Hydatid Disease Treatment in Delhi, India

Many hydatid cysts are asymptomatic and may, after growing for some years, cause pressure symptoms depending on the organ or tissue involved. In most patients with hydatid disease, the right lobe of the liver is invaded and contains a single cyst. A cyst may be found in the lung, bone, or brain.

The site of infection, parasite load, and the size of the cysts decide the extent of symptoms.

Cystic echinococcosis (CE): The symptoms are produced by the effect of the mass or cyst complications. Symptoms do not manifest at an early stage. However, they may present clinical signs when developed in the brain or the eyes. Most symptomatic cysts are more than 5 cm in diameter. Symptoms include:

Nonspecific pain

• Cough
• Low-grade fever
• A sensation of abdominal fullness
• In the liver, the pressure from the cyst may cause obstructive jaundice and abdominal pain.
• The classic triad of jaundice, biliary colic, and urticaria is observed with biliary rupture.
• Rare symptoms include the passage of hydatid membranes in the emesis (hydatid emesia) and the passage of membranes in the stools (hydatid enterica).
• If lungs are involved, symptoms may be chronic cough, dyspnea, pleuritic chest pain, and hemoptysis.
• Expectoration of cyst membranes and fluid may be observed with intrabronchial rupture.
• Dizziness, headache, and a reduced level of consciousness may signify cerebral involvement. Specific neurologic deficits may occur depending on the location of the cyst in the brain.
  

Alveolar echinococcosis (AE): The liver is the site of infection, and it closely mimics cirrhosis or carcinoma. Symptoms may be:

• Progressive liver dysfunction that leads to liver failure
• Distant metastasis and involvement of other organs (e.g., lung, brain, bone) can occur.

Tapeworms cause echinococcosis. These are the larval cestodes of the phylum Platyhelminthes. Their life-cycle consists of two hosts, one definitive and the other intermediate. Humans act as accidental intermediate hosts. The life cycle has three developmental stages:

• The adult tapeworm in the definitive host
• Eggs in the environment
• The metacestode (larvae) in the intermediate host

The definitive host ingests metacestodes. In the definitive host, the metacestodes mature into the tapeworm and release eggs into the environment. The intermediate host eats the eggs that hatch into metacestodes, infesting the lungs, liver, muscles, and some other organs of the intermediate host.

Two biological forms of E granulosus (depending on the geographic location and type of the intermediate host) have been recognized:

The Northern type: These infest when a human comes in contact with an infected wolf or giant deer’s faeces. They are common in areas where reindeer are domesticated.

The European type: Intermediate hosts include pigs, sheep, camels, cattle, horses, goats, and other animals.

Intermediate hosts for E multilocularis are rodents such as mice, rats, hamsters, gerbils, and squirrels. Exposure to food and water contaminated by the faeces of a definitive infected host such as domesticated animals or rodents; or poor hygiene in areas of an infestation can lead to echinococcosis.

The drugs available to treat echinococcosis are limited. Anthelmintic benzimidazoles, such as albendazole and mebendazole, are prescribed for treatment and prophylaxis. Praziquantel can be used as an adjunct for therapy.

For inpatient care, individuals who have had surgical resection of their hydatid cyst is similar to any other surgery on the affected organ of the body.

Special consideration is made for patients with hepatic cystic echinococcosis (CE) diagnosed with biliary communication. These patients must be kept under observation for signs and symptoms of biliary obstruction or fistula formation. If either of these complications occurs, the patient is treated by percutaneous or endoscopic stenting of the biliary tree with or without sphincteroplasty. 

Treatment with benzimidazoles is continued for approximately one month postoperatively. Prophylactic antibiotics are prescribed for surgery as indicated in patients with a cystobiliary fistula to treat infected cysts and associated infections. Benzimidazoles are continued after discharge.

Complications associated with the cysts can be explained as follows:

Postoperative risk factors pertaining to hepatic hydatidosis include:

• age
• previous surgery for hepatic hydatidosis
• localization in the hepatic centre
• the presence of biliary communications
• cystic evolutionary complications

Complications pertaining to the parasite include:

• Recurrence
• Infection
• Metastasis
• Spillage and seeding (secondary echinococcosis)
• Allergic reaction or anaphylactic shoc
  
  

Those pertaining to the medical treatment include:

• Hepatotoxicity
• Anaemia
• Thrombocytopenia
• Alopecia
• Embryotoxicity
• Teratogenicity
• Spillage and seeding (secondary echinococcosis)
  
  

Complications related to puncture, aspiration, injection, and reaspiration (PAIR) intervention include the following:

• Haemorrhage
• Mechanical damage to other tissues
• Infections
• Allergic reaction or anaphylactic shock
• Persistence of daughter cysts
• Sudden intracystic decompression leading to biliary fistulas

Those related to scolicidal agents include chemical sclerosing cholangitis.

A rare case of alveolar echinococcosis embolism that required emergency surgical intervention has been reported.

Risk factors responsible for causing hydatid cysts are:

• Direct contact with faeces of infected animals
• Poor hygiene
• Animal breeders (occupational)
• People residing in areas where reindeer are bred are more likely to develop a hydatid cyst.
• Accidental consumption of soil, water, or food contaminated by the faecal matter of an infected dog
• Ingestion of food or water contaminated by tapeworms

The prognosis of hydatid cysts mainly depends on the type of infestation (i.e., whether it is cystic [CE] or alveolar echinococcosis [AE]). The prognosis is generally good in cystic echinococcosis, and it cures entirely with surgical excision without spillage.

In alveolar echinococcosis, the prognosis is poor. It cures only with early detection and total surgical excision. In patients with spillage, long-term chemotherapy may reduce the 10-year mortality rates.

Reviewed by Dr. Atul N.C Peters, Director - Bariatric, Minimal Access & General Surgery on 12-Jan-2023.