|
|
|
|
OJHAS Vol. 7, Issue 2: (2008
Apr-Jun) |
|
|
| Giant intra-abdominal hydatid cysts
with multivisceral locations |
|
Sujeet Raina, Senior Resident,
Mahesh DM, PG student
Vivek Sood, PG student
Jitender K Mokta, Assistant Professor
Rajiv Raina, Associate Professor
Satinder Singh Kaushal,
Professor &
Head,
Department of Medicine, Indira Gandhi Medical College,
Shimla - 171001 (Himachal Pradesh) |
|
|
| |
|
|
|
|
|
|
Address For Correspondence |
Fire Officers Building,
Stokes Place,,
Shimla (H.P) 171002
E-mail:
sujeetrashmishera@yahoo.co.in |
|
|
|
|
|
Raina S, Mahesh DM, Sood V, Mokta JK, Raina R, Kaushal SS. Giant intra-abdominal hydatid cysts
with multivisceral locations. Online J Health Allied Scs.
2008;7(2):10 |
|
|
|
Submitted: April 18, 2008; Accepted:
June 20, 2008; Published: July 21, 2008 |
|
|
|
|
|
|
|
|
| |
| Abstract: |
|
The
disseminated intra-peritoneal hydatid disease is a very rare finding.
A case of disseminated intra abdominal hydatid disease is presented
along with a review of literature and various therapeutic modalities.
Key Words:
Hydatid cyst, peritoneal hydatosis, rectovesical hydatid cyst |
|
Hydatid disease is a parasitic infection
caused by the larval stage of the cestode, Echinococcus granulosus.
It is endemic in many parts of the world, including India. Most frequently
it affects the liver and lung. Involvement of the peritoneal cavity
is uncommon, accounting for 13% of abdominal echinococcosis. Unusual
locations as well as multiple primary or secondary hydatid disease pose
special therapeutic challenges.(1) We report a case of disseminated
abdominal hydatosis who presented with features of obstructive uropathy
and investigations revealed hydatid cyst in rectovesical pouch besides
liver, spleen and peritoneum.
A 28 year male shepherd presented with
a dull aching pain and gradually increasing lump in the right hypochondrium
and epigastric region over six months. There was history of acute retention
of urine thrice in the past twelve days for which patient was catheterized.
Anorexia and weight loss were associated complaints. History of constipation
was also present. There was no history of jaundice. He was operated
upon for hepatic hydatic disease seven years back. Examination revealed
multiple cystic swellings in abdomen. Hepatospleenomegally was present.
Both liver and spleen were having irregular surface with multiple, nontender
cystic masses palpable over the surface. Soft irregular masses were
also felt in the umbilical and hypogastric regions. On per rectal examination,
a mass was felt from anterior rectal wall but rectal mucosa was free.
Review of other systems was normal. On laboratory investigations hemogram
revealed mild increase in the eosinophil count (3%) and raised ESR (55mm
at the end of 1 hour) , Biochemistry screen revealed normal investigations
including a normal liver function profile. Test for antibodies against
Echinococcus granulosus was 15.99 U/ml and was positive. Ultrasound
examination of the abdomen and pelvis revealed multiple, thin walled
cystic lesions of variable size in the liver and spleen with cartwheel
appearance. The peritoneum and the pelvis were studded with similar
cystic lesions. Plain CT scan of the abdomen revealed multiple, well
defined cystic lesions throughout the abdomen.(Fig-1) The
cysts were multi loculated with multiple internal septations suggestive
of hydatid disease. Liver and spleen appear to be replaced by the multiseptated
cysts.(Fig-2) A large cyst is seen in the
pelvic cavity producing a pressure affect on surrounding structures
but not invading them.(Fig-3) A diagnosis of secondary echinococcosis
was made on clinical features and investigations. Patient was started
on albendazole (15mg/kg/day) and follow up was advised. Patient has
been lost in the follow up.
|
 |
|
Figure-1
CT abdomen showing peritoneal hydatid cyst |
|
|
|
 |
|
Figure-2
CT abdomen showing hydatid cyst in liver and spleen |
|
|
|
 |
|
Figure-3
CT abdomen showing hydatid cyst in rectovesical pouch |
Hydatid disease is a parasitic disease caused by the larval stage of
Echinococcus granulosus. Hydatid disease remains a continuous public
health problem in endemic countries including India.
