Echinococcosis (hydatid disease)

The parasite spreads among stock raising people and also among urban dwellers and has to do with sanitary conditions and the activity of health care authorities The diagnostics of Echinococcosis has been improved, too; there are means of detecting more precisely the localisation of parasitic cyst and the specifics of its condition Despite this progress the problem of Echinococcosis has not lost its importance

Etiology and pathogenesis

According to the classification by I.Y. Deineka Echinococcosis is of Plathelminthes phylum Cestoidea class Echinococcus genus Echinococcus granulosus species

Etiology and pathogenesis

Tapeworm belongs to endoparasitic helminthes At the stage of sexual maturity they live in the small intestine of some carnivorous animals Transport host can get infected not only by swallowing worm ova but also when elements of parenchymatous layer of echinococcus (asexual development stage)

Etiology and pathogenesis

Humans can get infected in three ways: through mucous membranes of the gastrointestinal tract through mucous membranes of the respiratory tract through wound surface

Etiology and pathogenesis

Most often onchospheres enter the body through the gastrointestinal tract Under the impact of gastric juice the outer layer of the onchosphere is destroyed, it attaches itself to the mucous membrane of an organ, perforates it and enters blood stream and lymph flow Moving with the blood stream through the portal system the onchosphere reaches the liver

Etiology and pathogenesis

4 types of this disease in humans according to the peculiarities of pathogenesis Primary Echinococcosis developing in one or several organs after viable onchospheres have entered the body secondary multiple echinococcosis in the abdominal cavity developing upon perforation of the cyst

Etiology and pathogenesis

Metastatic echinococcosis developing due to echinococcus cyst opening into the cardiac cavity or a great blood vessel Implantation echinococcosis developing upon penetration of onchospheres into a wound

Etiology and pathogenesis

The average lifespan of a cyst is 10-20 years Cysts older than 10 years can cause complications to develop The cyst of the parasite is usually of a round or oval shape Its walls consist of two layers: the inner chitinous coat resembling the white of the egg and the outer coat, the fibrous capsule

Classification of liver echinococcosis

According to pathogenic principle Primary Secondary: secondary disseminated secondary recurrent secondary metastatic Primary multiple echinococcosis of various organs including the liver

Classification of echinococcosis
According to the number, size and segmental localisation of cysts stating the localisation segments and their size small (under 5 cm) middle (under 10 cm) large (over 10 cm) single-cystic polycystic

Classification of echinococcosis
According to clinical and anatomic types non-complicated complicated

Classification of echinococcosis
According to the stages of clinical course of the disease 1st latent or masked stage 2nd stage of development of symptoms 3rd stage of complications

the liver (63%) lungs (25%) muscles (5%) bones (3%) kidneys (2%) brain (1%) spleen (1%)

Clinical presentations
Clinical presentations of echinococcosis of liver are various depending to a great extent on the stage of development of the parasite and on some other factors: the nature of the body's nonspecific reaction to the developing onchosphere, the rate of growth of echinococcus cysts, their number and size; the changes taking place in the affected organ.

Clinical presentations
In most cases the disease develops for several years, sometimes decades as the echinococcal cyst develops very slowly The first signs of the disease manifest themselves only when the cyst has grown enough to compress the surrounding tissues of liver and sometimes the adjacent organs causing their dysfunction In some cases the disease manifests itself only when the echinococcus cyst causes various complications

Clinical presentations
The first stage It lasts from the moment of onchosphere entering the body to the first clinical presentations of the disease. It lasts for several years. The disease is usually detected by chance when the patient is examined in association with another problem or during surgery undertaken for another problem.

Clinical presentations
The second stage The patient complains of dull pains, sensation of heaviness, compression and tension in the right subcostal region or in epigastrium or in the lower thoracic region. These signs are often accompanied by weakness, general malaise, loss of appetite. Objectively enlargement of liver is detected, often of its right portion or of all parts of the organ if there are multiple cysts.

