The Liver

C.Masina
 The Liver
• The largest internal body organ
• Largest gland
• Largest organ apart from skin
• Weighs about 1.5kg
• Found in the upper abdominal cavity: extends
from right upper quadrant to left upper quadrant
of the abdomen
• Attached to diaphragm by
 falciform and coronary ligaments
 Left and right triangular ligaments
 Functions
• Bile production and secretion
• Detoxification
• Storage of glycogen
• Protein synthesis
• Production of heparin and bile pigments
• Erythropoiesis (in fetus)
 Liver surfaces
• Divided into 2 anatomical regions:
1. Diaphragmatic surface:
 Smooth and dome-shaped surface
 Anterior liver part
 Inferior to diaphragm
 Separated from diaphragm by subphrenic recess
and from posterior organs {kidney and suprarenal
glands} by hepatorenal recess
 Covered by peritoneum except
1.Diaphragmatic surface
 2. Visceral surface
 Covered by visceral peritoneum except porta
hepatis and gall bladder bed.
• The visceral surface is related to:
 Right side of the stomach i.e. gastric and pyloric areas
 Superior part of the duodenum i.e. duodenal area
 Lesser omentum
 Gall bladder
 Right colic flexor
and right transverse area ; colic area
 Right kidney
and suprarenal gland; Renal area
Posterior liver view
Liver lobes
 Right and left lobe
 Functionally independent
i.e. each with own blood and nerve
supply

Blood supply in by:

 Hepatic artery
 Portal vein

Blood out through:

 Vein and
 biliary drainage
Liver lobes
1.The Right lobe
Demarcated
by :
1. Gall bladder
fossa

2. Inferior
vena cava
fossa

3. Imaginary line
from fundus of
gall bladder and
inferior vena cava
Liver lobes
2. Left lobe
Divided into:
Medial and lateral
segments

1.Medial superior
– caudate lobe

2.Medial inferior
- quadrate lobe
2. Left lobe cont…
 The lateral segment
is separated from the
medial segments
by:

 On visceral surface:
1. fissure of
ligamentum
teres (round
ligament)
2. fissure of
ligamentum
venosum
 On
diaphragmati
c
surface:
1. Attachment of
falciform ligament
 Visceral surface
1. The round ligament(ligamentum
teres) – obliterated umbilical vein
2. The ligamentum venosum – fibrous
remnant of fetal ductus vein
3. The Porta hepatis (hepatic potal;
portal fissure) - transverse fissure
on the visceral surface of the liver.
– It gives passage to the:
1. Portal vein
2. Hepatic artery
3. Hepatic nerve plexus
4. Hepatic ducts
5. Lymphatic vessels
Peritoneal relations of the Liver
The Lesser omentum
• Encloses the portal triad (bile duct, hepatic artery and portal vein
)
• Passes from the liver to lesser curvature of the stomach + 2 cm of
duodenum
• Thick free edge -- hepatoduodenal ligament
• Sheet like remainder – hepatogastric ligament
 To be continued ….
• To be continued………………..