The most frequently involved organs are the liver (55-70%) followed
by the lung (18-35%); these two organs affected simultaneously in about
5-13% of cases, the spleen (5%) and other organs (5%).(1-2 ) Apart from common sites such
as liver and lungs in humans, hydatid cysts can present in unusual sites
which include peritoneum, kidney, muscle, adrenal gland, ovary, pancreas,
thyroid gland, pleura, diaphragm, uterus and brain.(1) The peritoneal hydatid disease represents
an uncommon occurrence with an overall frequency of peritoneal disease
in cases of abdominal echinococcus at approximately 13%. Peritoneal
hydatidosis is almost always secondary to hepatic disease, although
some unusual cases of primary peritoneal hydatidosis have been described.
Peritoneal involvement is usually undetected unless cysts are large
enough to cause symptoms. Most of the cases of peritoneal hydatid disease
are secondary to previous surgery for liver hydatidosis; however, spontaneous
microrupture of a hepatic cyst into peritoneum has also been reported.
Intraperitoneal rupture of hepatic or splenic cysts results in release
of brood’s capsule, scolices and daughter cysts which implant and
develop independently leading to multiple disseminated intraperitoneal
hydatid disease. This phenomenon is called secondary echinococcosis.(3)
Peritoneal hydatid disease may grow and occupy the entire peritoneal
cavity, simulating a multilobulated mass. This pathological condition
is known as encysted peritoneal hydatidosis. Peritoneal hydatid disease
represents an uncommon occurrence and its diagnosis is more accurate
today due to the new imaging techniques.(4) A double contrast
CT scan is 90-100% accurate for diagnosing secondary echinococcosis
and is superior to USG in identifying additional extrahepatic intra
abdominal cysts.(3) CT is the modality of choice for these patients
because it permits imaging of the entire abdomen and pelvis.(5)
The goal of treatment is to prevent secondary complications
of the disease. In cases of disseminated systemic disease, inoperable
cases, cyclic therapy with a benzimidazole compound is preferred and has been found to cure disease
in 10-30% of cases, to slow progression in 50%-70% and to yield no change in 20%- 30%.(6) Albendazole seems to be more effective
owing to better penetration and absorption. These agents
have actually been used in several studies as a conservative
treatment, leading to some decrease or stabilization of the
cyst size, especially in cases with small cysts. Albendazole is combined
with surgery to prevent postoperative
recurrence.(2) After medical therapy, follow up is advisable with USG
or CT scan. After medical treatment, hydatid cysts shows gradual reduction
in cyst size and number. The cyst becomes poorly defined and denser.
Daughter cysts may disappear or may rupture and the laminated membrane
may separate from the pericyst and collapse. Thickening and calcification
of the cyst wall can be taken as therapeutic response if it was absent
before treatment. Cyst disappearance should be regarded as the criteria
with most promising prognostic value.
Surgical removal
of the cyst is customized to each patient depending on the patient's
general condition, the number and localization of cysts, and the surgeon's expertise.(1-2) Recurrence of hydatid disease after after radical procedures is very low, but not zero and the
possibility of recurrence always remains.(2) PAIR( puncture, aspiration,
instillation of scolicidal agents and reaspiration) technique is also
possible in cysts relapsing after surgery or failed chemotherapy. However
PAIR is contraindicated in cysts that communicate with biliary tree,
superficial cysts and cysts with thick internal septal divisions.(7)
The purpose
of reporting this case is to highlight the uncommon presentation of
hydatid disease due to multivisceral and peritoneal locations.
- Syed Abdullah
Iqbal, Masood Jawaid, Fareya Usmani: Disseminated Intra-Abdominal Hydatidosis:
A Very Rare Presentation. The Internet Journal of Surgery.
2007;11:1.
-
Safioleas MC, Misiakos
EP, Kouvaraki M, et al. Hydatid Disease of the Liver. Arch Surg. 2006;141:1101-8
-
Sahu SK, Singh P, Sachan PK,et al. Secondary echinococcosis.
Indian
J Surg 2006;68:334-5.
-
Tarcoveanu E, Dimofte G, Bradea C,et al. Multiple Peritoneal Hydatid
Disease after Rupture of a Multivesicular Hepatic Hydatid Cyst. Case
report. J Gastrointestin Liver Dis 2006;15:301-5
-
Yuksel M, Demirpolat G, Sever A, et al. Hydatid disease involving
some rarelocations in the body: a pictorial essay. Korean J Radiol
2007;8:531-40
-
Karmali S, Thompson
SK, McKinnon G, et al. A 37-year-old woman with fever and
abdominalpain. CMAJ 2005;172:1683.
-
White CA, Weller PF. Cestodes. In: Kasper DL, Braunwald E,
Fauci SA, Hauser SL, Longo DL, Jameson JL, eds. Harrison′s Principles
of Internal Medicine. 16th ed. New York. McGraw-Hill.2005. pp 1275-6
|