Clinical presentations
The second stage If the parasitic cyst is localised on the inferior front surface of the liver, bulging forth of the front abdominal wall can be detected, in lateral localisation of cyst - deformity of costal arch and ribs like a hunch. The enlarged liver feels dense upon palpation. Protrusions, usually smooth and semispherical in shape, of dense elastic consistence, can be felt on its surface.

Clinical presentations
the 3rd stage The 3rd stage is characterised by various complications due to echinococcosis. They can develop as a result of changes taking place both in the cyst itself (suppuration, perforation, calcification) and in the affected organ and the body as a whole.

Complications
the ascites upon the compression of lower vena cava the development of jaundice due to obturation of bile ducts the suppuration of echinococcal cyst septic condition The abscess can burst into the pleural or abdominal cavity, into perirenal fat

Physical examination
Skin:Jaundice could be a sign of biliary obstruction. Spider angiomas are a sign of portal hypertension secondary to either biliary cirrhosis or obstruction of the inferior vena cava. Urticaria and erythema may be seen. Vital signs: Fever could be a sign of secondary infection or allergic reaction. Hypotension is observed with anaphylaxis secondary to a cyst leak

Physical examination
Lungs: Decreased breath sounds over the affected area are signs of airway obstruction with consolidation of the affected segment, lobule, lobe, or the whole lung. Abdomen: The most common sign is abdominal tenderness. Hepatomegaly may be present or a mass may be felt. Tender hepatomegaly is a sign of secondary infection of the cyst, especially when coupled with fever and chills. Ascites is rare. Splenomegaly can be the result of either splenic echinococcosis or portal hypertension.

Physical examination
Extremities: Bone involvement can result in tenderness over the affected area and, rarely, a palpable mass. Muscle involvement is usually characterized by a palpable mass. Brain: Findings from the neurologic examination are nonspecific and depend on the area of the brain involved. They range from very mild to full coma.

Diagnostics
the increased eosinophil levels in blood which occurs in 70-80% of all cases Biological tests - Canzoni's reaction (0.1-0.2 ml of sterile filtrate of echinococcal fluid) Latex-agglutination test Plain X-ray of abdominal cavity Ultrasound investigation Computerised tomography Laparoscopy

TREATMENT
Closed single echinococcectomy in noncomplicated or suppurative echinococcosis Open single echinococcectomy Enucleation of the parasite together with the fibrous capsule Resection of the liver

Indications for surgery

1. large liver cysts with multiple daughter cysts 2. superficially located single liver cysts that may rupture 3. liver cysts with biliary tree communication or pressure effects on vital organs or structures 4. infected cysts 5. cysts in lungs, brain, kidneys, eyes, bones, and all other organs.

Contraindications
1.General

contraindications to surgical procedures - extremes of age, pregnancy, severe preexisting medical conditions 2. Multiple cysts in multiple organs 3. Cysts that are difficult to access 4. Dead cysts; calcified cysts 5. Very small cysts

Choice of surgical technique:

1. Radical surgery (total pericystectomy or partial affected organ resection, if possible), 2. Open cystectomy 3. Simple tube drainage for infected and communicating cysts The more radical the procedure, the lower the risk of relapses but the higher the risk of complications.

Description of surgical procedure

1.Eradication of the parasite by mechanical removal 2.Sterilization of the cyst cavity by injection of a scolicidal agent 3.Protection of the surrounding tissues and cavities.

Description of surgical procedure

Scolicidal agents include formalin, hydrogen peroxide, hypertonic saline, chlorhexidine, absolute alcohol. The cavity is then filled with isotonic sodium chloride solution and closed. In the case of hepatic cysts, the fluid is inspected for bile staining and at the end of the evacuation and irrigation process.

Prevention
1.Education on proper hygiene 2.Proper cleansing of uncooked food and avoidance when possible 3.Dietary regulation of pet dogs (stop the habit of feeding viscera of intermediate hosts, such as sheep, to pet dogs) 4.Regulate pet dog activity to prevent ingestion of sheep material

Prevention
5.Avoidance of unregulated dogs 6.Treatment of pet dogs in endemic areas for intestinal echinococcosis with praziquantel (5 mg/kg) periodically 7.Control of the dog population 8.Regulation of livestock butchering