• To be continued………………..
Anatomy of the liver and biliary
system
Dr. Mohammed Mahmoud Mosaed
 The liver
• The liver is largest gland in the
body .
• The greater part of the liver is
situated under cover of the
right costal margin, and the
right hemidiaphragm separates
it from the pleura, lungs,
pericardium, and heart.
The liver extends to the
left to reach the left
hemidiaphragm
 Lobes of the liver
• The liver divided into:
• 2 large lobes; right and left lobe
by the attachment of the
peritoneum of the falciform
ligament
• The right lobe is further divided into
a quadrate lobe and a caudate lobe
by the presence of the gallbladder,
the fissure for the ligamentum
teres, the inferior vena cava, and
the fissure for the ligamentum
venosum
• The quadrate and caudate lobes are
a functional part of the left lobe of
the liver.
 Surfaces of the liver
• Surfaces of the liver include:
• a diaphragmatic surface in the
anterior, superior, and
posterior directions; and
• a visceral surface the
inferior
in direction
• The convex upper surface of
the liver is molded to the
undersurface of the domes of
the diaphragm. The
posteroinferior, or visceral
surface, is molded to adjacent
viscera and is therefore
irregular in shape;
• The posteroinferior, or visceral surface, is related
to adjacent viscera and is therefore irregular in
shape; it lies in contact with
• the abdominal part of the esophagus,
• the stomach,
• the duodenum,
• the right colic flexure,
• the right kidney and suprarenal gland,
• the gallbladder.
 Porta hepatis (hilium of the liver)
• Site: it is found on the posteroinferior surface and
lies between the caudate and quadrate lobes. The
upper part of the free edge of the lesser omentum is
attached to its margins.
• Structures forming the hilium of the liver
• the right and left hepatic ducts,
• the right and left branches of the hepatic artery,
• the portal vein, and
• Sympathetic and parasympathetic nerve fibers.
• A few hepatic lymph nodes, they drain the liver and
gallbladder and send their efferent vessels to the
celiac lymph nodes.
 Important Relations of the liver
• Anteriorly: Diaphragm, right and left costal margins, right and
left pleura and lower margins of both lungs, xiphoid process,
and anterior abdominal wall in the subcostal angle.
• Posteroinferiorly (visceral surface): Diaphragm, right kidney,
hepatic flexure of the colon, duodenum, gallbladder,
inferior vena cava, esophagus and fundus of the stomach.
 Peritoneal Ligaments of the Liver
• The falciform ligament, which is a
two-layered fold of
peritoneum, ascends the
umbilicus to the liver. from the
• It has a sickle-shaped free margin
that contains the
ligamentum teres, the remains
of the umbilical vein. The
falciform ligament passes on
to the anterior and then the
superior surfaces of the liver
and then splits into two
layers. The right layer forms
the upper layer of the
coronary ligament; the left layer
 Bare area of the liver
• The right extremity of the coronary
ligament is known as the right
triangular ligament of the liver. It
should be noted that the peritoneal
layers forming the coronary
ligament are widely separated,
leaving an area of liver devoid of
peritoneum. Such an area is referred
to as a bare area of the liver.
• The right triangular ligament is
situated at the right extremity of the
bare area, and is a small fold which
passes to the diaphragm,
formed being apposition of the
upper by lower layers of the
coronarythe and
ligament.
• The ligamentum teres (obliterated umbilical
vein) it lies in the free margin of the falciform
ligament and passes into a fissure on the visceral
surface of the liver and joins the left branch of the
portal vein in the porta hepatis.
• The ligamentum venosum, a fibrous band that is
the remains of the ductus venosus, is attached to
the left branch of the portal vein and ascends in a
fissure on the visceral surface of the liver to be
attached above to the inferior vena cava.
Blood Supply:
Arteries:
• The hepatic artery, a branch of
the celiac artery, divides
into right and left terminal
branches that enter the
porta hepatis.
Veins:
• The portal vein divides into
right and left terminal
branches that enter the
porta hepatis behind
the arteries. The hepatic
veins (three or more) emerge
from the posterior surface
of the liver and drain into
the inferior vena cava.
Blood Circulation through the Liver:
• The blood vessels conveying blood to the liver are the
hepatic artery (30%) and portal vein (70%). The
hepatic artery brings oxygenated blood to the
liver, and the portal vein brings venous blood rich
in the products of digestion, which have
been absorbed from the gastrointestinal tract.
• The arterial and venous blood is conducted to the central
vein of each liver lobule by the liver sinusoids.
• The central veins drain into the right and left hepatic
veins, and these leave the posterior surface of the
liver and open directly into the inferior vena cava.
 Lymphatic drainage and innervation of
the liver
Lymph Drainage:
• The liver produces a large amount of lymph about one third to one
half of all body lymph. The lymph vessels leave the liver and
enter several lymph nodes in the porta hepatis. The efferent
vessels pass to the celiac nodes.
• A few vessels pass from the bare area of the liver through the
diaphragm to the posterior mediastinal lymph nodes.
Nerve Supply:
• Sympathetic and parasympathetic nerves form the celiac plexus.
The anterior vagal trunk gives rise to a large hepatic branch,
which passes directly to the liver.
 Biliary system:
• Biliary system consist of:
• The right and
hepatic
left ducts,
• the hepatic
common duct,
• the gallbladder, and
the cystic duct.
• Common bile duct
 Hepatic Ducts
• The right and left hepatic ducts emerge from the
right and left lobes of the liver in the porta
hepatis.
• After a short course, the hepatic ducts unite to
form the common hepatic duct.
• The common hepatic duct is about 1.5 in. (4 cm)
long and descends within the free margin of the
lesser omentum. It is joined on the right side by
the cystic duct from the gallbladder to form the
bile duct.
 Bile Duct
• The bile duct (common bile duct) is about 3 in. (8 cm) long.
• In the first part of its course, it lies in the right free margin of the
lesser omentum in front of the opening into the lesser sac.
Here, it lies in front of the right margin of the portal vein and
on the right of the hepatic artery.
• In the second part of its course, it is situated behind the first part of
the duodenum to the right of the gastroduodenal artery.
• In the third part of its course, it lies in a groove on the posterior
surface of the head of the pancreas. Here, the bile duct comes
into contact with the main pancreatic duct.
• The bile duct ends below by piercing the medial wall of the second
part of the duodenum about halfway down its length.
 Hepatopancreatic ampulla
• The common bile duct is usually joined by the main
pancreatic duct, and together they open into a small
ampulla in the duodenal wall, called the
hepatopancreatic ampulla (ampulla of Vater). The
ampulla opens into the lumen of the duodenum by
means of a small papilla, the major duodenal
papilla. The terminal parts of both ducts and the
ampulla are surrounded by circular muscle, known
as the sphincter of Oddi. Occasionally, the bile and
pancreatic ducts open separately into the
duodenum.
 Gallbladder
• The gallbladder is a pear-shaped sac
lying on the undersurface of the
liver. It has a capacity of 30 to 50 mL
and stores bile, which it
concentrates by absorbing water.
Relations:
• Anteriorly: The anterior abdominal wall
and the inferior surface of the liver.
• Posteriorly: The transverse colon
and
the first and parts of the
second duodenum.
• Parts of gallbladder
• The gallbladderis divided into the
fundus, body, and neck.
 Parts of the gallbladder
• The fundus is rounded and projects below the inferior margin of
the liver, where it comes in contact with the anterior
abdominal wall at the level of the tip of the ninth right costal
cartilage.
• The body lies in contact with the visceral surface of the liver and
is directed upward, backward, and to the left.
• The neck becomes continuous with the cystic duct, which turns
into the lesser omentum to join the common hepatic duct,
to form the bile duct.
• The peritoneum completely surrounds the fundus of the
gallbladder and binds the body and neck to the visceral surface
of the liver.
 Cystic Duct
• The cystic duct is about 1.5 in. (3.8
cm) long and connects the neck
of the gallbladder to the
common hepatic duct to form
the bile duct. It usually is
somewhat S-shaped and
descends for a variable distance in
the right free margin of the
lesser omentum.
• The mucous membrane of the cystic
duct is raised to form a spiral
fold that is continuous with a
similar fold in the neck of the
gallbladder.
• The fold is commonly known as the
spiral valve. The function of the
 Blood Supply lymphatic drainage and
innervation of gallbladder
• Blood supply: The cystic artery, a branch of the right hepatic
artery, supplies the gallbladder. The cystic vein drains directly
into the portal vein. Several very small arteries and veins
also run between the liver and gallbladder.
• Lymph Drainage:
• The lymph drains into a cystic lymph node situated near the neck
of the gallbladder. From here, the lymph vessels pass to
the hepatic nodes along the course of the hepatic artery and
then to the celiac nodes.
• Nerve Supply:
• Sympathetic and parasympathetic vagal fibers form the celiac
plexus. The gallbladder contracts in response to the
hormone cholecystokinin, which is produced by the mucous
membrane of the duodenum on the arrival of fatty food from the
 Prepared by:
Prerit Devkota
2nd year Resident
Department of
EM/GP
PAHS

