HYDATID LIVER DISEASE SPECTRUM OF APPEARANCES

Transcription

1 HYDATID LIVER DISEASE SPECTRUM OF APPEARANCES DR JAIKISHOR JOTHIRAJ 1 ST YEAR POSTGRADUATE MDRD SRMMCH CHENNAI GUIDED BY PROF & HOD DR SRINIVASA MUDALI PROF DR VINAYAGAM.S PROF DR SARAVANAN K.C

2 CASE 1 5/F 5yr old girl came with the c/o pain in the rt hypochondrium for the past 3 months

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5 SNOWSTORM SIGN=HYDATID SAND

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7 DAUGHTER CYSTS

8 CASE 2 60 yr old female with C/O pain in the LEFT hypochondrium

9 RACEMOSE OR HONEYCOMB APPEARANCE

10 Speck of marginal calcification with multiloculated cyst in LLL

11 OPERATIVE SPECIMEN

12 HISTOPATHOLOGICAL FINDING

13 CASE 3 75/f 75/f came with the following c/o pain in the pain in the rt hypochondrium for the past 4 months after 3 months she developed jaundice,intermittent fever,urticaria

14 Multiple peripheral loculated cysts within a large cyst honeycomb pattern

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19 CASE 4 48/M 48/m came with the following c/o pain in the rt & lt hypochondrium for the past 4 months

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22 MRI T1 SEQUENCE

23 MRI T2 SEQUENCE

24 HIPPOCRATES recognized human hydatid over 2000 yrs ago. The arab physician AL RHAZES made reference to hydatid disease of the liver in AD 900

25 Etiology infestation of the parasite echinococcus granulosus echinococcus multilocularis echinococcus Vogeli paca brazil echinococcus oligarthrus

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28 Cyst wall consits of 3 layers Ectocyst (laminated membrane) external membrane which may calcify Pseudocyst/Pericyst(adventitia) dense connective tissue capsule formed around the cyst as a part of host response Endocyst(germinal epithelium) the inner germinal that gives rise to brood capsules This brood capsules may separate from the wall & form a fine sediment called HYDATID SAND

29 CLINICAL FEATURES Simple/uncomplicated/multivesicular/univesicular cysts are asymptomatic Pressure on the adjacent organs symptoms Abdominal pain,tenderness,palpable mass. Secondary infection hepatomegaly,chills,fever Urticaria,erythema generalized anaphylactic reactions Biliary rupture jaundice,biliary colic,urticaria

30 CLASSIFICATION TYPE 1 Simple Cyst 2A TYPE 2 ACTIVE PHASE 2B 2C 3A TYPE 3 CALCIFIED CYSTS 3B 3C TYPE 4 COMPLICATED

31 Type I: Simple Cyst Appear as a well defined anechoic mass with or without hydatid sand and septa. usg Unilocular cysts are considered to be an initial stage in the development of the parasite SNOWSTORM SIGN==HYDATID SAND Rolling the patient during evaluation disperses the sand, creating small echogenic foci, or falling snowflakes.

32 WATER LILLY SIGN =partial /complete detachment of endocyst from pericyst (due to intracystic pressure as a sign of degeneration /trauma /host response /response to therapy is pathognomic. Floating membranes doesn t indicate the death of the parasite At CT, a type I HC appears as a well defined, water attenuation mass. The septa and cyst wall enhance in contrast CT and magnetic resonance

33 MR imaging features T1W1 and T2WI MR imaging, a finding that helps to differentiate type I HC from a simple liver cyst. A low signal intensity rim ( rim sign ), which is more evident on T2W1, is characteristic of hydatidosis

34 Type II hydatid cysts It is the active phase of hydatid disease type II HCs can spread to near by tissue by outpouching a new cyst from the main cyst An hourglass appearance can be seen. This type is classified into three stages

35 MRI shows daughter cysts as hypointense or isointense relative to the maternal matrix on T1 and T2 weighted images. Type IIB HCs a rosette appearance RACEMOSE/HONEYCOMB APPEARANCE multiple septa between the daughter cysts inside the mother cysts occupying the entire volume SPOKE WHEEL PATTERN daughter cysts separated by echogenic material of hydatid matrix likely to be hydatid

36 type IIC cysts that contain scattered calcifications within the cyst wall and daughter cysts within the cavity. Scattered calcification at the cyst wall does not imply a dead cyst but degeneration at the cyst wall CT is the preferred imaging method to evaluate these types of HCs due to calcification

37 Type III: Calcified HCs IT is the inactive or dead phase of HD. 3 types: (1) Total and thick continuous calcification (ringlike) of the cyst wall (2) total calcification within the cyst matrix and a decrease in cyst size (3) curvilinear calcification within the ruptured internal membranes EGG SHELL CALCIFICATION in cyst wall least common

38 Type IV: Complicated HCs Transdiaphragmatic growth through bare area of liver 1. Chronic biliary fistula (5 15%) 2.Peritoneum 13% 3.rupture into pleural cavity 4. Seeding in pulmonary parenchyma 5.Hollow viscus infection following rupture (5 8%)

39 Internal rupture leads to the water lily sign With time, cystic fluid decreases, and the HC mimics a solid mass Collapsed membranes within the cavity are detected as serpentine structures Compression of vital structures (bileduct,portal vein ) Coexisting cholelithiasis recurrence

40 KEY POINTS CT helps in differentiating parasitic from nonparasitic cysts. Parasitic cysts pathognomically have a thick wall A solid heterogeneous mass is difficult to differentiate from granulomas or tumors, although calcification suggests echinococcal cyst.

41 MRI may have some advantages over CT in the evaluation of postsurgical residual lesions, recurrences, and selected extrahepatic infections. It is also superior in identifying changes of the intrahepatic and extrahepatic venous system and in identifying cysto biliary fistulas

42 MR PROTON SPECTROSCOPY pyruvate levels DIRECT CHOLANGIOGRAPHY is indicated in intrabiliary rupture & bile duct obstruction RADIO NUCLIDE SCAN bronchobiliary fistula ELISA SEROLOGICAL TESTS IgM & IgA antibodies active phase CASONI S INTRADERMAL TEST

43 DIFFERENTIAL DIAGNOSIS SIMPLE CYST AMOEBIC LIVER ABSCESS HAEMATOMA METASTASIS MESENCHYMAL HAMARTOMA

44 THANK YOU

45 REFERENCES GRAINGER & ALLISON DAVID SUTTON RADIOGRAPHICS Pinar Polat, MD Mecit Kantarci, MD Fatih Alper, MD,Selami Suma, MD Melike Bedel Koruyucu, MD Adnan Okur, MDmarch april 2003 Polat P, Kantarci M, Alper F, Suma S, Koruyucu MB, Okur A. Hydatid Disease from Head totoe. RadioGraphics 2003; 23: Mortele KJ, Segatto E, Ros PR. The infected liver: radiologic pathologic correlation. Radiographics.2004; 24: