Gastro 53 Liver infections Liver abscess Hydatid cyst of liver

1) Needle aspiration of pus - for ≤5 cm diameter collection. Repeat needle aspiration may be required.

2) Percutaneous catheter drainage - >5 cm diameter

3) Surgical drainage in the following circumstances:

• •Multiple abscesses (depending on number, position, and size)
• •Loculated abscesses
• •Abscesses with viscous contents obstructing drainage catheter
• •Underlying disease requiring primary surgical management
• •Inadequate response to percutaneous drainage within seven days

4) Antibiotics according to culture sensitivity for a four to six week course of treatment

fd

• (a) cystic echinococcosis (hydatid disease) caused by E. granulosus
• (b) alveolar echinococcosis (alveolar hydatid disease) caused by E. multilocularis.and
• (c) polycystic echinococcosis caused by E. vogeli or E. oligarthus

The cyst grows very slowly in size. So symptom does not appear until adult life. An interval of 20–30 years has been known to exist between primary infection and manifestation of the symptoms.

• Definite host - Dog
• Intermediate host - Sheep
• Intermediate accidental host - Humans

The egss hatch in the duodenum. and the released oncosphere penetrates the mucosa and reaches a blood vessel. The bloodstream can carry the oncosphere to any part of the body, but it most frequently settles in the liver and lungs. Once settled, the parasite develops its larval stage.

• The typical lesion is a cystic cavity filled with clear hydatid fluid containing live protoscoleces.
• The hydatid cyst of the liver has two layers:
• the outer acellular layer called the pericyst or ectocyst, a dense fibrous host reaction to the parasite that is 2 to 5 mm thick and it consists of compressed liver cells and fibrotic tissue, and an inner cellular germinal layer that is called the endocyst or the germinative membrane from which brood capsules containing protoscoleces proliferate toward the cystic cavity.

The pericyst is calclficated in approximately half of the patients

• (1) the outer pericyst - made by host cells
• (2) the middle laminated membrane - white structure
• (3) the inner germinal layer

Pericyst is not present in brain and pulmonary echinococcus. 

The presence of daughter cysts is a problem for chemotherapy, protoscollcide activity, and the standard PAIR procedure.

• CE2 - Rossette like, daughter cyst (active phase)
• CE3A - cyst with daughter membrane (Water lily)
• CE3B - daughter cyst

• 
• 

Type I - Univeslcular hydatid cyst with liquid component only. 

Type 2 - Univesicular cyst with floating membranes

Type 3 - Multivesicular cyst with prominent liquid component (daughter vesicles)

Type 4 Pseudotumoral leslon with prominent solid component

Type 5 - calcified solid lesion

• The brood capsules arise from germinal epithelium. The brood capsules undergo localized proliferation and invagination of their wall to form scolices.
• Some brood capsules separate from germinal membrane and settle at the bottom of the cyst cavity as fine granular sediment called hydatid sand. 

USG 

CECT - to delineate different cysts, more in relation to the liver segments, which will help to plan operative management.

MRI - delineation of intrahepatic and extraheaptic biliary tree and its relationship to the cyst and any evidence of cystobiliary communication.


ERCP - Routine ERCP is not required. In patient presenting with obstructive jaundice due to cystobiliary communcation, endoscopic sphincterotomy can allow removal of daughter cyst from the biliary tree.

• Symptoms -
• Right upper quadrant discomfort/pain
• Dyspepsia
• Vomting
• Nonspecific fatigue
• Asymptomatic
• Weight loss
• History of jaundice
• History of fever
• Allergy

• Signs -
• Fever
• Jaudice
• Malnutrition
• Pleural effusion
• Cholangitis
• Splenomegaly

• 1. Pressure effects:
• • Pressure of cyst on bile duct—obstructive jaundice
• • Pressure of cyst on portal vein—portal hypertension.

• 2. Rupture: It may rupture into
• • Peritoneal cavity
• • Into intestine or stomach—cyst content may be vomited out
• • Into biliary tree—biliary colic, fever and jaundice
• • Into pleural cavity —empyema
• • Into lungs—cyst content and bile may be coughed out.

3. Infection and suppuration—pain, rigor and fever.

4. Anaphylactic shock due to rupture of the cyst.

• (a) biliary colic,
• (b) partial intermittent or complete ductal obstruction with cholangitis and jaundice. and
• (c) germinative membranes in the feces.

• Rupture into a large bile duct may allow more or less complete emptying of the fluid and debris and lead to spontaneous cure or cholestatic jaundice with recurrent cholangitis.
• The rapid discharge of the cyst contents into a major bile duct or body cavity can lead to the sudden absorption of the hydatid antigen in a sensitized patient resulting in anaphylaxis.

• (a) subdiaphragmatic site of HC.
• (b) disseminated disease,
• (c) extra-abdomlnal location
• (d) compllcated. symptomatic cysts, and
• (e) pre-surgical evaluation and planning

MRCP is an excellent noninvasive tool for investigating jaundiced patients with liver hydatidosis.