Moderator : Dr. Samyukta K.C

 LIVER ABSCESS
⚫ Collection of purulent material in liver parenchyma forming a
cavity

⚫ Most common type of visceral abscess

⚫ Uncommon
⚫ 3.6/100000 populations UK/US
⚫ 15/100000 Asia
⚫ Prevalence stable,detection improved ,mortality improved

⚫ Can be:
⚫ Bacterial (pyogenic)
⚫ Parasitic (amoebic)
⚫ Fungal

⚫ Amoebic liver abscess – worldwide

⚫ Pyogenic liver abscess – USA
Pyogenic Liver
Abscess
 Pyogenic Liver Abscess
⚫ Liver abscess due to bacteria

⚫ Incidence : 2.3/100000 populations

⚫ Male : female = 1.5:1

⚫ Risk factors:
⚫ DM
⚫ Underlying hepatobiliary or pancreatic disease
⚫ Liver transplant
⚫ Regular use of PPI
⚫ Male gender
⚫ Colorectal Ca. ---- K. Pneumoniae --- Liver
abscess
Pathogenesis
⚫ Liver – recieves portal venous bacterial load regularly – clears up
– beyond capacity – abscess
⚫ Asia – gall stones and cholangitis
⚫ West – malignant obstruction
Pathogenesis
⚫ Portal vein :
⚫ diverticulitis, appendicitis, pancreatitis, inflammatory bowel
disease, pelvic inflammatory disease, perforated viscus, and
omphalitis in the newborn

⚫ Hepatic artery:
⚫ systemic infection (endocarditis, pneumonia, osteomyelitis) –
bacteremia

⚫ Penetrating/blunt trauma:
⚫ Intrahepatic hematoma/necrosis – infection – abscess
Microbiology and Pathology
⚫ Right lobe – 75%

⚫ 50% - solitary

⚫ Polymicrobial – 40% (pyelophlebitis/cholangitis) or monomicrobial

(systemic infections)

⚫ Gram negative and anarobes : 40 -60 %

⚫ Escherichia coli , Klebsiella pneumoniae , Staphylococcus aureus, Enterococcus
⚫ Pseudomonas, Proteus, Enterobacter,Peptostreptococcus

⚫ Fungal and mycobacterial – rare in immunocompromised

⚫ Blood culture : 50 – 60% positive

Clinical features
⚫ Classical presentation :
⚫ fever with chills, jaundice and RUQ pain with tenderness
on palpation

⚫ Complications:
⚫ Abscess rupture – peritoneal or pleural or pericardial space
⚫ Sepsis / septic shock
⚫ Klebsiella - endogenous endophthalmitis (3% ) in diabetics
Examination
⚫ Fever and RUQ tenderness

⚫ Jaundice – 25% , chest findings - 25%

⚫ Hepatomegaly – 50%

⚫ Ruptured abscess – signs of peritonitis and

shock
Diagnosis
⚫ Liver lesion on imaging (USG/CT/MRI)
+
⚫ Purulent material on Aspiration
+
⚫ Isolation of organism from pus(gram stain,AFB
stain,c/s,serology
,PCR)
Investigations
⚫ CBC

⚫ LFT

⚫ Albumin and PT/INR

⚫ CXR (50%) – elevated right hemidiaphragm, right pleural

effusion, or atelectasis

⚫ Abdomina X-ray : air-fluid levels or portal venous gas

Imaging

USG Vs. CECT – 85% vs.95% sensetivity

Differential Diagnosis
⚫ Hepatitis

⚫ Liver tumors

⚫ Right lower lobe pneumonia

⚫ Acute cholangitis

⚫ Acute cholecystitis

⚫ Hydatid cyst

⚫ Gall Stone
Treatmen
t⚫ Medical and Surgical
 Medical :

⚫ Emperic Atbx :
⚫ Started before pus culture or other reports
⚫ Should cover Streptococci,E.coli,Anarobes,E.histolytica
⚫ Ceftriaxone + Metronidazole , Ampicillin+Metronidazole+Gentamycin,
floroquinolone+Metronidazole
⚫ If Staphylococcus – Vancomycin

⚫ Duration :
⚫ 4-6 weeks : if incomplete drainage when surgically intervened
⚫ 2-4 weeks : if completely drained
Surgical Treatment
⚫ PNA or PCD
⚫ USG or CT guided

⚫ ERCP drainage – if infection continues through biliary tree

⚫ Single abscess </= 5cm ----- PNA or PCD – 7 days

⚫ Single unilocular >5 cm ---- PCD > PNA – 7 days

⚫ Multiple or multiloculated
⚫ abscess
PCD > PNA
Open Surgery
⚫ Indications :

o Inadequate response to PCD or PNA

o Abscess with viscious content that blocks catheter

o Infected hepatic malignant neoplasm, hepatolithiasis, or

intrahepatic biliary stricture
Follow up
Prognosis
⚫ Mortality : 2 – 12 %

⚫ Need for open surgical

intervention

⚫ Associated with malignancy

⚫ Anaerobic infection
Any Questions???
Amoebic Liver
Abscess
Amoebic Liver Abscess
⚫ Caused by protozoa - E.histolytica

⚫ h/o travel and dysentry or diarrhoea

⚫ Age : 20 – 40 yrs

⚫ M:F = 10:1

⚫ Menstruating women and IDA – low incidence

⚫ Alcohol consumption and immunocompromised state – high

risk
Pathogenesis
Patholog Glisson capsule is resistant
to hydrolysis by amoeba

Liquefactive necrosis Anchovy sauce

pus
Clinical features
Investigations
⚫ CBC
⚫ LFT
⚫ PT/INR – elevated
⚫ Indirect hemagglutination test (90%)– circulating
antibodies
⚫ Past Vs. Active infection
⚫ PCR – pus
⚫ X-ray,USG,CT
Treatmen
t ⚫ Uncomplicated : Medical therapy
⚫ Metronidazole/Tinidazole/Nitazoxanide – 7 – 10 days
⚫ Paramomycin (20-30 mg/kg/day) / DF – 7 - 10 days
⚫ Pregnant lady : Metronidazole / Chloroquine (6oo mg – 2 days
then 300 mg 3 weeks)

⚫ Complicated : PCD/PNA
⚫ Left lobe abscess
⚫ Lack of clinical response of medical therapy for 5 days
-UpToDate 2020
Prognosis
⚫ Poor prognosis
⚫ elevated serum bilirubin level (>3.5 mg/dL),
⚫ encephalopathy,
⚫ hypoalbuminemia (<2.0 g/dL),
⚫ multiple abscess cavities,
⚫ abscess volume larger than 500 mL

⚫ Mortality <1%
Take Home Messages
⚫ Liver abscess is one of the common cause for RUQ pain in our world
– amoebic liver abscess being most common

⚫ Can be diagnosed clinically aided by radiological investigation

⚫ Mostly involves right lobe in 20 – 40 yrs usually male population with

E.coli being most common organism

⚫ <5 mm – can be managed medically , if >5 mm : better to go for

percutaneous drainage (PCD/PNA) ; PCD being superior to PNA
for
⚫ early clinical improvement,
⚫ less duration of hospital stay and
⚫ earlier reduction in 50% reduction of abscess size
References
⚫ Sabiston textbook of surgery, 20th edition

⚫ UpToDate 2020

⚫ Kulhari M, Mandia R. Prospective randomized comparative

study of pigtail catheter drainage versus percutaneous
needle aspiration in treatment of liver abscess. ANZ
Journal of Surgery. 2018;89(3):E81-E86.
Any Queries???
Thank you!!
HYDATED DISEASE
(Echinococcoses)

DR. M E H M O O D - UR-
REHMAN
PG- WARD 26 JPMC
 Layout

⚫ History
⚫ Genus
⚫ Epedemiology
⚫ Organs affected
⚫ Hosts of parasite
⚫ E.granulosa morphology,life cycle and pathogenecity
⚫ Clinical feature
⚫ Investigations
⚫ Managemant
⚫ prevention
 HISTORY

⚫ Hydated means “drop of water”

⚫ Echinococcus: “hedgehog” .it was coined by Rudholphi in
early 19s.

Hydated disease (one of the oldest disease) know to

mainkind,is a parasitic infestation caused by tapeworm of
genus Echinococcus.
It was first described in th talmud as a “Bladder full of water”.
Hippocrates described the hydated disease more then two
thousand years ago with a very intresting expression
“Liver filled with water”
 Genus Echinococcus

4 species
⚫ E.granulosus-The most commonest cuases
“cystic” hydated
diseaase.
⚫ E.multilocularis-most virulant causes alveolar
disease.
⚫ E.vogeli & oligarthus-the polycystic echinococcosis.
 EPIDEMIOLOGY

⚫ E.granulosa is present worldwide (more common

in sheep and cattle raising countries) including
Pakistan and India.
⚫ E.multilocularis the alveolar form common in central
and northern Europe, north America and Asia
⚫ E.vogeli and oligarthus in central and south America.
 Affectees and Death

⚫ Approximately 1.4 million are affected annually.

