management options in hepatic hydatid disease

Saudi Journal of Medicine & Medical Sciences | Vol. 2 | Issue 2 | May-Aug 2014 | 90-9490

Management Options in Hepatic Hydatid Disease

Mohamed I. YasawyDepartment of Internal Medicine, College of Medicine, University of Dammam, Dammam, Kingdom of Saudi Arabia

Correspondence: Dr. Mohamed Ismail Yasawy, Department of Internal Medicine, College of Medicine, University of Dammam,P.O. Box 40143, Al-Khobar 31952, Kingdom of Saudi Arabia. E-mail: [email protected]

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DOI:10.4103/1658-631X.136994

A B S T R A C T

Objective: The aim of this retrospective study is to analyse the outcome of 4 different methods in management of hepatic hydatid disease.

Patients and Methods: The study was carried out in the Military Hospital, Riyadh: 110 patients were included; 37 were treated medically; 26 patients were subjected to percutaneous drainage via ultrasound guidance. Fifty patients required surgical treatment, while the remaining 10 patients were managed endoscopically.

Results: The study showed different responses of the 4 methods applied.

Conclusion: This retrospective analysis revealed that percutaneous draiange of the hydrated cysts achieved the best yield among all other methods.

Key words: Hydatid disease, management, percutaneous drainage

ملخص البحث:تناقش هذه الدراسة الاسترجاعية نتائج أربعة طرق لعلاج مرضى عدارى الكبد . شملت الدراسة 110 مريضًا ، عولج منهم 37 دوائياً ، بينما

تم علاج 26 مريضًا بتجفيف أكياس المرض بوضع إبرة عبر الجلد بواسطة السونار . كما تم علاج 50 مريضًا جراحياً ، أما المرضى العشرة المتبقين فكان علاجهم عن طريق المنظار . بينت هذه الدراسة نسباً مختلفة لاستجابة المرضى للطرق الأربعة المتبعة وكانت أفضل النتائج هي

تجفيف الأكياس عن طريق وضع أنبوبه عبر الجلد بواسطة الأِشعة الصوتية.

ORIGINAL ARTICLE

(PAIR) are practised using different scolicidal agents with variable outcomes.

This retrospective study evaluates the outcome of different approaches in the management of hepatic E. granulosus.

PATIENTS AND METHODS

A total of 110 patients with hepatic hydatidosis were treated in Riyadh Armed Forces Hospital, Saudi Arabia. The diagnosis was based on epidemiological grounds, imaging studies and positive serology in some patients using indirect hemagglutination test with long-term follow-up. The study was completed in the year 2000.

Fifty-eight patients were females, and 52 males with age range of 12-80 years and the median age was 38 years. Twenty-four patients (19.5%) had a history of previous surgery for hydatid liver disease. Fifteen out of the 24 patients had more than two operative interventions for recurrence of the disease. According to treatment

INTRODUCTION

Echinococcosis or hydatidosis has been described over 1000 years ago and still seen all over the world and remains a major health problem especially among farmers and shepherds.[1-4] Hydatidosis has been classifi ed to two main groups of Echinococcus granulosus and Echinococcus alveolaris or multilocularis. E. granulosus is the most common form. Until recently, surgery was the standard choice in the treatment of hepatic echinococcus. Currently, different therapeutic approaches such as surgical techniques, pharmacological, therapy, endoscopic intervention and lastly percutaneous aspiration irrigation and aspiration

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Yasawy: Hepatic echinococcosis treatment modalities

91Saudi Journal of Medicine & Medical Sciences | Vol. 2 | Issue 2 | May-Aug 2014

modalities, the 110 patients with liver involvement were retrospectively classifi ed into four groups. All the patients were followed with full blood count, biochemical profi le, echinococcal serology and imaging with ultrasound (US), computed tomography (CT) and in the case when it was indicated, magnetic resonance imaging and endoscopic retrograde cholangiopancreatography (ERCP) were done.

All patients had serology indirect hemagglutination titer of less than 120. Fourteen patients had lung involvement and more than one organ involvement seen in 33 patients. Other organs involvement were as follows: Spleen in fi ve patients, kidney in three and pelvic in two. Retrovesical, buttock, pericardium, femur, sacrum, spine and mediastinum were also involved with hydatid disease.

