2,3 On patient movement, the hydatid sand is dispersed in the cyst and appears as falling snowflakes, which is called the “snowstorm sign.” The cyst … Privacy, Help 2 MSY Medical College & Hospital, Meerut-Hapur Road, Meerut, Uttar Pradesh, India Research Article. 16 (8):953-9. Hydatid disease from head to toe. Acute abdominal pains with a sudden decrease in the volume of cyst and release of daughter vesicles during vomiting (hydatimesis) or in stool (hydatidentery) are highly suggestive of the opening of the cyst in the digestive tract. We are a community of more than 103,000 authors and editors from 3,291 institutions spanning 160 countries, including Nobel Prize winners and some of the world’s most-cited researchers. In the former, the cyst content drains to biliary tract and causes cholestatic jaundice. Among the laboratory examinations, eosinophilia is a sign of concern but is present in less than half of the patients. Some complications of the hydatid cyst of the liver are very rare. Larvae that escape hepatic filtering are carried to the lung, the site of an additional 15-30% of lesions. In endemic areas, the presence of symptoms suggestive of hydatid liver cyst in a person with a history of exposure to sheep and dogs supports the suspicion of hydatidosis. Symptoms of hydatid disease in humans. Other techniques:When a complete pericystectomy is not realizable under good conditions, 2 other techniques of treatment of cysto-biliary communication could be performed: The transparieto-hepatic fistulization described by Perdromo et al[39] which use of a T-tube of which one of the branches is intra-biliary and the other intra-cystic. The diagnosis is most easily set by ultrasound or other imaging techniques such as CT-scan or MRI, combined with case history. Results: some of the results of the study showed some differences comparing to the data from specialty literature, the possible causes being the small number of patients, the paraclinical examinations that were not sufficiently detailed to allow the study of a phenomenon in all its complexity, the lack of information from the patients' first presentation to a doctor or from their previous admissions. The cysts are usually filled with a clear fluid called hydatid fluid and are … During the endoscopic exploration the biliary tree is cleared of any hydatid material with a balloon catheter or a dormia basket. However, in the recent years percutaneous drainage has been used successfully to treat the hepatic hydatid cysts. Epidemiology. Infestation with Echinococcus granulosus is common in Iraq, where a close relationship exists between dogs, the carnivorous definitive hosts, and sheep, the herbivorous hosts of the parasite. The hydatid cyst from Echinococcus granulosus commonly involves the liver and lung but may also be found in other organs, including the brain, heart and bones.1–4 Hydatid cysts rupture into left-sided cardiac chambers may cause systemic emboli, and if ruptured into right-sided cardiac chambers may cause pulmonary emboli.5 Login to your personal dashboard for more detailed statistics on your publications. This method is used to detect post-operative complications following surgery. Hydatidosis of a different location, particularly the liver, may be associated. 2012;36(2):65-70. doi: 10.5152/tpd.2012.17. This drain should be kept between 5 and 8 weeks, and its withdrawn should be performed after a cholangiography. Total pericystectomy for a hydatid cyst the lower surface of the right hepatic lobe. Available from: http://emedicine.medscape.com/article/216432-overview . Laparoscopic has some advantages compared to open surgery. Other carnivores who eat the liver of the intermediate hosts can then become infected and adult worms can develop in their gastrointestinal tract. 2020 Jul-Sep;30(3):376-378. doi: 10.4103/ijri.IJRI_97_20. Most cysts tend to be located in the right lobe. In some cases, if the hydatid cyst contains bile due to associated rupture in the biliary tree, the patient will present peritonitis or even of hydatid choleperitonitis. 