⚫ In 1990 ,2000 deaths were reported
⚫ 2010, 1200 deaths reported.
 Organs affected

⚫ Liver:52-75%
⚫ Lungs:10-30%
⚫ Abd cavity:8%
⚫ Kidneys:7%
⚫ CNS: less then 2%
⚫ Bones:1-2%
⚫ Unusual sites :spleen,heart,adrenals glands,salivary
glands,eye,ovaries,pancreas and thyroid.
 Hosts

Organism Definitive host Intermediate host

E.Granulosus Dogs and other canidae Sheep,gaot,cattle,camel,b

uffalos,kangroos and
other wild herbivores

E.Multilocularis Foxes,dogs and cats Small rodents

(Small fox (Mice,rats
echinococcosis) ,squirrals,rabbits.)

E.Vogeli and oligarthus Bush Dogs and dogs Small rodents

 E.Granulosus

⚫ Most common,causes cystic disease in almost any

organ the most common being liver 75% followed
by lungs 10-30%.
⚫ Also called as Hydated worm , dog tapeworm
⚫ About 3-6mm long.
⚫ Definitive host is dog.Sheep and cattle being
intermediate host.
⚫ Human is incidental and usually dead end
host.
 Morphology

⚫ Adult worm :3-6mm long.

⚫ SCOLEX: pyriform with 4 suckers and a rostellum
with 2 circular rows of hooklets.
⚫ NECK:thick and short.
⚫ STROBILA: 3-4 proglottids
usually(immature,mature and gravid).
Morphology
Life cycle
 Life cycle

⚫ Adult warm resides in the small intestine of

definitive host,eggs are produced by the gravid
proglottids which are released in feces,being
ingested by
intermediate host or incidental host like
human.the egg hatches in small intestine and
releases oncosphere (embryo with 6 suckers)
which
penetrate intestinal wall and reach diff organs like
liver through blood stream and develops into cyst.
⚫ The cyst enlarges creating many protoscolices
and daughter cyst within cyst.
 Life cycle

⚫ The cyst containing organs are then ingested by the

definitive host and and the cycle restarts.
⚫ In case of human the eggs are ingested accidently in
vegetables berries and soil.
 Pathogenicity

⚫ Hydated cyst represents LARVAL FORM.

⚫ Acquired during childhood.
⚫ Cyst displaces the vital host tissues , demages and
causes dysfunction.
⚫ Cyst can survive in the organs for many years.
⚫ Cyst wall is formed by
Pericyst
Ectocyst
Endocyst
 Clinical features

⚫ Can affect almost any organ most commonly liver and

lung.
⚫ in case of liver hydated cyst it can be asymptomatic or
patient can present with abdominal
pain,dyspepsia,vomiting,fever and jaundice.
⚫ Frequent sign is hepatomegaly/palpable mass.
⚫ Bacterial superinfection can cause pyogenic abscess.
⚫ Rupture can occur into billiary tree.
⚫ Free rupture into body either spontanously or during
surgery can cause fatal anaphylactic
reaction,fever,pruritis,oedema,dyspnea and stridor.
⚫ Incase of lung it can cause cough,SOB and chest pain and
mass effect.
 workup

⚫ Routine workup is of little value.

⚫ In patient with ruptured cyst there can be transient
elevation of liver enzymes,Amylase and
eosinophilia(60%).
⚫ Indirect hemagglutination test and ELISA are most
widely used to detect antibodies but they can give
false positive result in case of schistosomiasis
and namatodes that is why they are not specific
in diagnosing hydatidosis.
 Imaging studies

⚫ Plan radiograph,Usg,CT,MRI,MRCP,ERCP.
⚫ Plan radiograph can show liver,lung calcified cyst.
⚫ Usg is the most important and initial imaging study
for diagnosis , which can be supplemented by CT
and MRI.
⚫ CT is the study of choice which can be further
confirmed by MRI
⚫ In polycystic disease same imaging can show the
cyst.
 WHO Classification

⚫ In 2003 WHO IWGE proposed USG classification

based on the status of activity of cyst.
⚫ GROUP 1: Active group-cyst larger then 2cm and
often fertile.
⚫ GROUP 2: Transition group -cyst starting to
degenrate and entering a transition stage because of
host resistance or treatment.
⚫ GROUP 3: Inactive group -degenerated partially or
totally calcified cyst,unlikely to contain viable
protoscolices.
 Management options