Medical treatmentSeventy-fi ve patients were scheduled for prolonged medical treatment, in the form of albendazole alone 400 mg oral twice daily on four weekly courses or combined medical therapy, i.e., albendazole plus praziquantel 50 mg/kg in different regimes depending on response 5-10 courses were given. The course was as follows: 4 weeks treatment followed by 2 weeks free period for the purpose of preventing any side-effects of the treatment, then the cycle was repeated. In this group, 13 patients had a history of previous surgery, eventually only 37 patients accepted to continue the prolonged medical therapy (a year and more). Medical therapy was chosen because of the preference of the patients or the physicians or due to surgical contraindications.

Treatment with albendazole for hydatid cyst is effective but is needed to be repeated in several courses. Previous literature indicates that combination therapy (praziquantel added to albendazole) was found to be more effective in reducing cyst size or disappearance of cyst compared with albendazole alone.[5-7]

Endoscopic managementIn 10 patients with ruptured liver cyst into the biliary tree (i.e., communicating with biliary system) diagnostic ERCP and papillotomy was performed. The procedure was continued for evacuation and cleaning of the common bile duct and placement of nasobiliary tube performed. The cyst was irrigated with hypertonic saline 23% for three consecutive days and followed by adjuvant medical therapy for a period of maximum of three courses.[8]

Surgical treatmentSurgery was the only form of treatment before the introduction of pharmacological treatment. Fifty patients

were treated with different surgical procedures out of which 12 patients had a history of previous surgical intervention and recurrence. The indication for surgery was poor medical response, drug intolerance and ruptured cysts without biliary communication and patients’ preference.

PAIRTwenty-six patients were subjected to this technique. These patients were put on chemotherapy 1 month before and 1 month after the procedure. Out of the 26 patients, three had previous surgery with recurrence. Four had poor medical response and four had large cysts (more than 15 cm diameter). Treated hepatic hydatid cysts were at different radiological types of Garbi classifi cation.[9]

PAIR was performed under aseptic condition and heavy sedation using US or CT guidance. The cyst was punctured using 19 gauge, 20 cm long aspiration needle. A small amount of 10-30 ml fl uid was aspirated, for cyst decompression followed by insertion of 12-14 French aspiration catheters. Once the cyst was almost empty, two-third of aspirated materials was replaced by hypertonic saline and left for 20-30 min (for cyst irrigation as a scolicidal agent). The fl uid was then re-aspirated and the catheter was left in place up to 72 h to drain by gravity. Adjuvant medical therapy was also given for a total period of up to 3 months.[10]

RESULTS

A total of 50 patients had surgery of whom 12 had a history of previous surgeries and recurrence. During the follow-up period 8% of our surgically treated patients showed evidence of recurrence. Some patients who had recurrence were referred for medical therapy. Of 22 patients who had albendazole alone showed disappearance of the cyst in 18% of patients, with recurrence of 2.7% during 10 years follow-up. In the 15 patients who had combination therapy, cycts disappeared in 33% of them with no recurrence during the follow-up. The remaining cysts showed evidence of shrinkage and intra-cystic changes. All endoscopically treated patients showed complete clearance of the cyst without any early or late side-effects or complications.

PAIR patients showed gradual disappearance and signifi cant shrinkage of the cysts in all patients. During long-term follow-up, no recurrence or reactivation of cysts was seen in this group of patients. Aspiration at the site of the aspirated cyst showed only granulation tissue without any evidence of viable scolesis.



Saudi Journal of Medicine & Medical Sciences | Vol. 2 | Issue 2 | May-Aug 201492

DISCUSSION

Despite improved surgical techniques and the use of scolicidal compounds, the recurrence and dissemination is still a major problem.[1,5] Spillage is known to occur at surgery and may have fatal consequences.

Recently, three alternative forms of therapy have been introduced, i.e., drug therapy, endoscopic (for ruptured hepatic cyst with communication with biliary tree) and percutaneous aspiration methods. Mebendazole, a benzimidazole was the fi rst compound used in the treatment of the human hydatidosis[11,12] and since mebendazole has poor absorption, it was replaced by albendazole, another benzimidazole compound, which by a dose of 10-14 mg/kg body weight; the scolicidal effect can be achieved.[12]

Due to the potential risk of anaphylaxis, percutaneous aspiration and drainage of hydatid cyst is debatable.[4,13] However, this complication has never been quantifi ed. There are many reports in which echinococcus cyst had been punctured and/or aspirated without immediate complications such as anaphylaxis, asthma or laryngeal edema.[10,14,15]

In our study in 26 patients, 32 cysts were punctured aspirated and drained without any major life-threatening events as complications. Reactions were limited to transient fever and small pleural effusion only one patient developed severe urticarial reaction with shortness of breath assessed as a mild form of anaphylaxis and responded very well to antihistamine and cortisone.

