radiologist.
INDICATIONS
 Large cyst with multiple daughter cyst.
 Superficial liver cyst.
 Cyst of liver with billiary communications or pressure
effect.
 Infected cyst.
 Cyst in lung, brain, kidneys, eyes, glands,heart,brain.

38. Options include
 Pericystectomy with omentoplasty
 Hepatic segmentectomy
 Conservative open cystectomy or tube drainage of
infected cyst
Scolicidal agents (hypertonic saline 15-20% and
ethanol 75-90% or 1% povidine solution) are used
during surgery.
These procedures are also being tried laparoscopically.

39. Conservative management
(open cystectomy)
 The conservative technique consist of aspiration of
the cyst,instilation of scolicidal agents and
evacuation of cyst contents and leaving the pericyst.
 The residual pericyst is managed by
1. Marsupialization (suturing the edges of opened
pericyst with skin).
2. Cappitonage (suture oblitration)
3. Partial pericystectomy and omentoplasty.

40. Marcupialization.

41. cappitonage

42. PAIR

43. PAIR (1986)
PAIR PROTOCOL (for hepatic hydated cyst)
 Prophylaxis with albendazole
 Puncture and parasitological examination if possible or
fast test for antigen.
 Aspiration of cystic fluid (10-15cc).
 Test for billirubin in cystic fluid.
 If billirubin present then stop procedure
 If absent aspirate all cystic fluid.
 Injection of 95% ethanol or hypertonic saline 15%(1/3 of
the aspirated fluid)
 Reaspiration of protoscolicidal solution after 15 min.

44. Contraindications of PAIR
 Non co operative patient.
 Risky location of cyst.
 Cyst in spine brain and heart.
 Calcified cyst
 Cyst in communication with billiary tree
 Ruptured cyst

45. Laparoscopic management
A specialized apparatus has been developed to remove
hydated cyst through laparoscope called
perforator-grinder-aspirator appratus.
This instrument perforates the cyst,grinds the
particulate matter and sucks it all out.
The advantage of this instrument over the
conventional is that it does not get blocked by the
daughter cyst and laminated membrane.

46. Complications
 All complications related to surgery and anesthesia.
 Related to parasite recurrence
 Metastasis
 Spillage and seeding (anaphylaxis and allergy)
 Infections
 Related to medical treatment
 Hepatotoxicity
 Anemia
 Thrombocytopenia
 Alopecia
 teratogenicity

47. Complications
 Related to PAIR
Hemorrhage
Mechanical damage
Infections
Allergies
Persistence of daughter cyst
Sudden intracystic decompression leading to billiary
fistula
 Related to scolicidal agent: cholangitis

48. Preventions.
 Keep dogs away from eating infected feces and
contaminated meat.
 Keep yourself away from eating raw offal and food or
substances infected with dogs feces.

49. THANKYOU