⚫ Medical.
⚫ Surgical
⚫ PAIR.
 Medical management

⚫ INDICATIONS
 Primary liver and lung cyst that are inoperable
because of location or some other medical reason.
 Cyst in 2 or more organs.
 Peritoneal cyst.
 Medical management

⚫ Albendazole 10-15mg/kg/day or 400mg twise daily

for adults.given in cycles of 28 days with 2 weeks
treatment free period.
Schedules
1. Inoperable cases- 3 cycles
2. Pre operative cases- 6 weeks continues to reduce
risk of recurrance
3. Post operative cases- 3 cycles to reduce recurrance
incase of intra operative spillaeg of cyst contents.
 Contraindications of medical treatment

⚫ Early pregnancy
⚫ Bone marrow suppression
⚫ CLD
⚫ Large cyst with risk of rupture
⚫ Inactive or calcified cyst.
⚫ Bone Cyst (relative contraindication)

30% patients have complete recovery after medical

treatment.
 SURGICAL MANAGEMENT

Usually managed in a tertiary care unit by a

multidisciplinary team of surgeon , physician and
interventional radiologist.
INDICATIONS
⚫ Large cyst with multiple daughter cyst.
⚫ Superficial liver cyst.
⚫ Cyst of liver with billiary communications or pressure
effect.
⚫ Infected cyst.
⚫ Cyst in lung, brain, kidneys, eyes, glands,heart,brain.
Options include
⚫ Pericystectomy with omentoplasty
⚫ Hepatic segmentectomy
⚫ Conservative open cystectomy or tube drainage of
infected cyst
Scolicidal agents (hypertonic saline 15-20% and
ethanol 75-90% or 1% povidine solution) are used
during surgery.
These procedures are also being tried
laparoscopically.
 Conservative management
(open cystectomy)

⚫ The conservative technique consist of aspiration of

the cyst,instilation of scolicidal agents and
evacuation of cyst contents and leaving the pericyst.
⚫ The residual pericyst is managed by
1. Marsupialization (suturing the edges of opened
pericyst with skin).
2. Cappitonage (suture oblitration)
3. Partial pericystectomy and omentoplasty.
Marcupialization.
cappitonage
PAIR
 PAIR (1986)

PAIR PROTOCOL (for hepatic hydated cyst)

⚫ Prophylaxis with albendazole
⚫ Puncture and parasitological examination if possible or
fast test for antigen.
⚫ Aspiration of cystic fluid (10-15cc).
⚫ Test for billirubin in cystic fluid.
⚫ If billirubin present then stop procedure
⚫ If absent aspirate all cystic fluid.
⚫ Injection of 95% ethanol or hypertonic saline 15%(1/3 of
the aspirated fluid)
⚫ Reaspiration of protoscolicidal solution after 15 min.
 Contraindications of PAIR

⚫ Non co operative patient.

⚫ Risky location of cyst.
⚫ Cyst in spine brain and heart.
⚫ Calcified cyst
⚫ Cyst in communication with billiary tree
⚫ Ruptured cyst
 Laparoscopic management

A specialized apparatus has been developed to remove

hydated cyst through laparoscope called
perforator-grinder-aspirator appratus.
This instrument perforates the cyst,grinds the
particulate matter and sucks it all out.
The advantage of this instrument over the
conventional is that it does not get blocked by the
daughter cyst and laminated membrane.
 Complications

⚫ All complications related to surgery and anesthesia.

⚫ Related to parasite recurrence
 Metastasis
 Spillage and seeding (anaphylaxis and allergy)
 Infections
⚫ Related to medical treatment
 Hepatotoxicity
 Anemia
 Thrombocytopenia
 Alopecia
 teratogenicity
 Complications

⚫ Related to PAIR
 Hemorrhage
 Mechanical damage
 Infections
 Allergies
 Persistence of daughter cyst
 Sudden intracystic decompression leading to billiary
fistula
⚫ Related to scolicidal agent: cholangitis
 Preventions.

⚫ Keep dogs away from eating infected feces and

contaminated meat.
⚫ Keep yourself away from eating raw offal and food or
substances infected with dogs feces.
THANKYOU