Despite there are accumulations of data showing the safety of percutaneous aspiration drainage[16-19] anaphylactic reactions still remain as an unusual fatal complication. Based on that fact, all hydatid cysts punctures should be carried-out under strict monitoring.

Our retrospective study evaluated four different approaches in the management of hepatic hydatidosis and showed the following conclusions.1. Mebendazole large dose (scolicidal dose) tolerance and

compliance were very poor. The single medical therapy with albendazole in some cases is effective with 18% cure in our study whereas the combination therapy, i.e., albendazole with praziquantel is more effective (33%) cure[7,19] than albendazole alone and requires shorter period of therapy [Figures 1 and 2]. In general, medical therapy requires a long period of treatment up to a year or more and it is not advised during pregnancy.[20]

No serious complications were noted in our study except neutropenia in few patients and hence regular

and scheduled follow-up is needed. There was a rupture of the cyst in 6 patients due to destruction of the cyst wall causing detachment and collapse of the inner membrane as an effect of treatment and in such situations, surgical intervention should be considered [Figure 3] Chemotherapy was effective as a pre- and post-intervention prophylaxis in controlling of spillage and dissemination in contrast of patients who had no prophylactic treatment. Long-term follow-up showed disappointingly reactivation and as recurrence of the eliminated or shrunken cyst in one of the 37 patients, i.e., 2.7% but in longer follow-up this reactivation rate may be even more.

2. Endoscopic management: ERCP is a very effective treatment modality in ruptured hepatic cyst communicating the biliary tree [Figures 4-6]. At 10 years follow-up showed that the complete three step procedure[8] were curative and no evidence of secondary sclerosis (cholangitis) from usage of hypertonic saline was seen.

3. Surgical therapy: was associated with high recurrence rate. Twenty-four out of 110 patients had a history of previous operations and recurrence rate was as high as 50% in patients having repeated operations. At present analysis of our post-surgical recurrence rate is 8% in 10 years follow-up.

4. US and CT (imaging) guided percutaneous drainage is relatively safe and more effective with combinations of short period chemotherapy[10] and defi nitely more economic and easy if performed by experts. Follow-up showed more promising outcomes compared with surgery and chemotherapy [Figure 7] so it should be performed whenever it is indicated and long-term follow-up will answer more questions, but could we say “Surgical era for simple hydatid cyst is over?”

CONCLUSION

We can summarize that PAIR is the most effective form of therapy for the management of hepatic hydatidosis

Figure 1: Albendazole effect in large pelvic hydatid cyst



93Saudi Journal of Medicine & Medical Sciences | Vol. 2 | Issue 2 | May-Aug 2014

by means of rapid outcome and cost-effectiveness. Short admission period even as an outpatient setting with negligible complication is the most suitable procedure.

Endoscopic management is a curative procedure for ruptured hepatic hydatid cyst but expertise is required. Pharmacological management should be performed if PAIR is contraindicated. Surgery role with availability of the above procedure are signifi cantly limited.

REFERENCES1. Arambulo P 3rd. Public health importance of cystic echinococcosis

in Latin America. Acta Trop 1997;67:113-24.

2. Chai JJ. Epidemiological studies on cystic echinococcosis in China — A review. Biomed Environ Sci 1995;8:122-36.

3. Behrns KE, van Heerden JA. Surgical management of hepatic hydatid disease. Mayo Clin Proc 1991;66:1193-7.

4. Fìlice C, Brunetti E, Bruno R, Crippa FG. Percutaneous drainage of echinococcal cysts (PAIR — Puncture, aspiration, injection, reaspiration): Results of a worldwide survey for assessment of its safety and effi cacy. WHO-Informal Working Group on Echinococcosis-Pair Network. Gut 2000;47:156-7.