We use albendazole 4 weeks before surgery. If we suspect that during surgery we have any kind of spillage. we use it for 6 months postoperatively, and if not. we use it for 3 months postoperative.

• 1. Inoperarable patients with primary liver and lung cystic echinococcosis. 
• 2. Patients with multiple cysts in two or more organs. 
• 3. Multiple small (<5cm, CE1 and CE3)
• 4. Cyst deep in liver parenchyma 
• 5. Prevention and management of secondary hydatidosis 
• 6. Management of recurrent hydatidosis 
• 7. Unilocular cyst in unfit elderly patients.
• 8. Pulmonary echinococcosis 
• 9. Long term administration in hydatid cyst of bone, brain and eye.

• Large cysts (>10cm)
• Cysts with multiple septa divisions (Honeycomb/rossette like cysts)
• Cysts that are prone to rupture, i.e superficial. 
• Infected cyst
• Inactive cyst / Asymptomatic calcified cyst 
• Severe chronic hepatic disease 
• Bone marrow depression 
• Early pregnancy 
• Diabetes is a relative contraindication

• • Potential risk of embryotoxicity and teratogenicity (observed in early stage of pregnancy in some laboratory animals). (Contraceptive measures are thus indicated in women, and PAIR should be performed without chemotherapy during early pregnancy)
• • Hepatotoxicity (transient increase of aminotransferases), neutropenia, thrombocytopenia, alopecia

• • Cyst type CL, CE1, CE3 and some CE2 (Gharbi Type I and II and some patients with type III and IV)
• • Relapse after surgery 
• • Failure of chemotherapy 
• • Multiple cyst of >5cm diameter in different liver segments 
• • Infected cysts
• • Pregnant women
• • Patients who fail to respond to chemotherapy alone / relapse after surgery
• • Patients in whom surgery is contraindicated

• • Non-cooperative patients and inaccessible or risky location of the cyst in the liver
• • Superficially located cyst
• • Cysts with multiple septa/division (CE2, CE3B)
• • CE4/ CE5
• • Cysts communicating with bile duct. 
• • Cyst in spine, brain and/or heart
• • Most cysts in lungs 
• • Cysts open into the abdominal cavity, bronchi and urinary tract

• • Same risks as any puncture (haemorrhage, mechanical lesions of other tissues, infections)
• • Anaphylactic shock or other allergic reactions
• • Secondary echinococcosis caused by spillage
• • Chemical ( sclerosing ) cholangitis if cysts communicate with the biliary tree
• • Sudden intracystic decompression, thus leading to biliary fistulas
• • Persistence of satellite daughter cysts
• • Systemic toxicity of alcohol or hypertonic saline in case of large cysts (total volume injected must be carefully calculated)

• „ 20% hypertonic saline
• „ Cetrimide solution
• „ Silver nitrate
• „ Formalin and
• „ 95% alcohol.

• Large cyst with multiple daughter cysts  (Type CE2, CE3B)
• Single liver cyst situated superficially that may rupture. 
• Infected cyst if PAIR is not available
• Cysts with cystobiliary communication 
• Cysts exerting pressure in adjacant organs
• Cysts in lung, brain, bones, kidney and other organs.

• Patients refusing surgery 
• Extreme age 
• Pregnant women 
• Concommitant severe disease 
• Numerous cyst 
• Cysts difficult to access 
• Dead cysts 
• Cysts partially or totally calcified. 
• Very small cysts (<5cm) - wait and see policy

• Size - <5cm - Albendazole, >5cm - PAIR/Surgery
• Multiple - Small - albendazole, if large and accessible - PAIR 
• CE2/CE3B - Surgery 
• CL/CE1/CE3A - Albendazole/PAIR 
• CE4/CE5 - Observe 
• Superficial - Surgery 
• Deep seated - Albendazole 
• Pregnant - PAIR 
• Infected - PAIR/Surgery
• Cystobiliary communication - Surgery 
• Adjacant pressure effect - Surgery

• Minor communication - fistula less than 5cm, mostly asymptomatic preoperatively, and revealed intraoperatively by the presence of bile leak.
• Major communication - more than 5mm in diameter, patients presented with obstructive jaundice and cholangitis

• (a) suture of the communlcation (e.g., simple suture, suture with with T-tube CBD drainage, intralameral pericystectomy:. and capitonnage).
• (b) internal drainage procedures (e.g., biliodigestive bypass. transduodenal sphincterotomy, internal transfistular drainage with or without transduodenal sphincteroplasty),
• (c) external drainage procedure (e.g., bipolar drainage, cystobiliary disconnection),
• (d) reconstructive procedures (e.g., pericystojejunostomy, intracavitary billodigestive bypass. or bile duct repair
• (e) liver resectlon.

• (a) leaving the cyst open.
• (b) simple cyst closure.
• (c) marsupialization.
• (d) external tube drainage.
• (e) introflexion.
• (f) capitonnage,
• (g) omentoplasty,
• (h) partial capitonnage plus omentoplasty 
• (I) Roux-en-Y cystojejunostomy