Presentation of a case of liver Hydatid Cyst (HC) treated in Al Hammadi Hospital, Suwaidi, Riyadh, Kingdom of Saudi Arabia in 2017. Includes US and CT images findings and operative technique. Followed by a review of HC including epidemiology, presentation, diagnosis, treatment and prevention in an illustrated presentation. This presentation is hoped to be of help to medical students, junior doctors, trainees in surgery as well as senior surgeons. Dr. Mohamad Al-Gailani FRCS Consultant Surgeon Medical Education & Training Director Al Hammadi Hospital, Suwaidi Riyadh KSA 2017

1. HYDATID CYST OF THE LIVER
Case Presentation
KSA 2017
DR. MOHAMAD AL-GAILANI FRCS
‫الكيالني‬ ‫محمد‬ ‫الدكتور‬
CONSULTANT SURGEON
MEDICAL EDUCATION & TRAINING DIRECTOR
SUWAIDI
Riyadh
KSA

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
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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
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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
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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
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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
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7. ULTRASOUND (PRE CHOLECYSTECTOMY)
JANUARY 2016
DR. MOHAMAD AL-GAILANI FRCS AHH SUWAIDI HYDATID CYST OF THE LIVER CASE PRESENTATION KSA 2017
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• Hydatid Cyst Liver 8x4.5
cm Right Lobe (Segment
VIII)
• Gall Bladder Distended,
Multiple Stones 5-10 mm
• Thickened Oedematous
Wall.
• CBD Normal

8. ULTRASOUND (POST CHOLECYSTECTOMY)
MARCH 2017:
DR. MOHAMAD AL-GAILANI FRCS AHH SUWAIDI HYDATID CYST OF THE LIVER CASE PRESENTATION KSA 2017
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• Right Lobe Liver Cystic
Mass 7.5x6.5 cm.
• Normal CBD.
• Absent Gall Bladder
(Cholecystectomy)
• Dx: Hydatid Cyst Right
Lobe Liver.

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
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10. CT scan (1)
June 2017
DR. MOHAMAD AL-GAILANI FRCS AHH SUWAIDI HYDATID CYST OF THE LIVER CASE PRESENTATION KSA 2017
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• Hydatid Cyst liver
Right Lobe
• Water Lily sign
• Normal CBD
WATER LILY
SIGN

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
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12. CT scan (2)
DR. MOHAMAD AL-GAILANI FRCS AHH SUWAIDI HYDATID CYST OF THE LIVER CASE PRESENTATION KSA 2017
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13. CT scan (3)
DR. MOHAMAD AL-GAILANI FRCS AHH SUWAIDI HYDATID CYST OF THE LIVER CASE PRESENTATION KSA 2017
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HYDATID
CYST

14. CT scan (4)
DR. MOHAMAD AL-GAILANI FRCS AHH SUWAIDI HYDATID CYST OF THE LIVER CASE PRESENTATION KSA 2017
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HYDATID CYST

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
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16. OPERATIVE FINDINGS:
DR. MOHAMAD AL-GAILANI FRCS AHH SUWAIDI HYDATID CYST OF THE LIVER CASE PRESENTATION KSA 2017
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The smaller HC at Gall
Bladder fossa
DR. M. AL-GAILANI FRCS, AHH SUWAIDI

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
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18. The smaller HC at Gall Bladder Fossa
DR. MOHAMAD AL-GAILANI FRCS AHH SUWAIDI HYDATID CYST OF THE LIVER CASE PRESENTATION KSA 2017
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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.
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20. HYDATID CYST DISEASE
DR. MOHAMAD AL-GAILANI FRCS AHH SUWAIDI HYDATID CYST OF THE LIVER
CASE PRESENTATION KSA 2017
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21. EPIDEMIOLOGY OF HC:
DR. MOHAMAD AL-GAILANI FRCS AHH SUWAIDI HYDATID CYST OF THE LIVER CASE PRESENTATION KSA 2017
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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. ECHINOCOCUS GRANULOSUS
TAPE WORM
DR. MOHAMAD AL-GAILANI FRCS AHH SUWAIDI HYDATID CYST OF THE LIVER CASE PRESENTATION KSA 2017
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SCOLEX SHOWING HOOKS

23. HYDATID CYST INTERMEDIATE HOST (SHEEP)
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Prevalence of HC in
slaughtered sheep in
Riyadh City around 1.06%.
E. Almalki Et Al.
Saudi Journal of Biological
Sciences (2017)

24. MAJOR PUBLIC HEALTH HAZARD!
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SHEEP OFFAL
(HC) FED TO
DOGS
DOGS EXCRETA CONTAING OVA CONTAMINATE
AGRICULTURE

25. ECHINOCOCUS GRANULOSUS OVUM
INFECTIVE TO HUMANS
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Resistant to all
antiseptics
including
Permanganate
antiseptic & even
to Formalin!

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
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OVA
SALADHC OVA INFESTED LETTUCE

27. HYDATID CYST
ACCIDENTAL INTERMEDIATE HOST (HUMANS)
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28. HYDATID CYST ANATOMY
DR. MOHAMAD AL-GAILANI FRCS AHH SUWAIDI HYDATID CYST OF THE LIVER CASE PRESENTATION KSA 2017
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ECTOCYST (HOST)
DAUGHTER CYSTS
ENDOCYST (HC)
GERMINAL LAYER

29. HC CAN AFFECT ANY ORGAN!
DR. MOHAMAD AL-GAILANI FRCS AHH SUWAIDI HYDATID CYST OF THE LIVER CASE PRESENTATION KSA 2017
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LIVER 65%
LUNG 25%
• Brain 1%
• Spleen 1%
• Bone 3%
• Kidney 2%
• Eyes
• Thyroid Gland
• Breast

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
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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
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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
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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
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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
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35. PUBLIC HEALTH & PREVENTION:
• Breaking down the life cycle by stray dog
control
• Preventing sheep offal from being fed to stray
dogs
• Thorough washing of all vegetables especially
lettuce with soap and running water
• Soaking of vegetables in Potasium Permangate
or any other antiseptic is ineffective!
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36. 36
DR. MOHAMAD AL-GAILANI FRCS AHH SUWAIDI HYDATID CYST OF THE LIVER CASE PRESENTATION KSA 2017