5. Bygott JM, Chiodini PL. Praziquantel: Neglected drug? Ineffective treatment? Or therapeutic choice in cystic hydatid disease? Acta Trop 2009;111:95-101.

Figure 2: Hydatid disease with the response to medical management

Figure 3: Computed tomography scan showing early response to medical therapy detachment of inner-membrane

Figure 5: Protroding daughter cyst following papillatomyFigure 4: (a) Daughter cyst in dilated common bile duct (CBD). (b) Endoscopic retrograde cholangiopancreatography shows CBD after evacuation of hydatid daughter cyst

a b

Figure 6: (a) Endoscopical ly evacuated daughter cysts. (b) Endoscopically removed hydatid membranes

a b

Figure 7: Stages of response in percutaneous aspiration irrigation and aspiration



Saudi Journal of Medicine & Medical Sciences | Vol. 2 | Issue 2 | May-Aug 201494

6. Yasawy MI, Mohamed AR, Al-Karawi MA. Albendazole in hydatid disease: Results in 22 patients. Ann Saudi Med 1992;12:152-6.

7. Yasawy MI, al Karawi MA, Mohamed AR. Combination of praziquantel and albendazole in the treatment of hydatid disease. Trop Med Parasitol 1993;44:192-4.

8. al Karawi MA, Yasawy MI, el Shiekh Mohamed AR. Endoscopic management of biliary hydatid disease: Report on six cases. Endoscopy 1991;23:278-81.

9. Gharbi HA, Hassine W, Brauner MW, Dupuch K. Ultrasound examination of the hydatic liver. Radiology 1981;139:459-63.

10. Yasawy MI, Mohammed AE, Bassam S, Karawi MA, Shariq S. Percutaneous aspiration and drainage with adjuvant medical therapy for treatment of hepatic hydatid cysts. World J Gastroenterol 2011;17:646-50.

11. Gil-Grande LA, Boixeda D, Garcia-Hoz F, Barcena R, Lledo A, Suarez E, et al. Treatment of liver hydatid disease with mebendazole: A prospective study of thirteen cases. Am J Gastroenterol 1983;78:584-8.

12. De Rosa F, Teggi A. Treatment of Echinococcus granulosus hydatid disease with albendazole. Ann Trop Med Parasitol 1990;84:467-72.

13. Neumayr A, Troia G, de Bernardis C, Tamarozzi F, Goblirsch S, Piccoli L, et al. Justifi ed concern or exaggerated fear: The risk of anaphylaxis in percutaneous treatment of cystic echinococcosis — A systematic literature review. PLoS Negl Trop Dis 2011;5:e1154.

14. Al Karawi MA, Mohamed AR, el Tayeb BO, Yasawy MI. Unintentional percutaneous aspiration of a pleural hydatid cyst. Thorax 1991;46:859-60.

15. Khuroo MS, Dar MY, Yattoo GN, Zargar SA, Javaid G, Khan BA, et al. Percutaneous drainage versus albendazole therapy in hepatic hydatidosis: A prospective, randomized study. Gastroenterology 1993;104:1452-9.

16. Men S, Yücesoy C, Edgüer TR, Hekimoğlu B. Percutaneous treatment of giant abdominal hydatid cysts: Long-term results. Surg Endosc 2006;20:1600-6.

17. Nepalia S, Joshi A, Shende A, Sharma SS. Management of echinococcosis. Available from: http://www.japi.org/June 2006/R-458.htm. [Last accessed on 2013 Feb 16].

18. Khuroo MS. Hydatid disease: Current status and recent advances. Ann Saudi Med 2002;22:56-64.

19. Yasawy MI, Alkarawi MA, Mohammed AR. Prospects in medical management of Echinococcus granulosus. Hepatogastroenterology 2001;48:1467-70.

20. Report of the WHO informal consultation on the use of praziquental during pregnancy/lactation and albendazole/Meb in children under 24 months. WHO/CDS/CPE/PVC, Geneva; 8-9 Apr, 2002. http://whqlibdoc.who.int/hq/2003/WHO_CDS_CPE_PVC_2002.4.pdf [Last accessed on 2013 Feb 16].

How to cite this article: Yasawy MI. Management options in hepatic hydatid disease. Saudi J Med Med Sci 2014;2:90-4.

Source of Support: Nil, Confl ict of Interest: None declared.

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management options in hepatic hydatid disease

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