68.12 and 68.13), an electrocardiogram, a complete blood count, international normalized ratio (INR), electrolyte and renal function tests, and liver function tests; in addition, blood should be grouped and screened. ... Echinococcus cyst in the liver. If the rupture is insidious, the release of brood capsules, scolices and even daughter cysts from a ruptured hydatid cyst into the peritoneal cavity leads to multiple cysts in the peritoneal cavity. The group consisted of 71 boys and 57 girls aged from 8 months to 16 years. Rupture into the peritoneum may present as acute abdominal pain. Total removal of all infective components of the cysts; the avoidance of spillage of cyst contents at time of surgery; management of communication between cyst and adjacent structures; All the surgical procedures can be divided into two large groups, a conservative group and a radical one. Hydatid cysts in the liver. 2 MSY Medical College & Hospital, Meerut-Hapur Road, Meerut, Uttar Pradesh, India The modern treatment of hydatid cyst of the liver varies from surgical intervention to percutaneous drainage or medical therapy. This phenomenon is called secondary echinococcosis [15-16]. Treatment of hydatid liver cyst has to be considered mandatory in symptomatic cysts and recommended in viable cysts because of the risk of severe complications [1]. This technique gives good results in case of central cyst with large cysto-biliary fistula in the right and/or left biliary canal. Intrabiliary rupture occurs in the right hepatic duct (55-60% cases), left hepatic duct (25-30% cases), hepatic duct junction, common bile duct (CBD), or cystic duct (8-11%); perforation into the gallbladder may be observed in 5-6% of cases. eCollection 2020. If the cyst … The Life cycle ofEchinococcus granulosus. The different schedules for the treatment are: Inoperable cases - as primary treatment - 3 cycles, Pre-operatively – to reduce the risk of recurrence 6 weeks continuous treatment. www.metinertem.com, www.laparoskopik.com , Liver hydatid cysts of the liver was treated with laparoscopic intervantion . The ERCP is effective in diagnosing biliary tree involvement from the cyst. Available from: Natural history and genesis of complications, Complications of hydatid cyst of the liver, Physical Sciences, Engineering and Technology, Biochemistry, Genetics and Molecular Biology, Pharmacology, Toxicology and Pharmaceutical Science, Reflecting walls (Cyst with reflecting calcified thick wall), Department of Surgery, Sahloul Hospital, Sousse, Tunisia, Department of Medical Imaging, Sahloul Hospital, Sousse, Tunisia, Department of Anesthesiology and Intensive Care, Sahloul Hospital, Sousse, Tunisia, Department of Pathology, Farhat Hached Hospital, Sousse, Tunisia. Fethi Derbel, Mohamed Ben Mabrouk, Mehdi Ben Hadj Hamida, Jaafar Mazhoud, Sabri Youssef, Ali Ben Ali, Hela Jemni, Nadia Mama, Hasni Ibtissem, Arifa Nadia, Chedia El Ouni, Walid Naija, Moncef Mokni and Ridha Ben Hadj Hamida (August 14th 2012). Dubei L. Strat V.: Algoritm de tratament minim invaziv al chistului hidatic hepatic. 2006;55:S39–43. During the natural evolution toward healing, dense calcification of all components of the cyst takes place. Intrabiliary rupture of a hepatic hydatid cyst is a common complication and may occur in 2 forms: an occult rupture, in which only the cystic fluid drains to the biliary tree and is observed in 10-37% of the patients; and frank rupture, which has an overt passage of intracystic material to the biliary tract and is observed in 3-17% of the patients. Presentation Patients with a liver hydatid may present either with liver enlargement and right upper quadrant pain due to pressure from the cyst or acutely with a complication. Whether the patient has detectable antibodies depend on the physical location, integrity and viability of the cyst. It has beenproposed that these agents contribute to clinical improvementof the disease by diminishing the size of the cyst. Purified fractions may yield high sensitivities (95%) and specificity (100%).