There were 12 females and 15 males aged between 22 -87years.
(median age-44)
The clinical presentation was -isolated fever (30%),
jaundice (22%),
cholangitis (22%),
abdominal mass (6%),
pruritus (7%),
peritonitis (7%).Fig. 1
Imaging revealed following complications: Cystobiliary communication (29.6%),
biliary compression (22%),
both cysto biliary and gastric communications (11%),
vascular compression (7.4%),
rupture in the peritoneal cavity (7.4%),
biliary and vascular compression (3.7%).
Fig. 1
The intraoperative explorations showed 44% of cysto biliary communication which were treated with different options,
but the first-choice treatment was the obliteration of communication (66%).
33% of patients received initial antibiotic treatment for cholangitis,
the others (66%) underwent surgery immediately.
Conservative surgery was opted in 78% of cases and radical surgery in 22% of cases.
Hydatidosis is a public health problem in livestock areas of developing countries.
Tunisia is a country known for its high-endemicity.
The hydatid cyst is a zoonosis caused by taenia granulosis.
Man is accidentally inserted into the parasite cycle and the liver is the organ most affected.
Hydatid cyst located partly or wholly in either the caudate lobe or the quadrate lobe owing to its anatomical proximity to vascular,
biliary elements and gastrointestinal tract is prone to complications.
Vascular complications related to portal vein:
CECT is the modality of choice with portal phase depicting the relationship of the cyst with portal vein for surgical planning.
Compression: Direct compression can be depicted by Doppler or CECT.
Portal thrombosis: Doppler demonstrates loss of colour signal,
with filling defect seen on CECT.Cavernous transformation of the main portal vein may also be seen in chronic thrombosis.
Portal hypertension may develop which can be seen as loss of respiratory phasicity and flow reversal on duplex ultrasound .
Rupture of cyst into portal vein: A rare complication,
can occur during intraoperative manipulation.
It can also manifest clinically as anaphylactic shock due to the passage of hydatid material into the bloodstream through a minimal cysto- vascular breach.
Ultrasound shows portal vein distention or one of its branches near the cyst.
the vascular lumen is filled by a hypoechoic material containing anechoic or echogenic round formations which are daughter vesicles.
The cross-sectional imaging (CT,
MRI) also confirms the diagnosis either by visualizing the cysto vascular breach directly and / or by demonstrating a vascular filling defect by cyst contents (highly attenuated in CT,
hypo on T1,
hyper on T2 in MRI) non enhancing on contrast enhanced study.
Gastrointestinal and peritoneal complication:
Because of the intimate relation of the visceral surface of liver with the stomach as well as the first and second portions of the duodenum,
the centro hepatic cyst can rupture in the digestive tract or in the Peritoneal cavity.
The CT with oral contrast is the investigation of choice.
In case of perforation into hollow viscera,
CT with oral contrast helps in demonstrating the communication with an air -contrast level in the cyst
In case of rupture in the peritoneal cavity,
ultrasound shows a hypoechoic hydatid cyst associated with an intraperitoneal effusion.
Biliary complications:
The hydatid cyst is often complicated by infection as well as cysto biliary communications
It is often latent but can be severe.
The biliary fistula manifest by retentive jaundice or acute cholangitis.
In case of rupture into the biliary tree,
the only direct sign is demonstrating the cyst wall defect or the large communication between the cyst and the biliary radicle.
The biliary fistula can be recognized as biliary dilatation near the cyst or hydatid material filling the main bile duct or biliary radicle as an anechoic,
echogenic rounded or linear structure without posterior acoustic showing in abdominal ultrasound.
Magnetic resonance cholangiography is a useful when complex biliary communications are predictable
Secondary infection of the cyst:
liver hydatid cyst infection is secondary to a contained rupture.
It occurs when endocyst and pericyst are separated secondary to degeneration or micro-trauma or may be reactive to treatment.
It mimics the liver abscess on imaging.
Ultrasound shows a heterogeneous hypoechoic appearance in the center surrounded by a hyperechoic halo.
Endocyst detachment can be also seen as a floating membrane.
CT shows poorly limited cyst with a highly-attenuated parenchymal rim,
the cyst content may be heterogeneous or with a gas level.
Perfusion changes near the lesion can also be observed and it represent an inflammatory reaction.