[1,3,21]. Khuroo et al [50] reported 88% disappearance of cysts with percutaneous drainage which was preceded by Albendazole therapy (10 mg/kg body weight) for 8 weeks. Hydatid disease remains a continuous public health problemin endemic countries. Prevention and treatment information (HHS). Serological tests detect specific antibodies to the parasite and are the most commonly employed tools to diagnose past and recent infection with E. granulosus. The hepatic hydatid cyst therapy is multimodal, including medical, surgical, and, lately, minimally invasive techniques. Intermediate host is sheep, man. Intrabiliary rupture of hydatid cyst of the liver. ( Figure 26-29)The management of the residual cavity is a challengingproblem especially in patients with gianthydatid Cysts.Various techniques have been described for the management of residual cavities, such as; external drainage,Capitonnage and omentoplasty, Pericystectomy – this procedure involves a non-anatomical resection of cyst and surrounding compressed liver tissue. -, Polat P, Kantarci M, Alper F, et al. The most common complications in order of frequency are infection, rupture to the biliary tree; rupture to the peritoneal cavity; rupture to the pleural cavity. Hydatid cysts can develop anywhere in the body, but two thirds occur in the liver and one quarter in the lungs. In many countries, hydatid disease is more prevalent in rural areas where there is a closer contact between people and dogs and various domestic animals which act as intermediate vectors. Significant risk factors for hydatid cyst perforation include younger age, cyst diameter of >10 cm, and superficial cyst location. hydatid cyst: [ sist ] 1. bladder. Post-operatively to prevent recurrence in cases of intraoperative cyst spillage 3 cycles. Cyst erosion is associated with pericystic inflammation. CT scan showing typical type III cyst in right lobe of liver. It is safe and efficient in selected patients. Hydatid cysts of the liver: TN(R)C classification. Keywords: Am J Case Rep. 2020 Aug 2;21:e923281. Introduction Hippocrates recognized human hydatid over 2,000 years ago. The cyst wall contains an outer chitinous layer and an inner germinal layer. Partial cystectomy and capitonnage, Hydatid cyst of liver with portal hypertension: partial cystectomy. When ruptured into biliary tree, hydatid cysts commonly manifest with findings of biliary obstruction and cholangitis. doi: 10.1590/0037-8682-0589-2020. We are IntechOpen, the world's leading publisher of Open Access books. Mortality: The surgical management of hydatid disease of liver carries a mortality rate of 0.9 to 3.6 %. Hydatid cysts appear as well-defined, circumscribed cystic lesions with a clear membrane; they do not infiltrate surrounding liver tissue, and cysts are staged according to the content patterns. PAIR in cystic echinococcosis. The modern treatment of hydatid cyst of the liver varies from surgical intervention to percutaneous drainage or medical therapy. Punctures of hydatid cysts have been discouraged in the past due to the potential risk of Anaphylactic shock and peritoneal dissemination. The liver is the most common site for hydatid disease (75%of cases), followed by the lungs (15%), the spleen (5%),and other organs (5%). Careers. (figure 32), Endoscopic sphincterotomy is performed after a 3-week waiting period in patients with low-flow fistulas or can be performed earlier in patients with high-flow fistulas [43-45]. Cysts in the liver may also cause cirrhosis. Plain radiographs of the abdomen and chest may reveal a thin rim of calcification delineating a cyst, or an elevated hemi diaphragm. The procedure involves removal of hydatid cyst, comprising laminar layer, germinal layer and cyst contents (daughter cysts and brood capsules). Cystic echinococcosus has a world wide geographical distribution. In the latter simple communications are frequently overlooked and could cause post-operativebiliary fistulae [37-39]. Hydatid Cyst Of Liver 1. Although most of the external biliary fistulas close spontaneously, they may be persistent in 4%-27.5% of the cases. In fact this approach to liver hydatid cyst offers a lower morbidity outcome and a shorter hospital stay and it is also associated with a faster surgery. Our team is growing all the time, so we’re always on the lookout for smart people who want to help us reshape the world of scientific publishing. Radical vs conservative surgery for hydatid liver cysts: experience from single center. The period of initial growth of … Imaging findings in hepatic hydatid disease depend on the stage of cyst growth (whether the cyst is unilocular, contains daughter vesicles, contains daughter cysts, is partially calcified, or is completely calcified. eCollection 2020. Chest radiograph showing a right pleural effusion with atelectasis, Thoracic CT-scan showing an atelectasis of the lower lobe of right lung (a) and hydatid cyst of the hepatic dome (b), Abdominal CT-scan showing a hepatic hydatid cyst of segment VII with communication with the right pleura. Recurrence rate varies with type of surgery; it is estimated up to 11.3 % within 5 years. 2021 Mar 8;54:e0589-2020. Diagnosis and treatment of uncomplicated hydatid cyst of the liver. The cyst comprises 3 layers: outermost pericyst is fibrous, middle ectocyst layer is laminated, hyaline and acellular and the inner endocyst is the germinative layer which consists of daughter cysts and brood capsules with scolices Considering that the early stages of infection are usually asymptomatic, the diagnosis of liver hydatid cyst may often be incidental, associated with an abdominal ultrasonography performed for other clinical reasons. Thoracic complications of hepatic hydatid cysts result from the proximity of hydatid cysts in the liver and the diaphragm and are seen in approximately 0.6% to 16% of cases. Patients may describe symptoms of mild upper right quadrant pain, urticarial skin rash, and episodes of pruritus. CT features include sharply marginated single or multiple rounded cysts of fluid density (3 – 30 Hounsfield units) with a thin dense rim. Liver hydatidosis is characterized by progressive growth of the hydatid cyst, which in its mature form is a fluid filled cavity, delimited by an external dense host fibrous reaction (pericyst) and two internal parasite derived layers (endocyst). Liver hydatid cyst represents one of the most frequent localizations of Echinococcus granulosus tapeworm in humans. CT scan showing a rupture hydatid cyst of the liver in the peritoneum, CT-scan of the abdomen showing multiple hydatid cysts in the peritoneal cavity due to rupture of hepatic hydatid cyst (secondary echinococcosis)(A). In three of four cases the cyst is a single one. This technique could be performed when it is a small fistula. Author information: (1)Division of Gastroenterology, Department of Internal Medicine, Tri-Service General Hospital, Taipei. Epub 2020 Oct 15. A differential diagnosis of hydatid cyst should be considered for cystic mass in any anatomical location of the body in endemic area. This approach is possible only in selected cases. However, in the types I and IV, we have to consider differential diagnosis. Hydatid cyst occurs as a result of infection by the larval cyst stage of the tapeworm, Echinococcus granulosus. Gharbi Classification on Ultrasonography features of Hydatid Cyst [23], (Figure19-20). All patients undergoing surgery for hepatic hydatid cysts should have a detailed preoperative assessment that includes a chest radiograph to exclude pulmonary cysts (Figs. It is not endemic in the United States, but the change in the immigration patterns and the marked increase in transcontinental transportation over the past 4 decades have caused a rise in the profile of this previously unusual disease throughout North America. Unable to load your collection due to an error, Unable to load your delegates due to an error. Hepatic hydatid disease is a parasitic zoonosis caused by the Echinococcus tapeworm. The Endoscopic management is useful in presence of intrabiliary rupture, which requires exploration and drainage of the biliary tract and also after surgery in presence of residual hydatid material (membranes and daughter cyst) left in biliary tree. Retrieval of retained pigtail in the liver. We hypothesized that cysts larger than 15 cm, or compressing main vascular structures, or located in both hemilivers should be considered, as well as complicated cysts, in the category of complex hydatid cysts. By Fethi Derbel, Mohamed Ben Mabrouk, Mehdi Ben Hadj Hamida, Jaafar Mazhoud, Sabri Youssef, Ali Ben Ali, Hela Jemni, Nadia Mama, Hasni Ibtissem, Arifa Nadia, Chedia El Ouni, Walid Naija, Moncef Mokni and Ridha Ben Hadj Hamida, Submitted: November 28th 2011Reviewed: May 7th 2012Published: August 14th 2012. The parasite is found worldwide. Cystic structures with laminating fibrous wall and inner germinal layer, Tissue section of a hydatid cyst showing daughter cyst. A special thank to Mr Bouraoui Chelly for his great help in the critical reading of the manuscript. Separation of membranes (ultrasonic water lily sign) due to collapse of germinal layer seen as an undulating linear collection of echoes. Once the eggs are ingested, they release larvae into the duodenum. Young TH(1), Hsieh TY, Liu YC, Chao YC, Hsu CT, Lee HS, Tang HS. These cysts grow at a rate of 1-3 cm/year and may remain undetected for years.Thus; they can reach very large sizes before they become clinically evident. Vascular erosions are very rare complications of the hydatid cysts of the liver. This technique was proposed in 1986 by the Tunisian team that first used it in a prospective study [48]. In these cases, cholangiography could be done by a catheter pushed into the ductus cysticus or the cystobiliary fistula]. This is "Hydatid cyst of liver - Stanley Surgeon" by Stanley Surgeon on Vimeo, the home for high quality videos and the people who love them. Dog is the common definite host. Hydatid disease is a major endemic health problem in certain areas of the world [1-3]. However, diagnostic tests such as CT and MRI are mandatory in liver hydatidosis because they allow thorough knowledge regarding lesion size, location, and relations to intrahepatic vascular and biliary structures, providing useful information for effective treatment and decrease in post-operative morbidity. CASONI TEST has been used most frequently in the past but is at present considered only of historical importance and has largely been abandoned because of low sensitivity. The clinical courses of 128 children with thoracic and liver hydatid cyst operated on from 1994 to 2000 were reviewed. Materials and methods: 88 patients were diagnosed with liver hydatid cyst at the General Surgery Clinic of the Colentina Hospital in Bucharest where they were admitted from January 2014 to July 2017. Hepatic resections – The arguments against hepatic resection as a primary modality of treatment are :firstly,outside of the dedicated liver units there is considerable morbidity and mortality from resection of what is essentially a benign condition.What is more, the distortion of the anatomy makes surgery harder. Different classifications of Ultrasonography have been described in the literature [24-25]. Ultrasonography is the screening method of choice. Bronchobiliary fistula leads to hemoptysis and cyst expectoration. The slow growing cysts are localized in the liver (in 75% of cases), the lungs (in 5-15% of cases) and other organs in the body such as the spleen, brain, heart and kidneys (in 10-20% of cases). The hydatid cyst … PAIR should only be performed in highly specialized centers with appropriately trained and experienced staff. CT- scan of the abdomen showing multiple intra peritoneal hydatid cysts. liver hydatid cyst; minimally invasive methods; surgical treatment. Excised hydatid cysts. The initial infection is asymptomatic, but an enlarging hydatid liver cyst can cause abdominal pain, nausea, hepatomegaly, or a palpable mass. Hydatid disease in people is mainly caused by infection with the larval stage of the dog tapeworm Echinococcus granulosus. Sometimes the germinal Epithelium daughter cysts, which if left untreated may cause recurrence. Radical procedures have lower rate of complications and recurrences but many authors consider them inappropriate, claiming that intraoperative risks are too high for a benign disease. 2000 May-Jun;20(3):795–817. Spillage may lead to peritoneal hydatidosis, Morbidity: Biliary leakage is the most frequent postoperative complication following surgery for hydatid cysts of liver. Case Rep Pediatr. Ultrasonography (US) is the screening method of choice. Generally, pleural hydatid cysts arise as secondary exten-sions from the lung or are due to rupture of liver hydatid cysts into the pleural space.10 These show features similar to liver hydatid cysts depending on the stage of the lesion. ( Figure 21-24). The injection of radioopac solution or methylene blue is helpful to diagnose intrabiliary rupture or to see the orifice. The symptoms depend not only on the size and number of cysts, but also on the mass effect within the organ and upon surrounding structures.[21]. Simple cysts of the liver are relatively common, encountered in about 2.5% of the population. The most common symptom, when it occurs, is right upper quadrant or epigastric pain and the most common findings on examination are an enlarged liver and a palpable mass. [22,30, 32], Endoscopic retrograde cholangiopancreatography (ERCP) remains an important tool in cases where a rupture into the biliary tree has occurred, allowing both the diagnosis of major biliary communication and clearance of the common bile duct (CBD) prior to surgery or intervention by the means of sphincterotomy [34], Direct cholangiography: intra-operative cholangiography is performed through a cystic drain or a T-Tubein a suspected intrabiliary rupture and bile duct obstruction. Albendazole seems to be more effectiveowing to better penetration and absorption. The symptoms of hydatid disease vary according to which body organs are infected. As the cysts enlarge local pressure causes a mass effect on surrounding tissue producing commensurate symptoms and signs. The group consisted of 71 boys and 57 girls aged from 8 months to 16 years. The ADC and cyst-to-liver ADC ratio of the hydatid cysts were significantly lower than those of simple cysts (p < 0.005). Imaging findings are the basis for the diagnosis of hepatic hydatid cysts. Post-operative cholangiography showing a cysto-biliary fistula. The cysts can increase in size to … eCollection 2021. It can be performed successfully in up to 90% of patients if a cyst does not have a risky localisation. Kattan YB. In addition to that advantage, Laparoscopic procedure gives a better visual control of the cyst cavity under magnification which allows a better detection of biliary fistula. There are two different clinical settings associated with intrabiliary rupture: frank intrabiliary rupture and simple communication. This technique should be performed for central cyst with a large bilio-cystic fistula. Features are suggesting hydatid aetiology include dependent debris (hydatid sand) moving freely with change in position; presence of wall calcification or localized thickening in the wall corresponding to early daughter cysts. Multiple peritoneal cysts(B), An operative view in a 12 years old male showing a hydatid cyst of the liver with spontaneous rupture in peritoneum, Operative view showing a hydatid cyst of the peritoneum, Operative view showing a peritoneal echinococcosis. Adhesion formation determines whether the rupture is confined to lung parenchyma or the free pleural space, or both. Serology tests such as ELISA or immunoblotting can be used in addition, being 80-100% sensitive for liver cysts but only 50-56% for lungs and other organs [21]. If the cystobiliary opening was less than 5 mm, spontaneous drainage of the cystic content was uncommon and could be treated by suturing under the direct vision. Liver hydatid disease is a common benign condition in many countries. Patients with alveolar echinococcosis have most of the time detectable antibodies.Fine needle biopsy should be avoided if dealing with E. granulosus since there is a great danger of leakage with subsequent allergic reactions and secondary recurrence. The hydatic cyst is mainly found in the liver (75% of the cases), being asymptomatic in most cases and discovered accidentally on a routine abdominal ultrasound or an ultrasound performed for diagnosing other pathologies. 2018 Jan;88(1-2):26-31. doi: 10.1111/ans.14117. Multiple Giant Liver Cysts in a Nepalese Lad. The World Health Organization guidelines for indications and contraindications of PAIR are as follows:[54], Nonechoic lesion greater than or equal to 5 cm in diameter, Cysts with daughter cysts and/or with membrane detachment, Patients in whom surgery is contraindicated, Patients who fail to respond to chemotherapy alone, Inaccessible or risky location of the liver cyst. The bloodstream reaches, including the lung, peritoneum, kidney, brain, mediastinum, heart, … The most frequent extrahepatic locations are the lungs, the spleen and the peritoneum. Microscopic (histologic) description. In case of peritoneal hydatidosis, CT scan is indicated before surgery to assess the number and the exact localisations of the cysts. A cyst is defined as a rounded, dense to the touch education. The disease progresses symptom-free in most patients, due to a slow growth rhythm of the cyst. Larvae that escape the host's defenses and persist in a host organ develop into small cysts surrounded by a fibrous capsule. 1 Department of Radiodiagnosis,Teerthanker Mahaveer Medical College & Research Center, Moradabad, Uttar Pradesh, India. Classification of hydatid cysts based on the ultrasound appearance. Hydatid cysts are most commonly found in the liver and lungs, although they may also occur in other organs, bones and muscles. ANZ J Surg. 1 Department of Radiodiagnosis,Teerthanker Mahaveer Medical College & Research Center, Moradabad, Uttar Pradesh, India. The most frequent clinical signs and symptoms are abdominal pain, splenomegaly, and fever ( , 33 ). In secondary echinococcosis, the CT –scan shows the hydatid cysts and many peritoneal cysts. This parasitic infection occurs worldwide and is endemic in some countries such as Australia and the Middle East, especially in sheep farming areas. This chapter is distributed under the terms of the Creative Commons Attribution 3.0 License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Most primary infections consist of a single cyst, but up to 20%-40% of infected people have multiple cysts. Calcifications occur in the pericyst; the host is at the origin of the image of pericystic wall. However, there are many potential local complications (eg, intrahepatic complications, exophytic growth, transdiaphragmatic thoracic involvement, perforation into hollow viscera, peritoneal seeding, biliary communication, portal vein involvement, abdominal wall invasion). Multiple cysts with normal intervening parenchyma (differential diagnosis are necrotic secondaries, Polycystic liver disease, abscess, chronic hematoma and biliary cysts. About fistulization to the skin, It occurs most often by a cutaneous orifice leaving pus welling and sometimes hydatid membranes [17-18]. Calcifications occur in the pericyst; the host is at the origin of the image of pericystic wall. The Criteria to exclude laparoscopic treatment of hydatid cyst of liver are, Nevertheless, a disadvantage of laparoscopy is the lack of precautionary measures to prevent spillage under the high intraabdominal pressures caused by pneumoperitoneum, allergic reactions are more common in laparoscopic interventions due to peritoneal spillage, though the length of stay is generally shorter and morbidity rates are lower in comparison with open procedures.[40]. Antigens can be derived from the whole parasites or organelles, or soluble antigens from cyst fluid. With secondary infection, tender hepatomegaly, chills, and spiking temperatures occurs. The T-Tube is kept 4 at 6 weeks and is withdrawn only after cholangiography. This is technically a more difficult procedure than cystectomy and can be associated with considerable blood loss; it can also be hazardous in the case of large and complicated cysts when the cyst distorts vital anatomical structures such as; hepatic veins or biliary ducts. Indirect immunofluorescence assay (IFA) is the most sensitive test (95%) in patients with hepatic CHD. Biliary rupture may occur through a small fissure or bile duct fistula. The clinical signs appear gradually with the increase volume of the cyst. Patients with senescent, calcified or dead cysts usually are sero-negative. The hepatic hydatid cyst therapy is multimodal, including medical, surgical, and, lately, minimally invasive techniques. Surgery is still the treatment of choice and can be performed by the conventional or laparoscopic approach. Alveolar echinococcosis (AE) disease is caused by infection with the larval stage of Echinococcus multilocularis , a ~1–4 millimeter long tapeworm found in foxes, coyotes, and dogs (definitive hosts). The indications for thoracotomy become rare. [26-28], It is also helpful in identifying exogenous cysts, and the volume of the cyst can be estimated. A special instrument has been developed for the removal of the hydatid cyst with the laparoscope called the perforator-grinder-aspirator apparatus. Radiographics. Hydatid disease: radiologic and pathologic features and complications. Complications may be evident such as echogenic cyst in infection or signs of biliary obstruction (dilated bile ducts with some images corresponding to hyperechoic vesicles or hydatid membranes within the biliary tract) usually implying a biliary communication. However, rupture in the gastrointestinal tract; bladder and the vessels are very rare. Surgery is still the treatment of choice and