Diagnosis and treatment of the hydatid disease of the liver

Transcription

1 J. Nippon Med. Sch., Vol. 51, No. 1 (1984) Note for Clinical Doctors (107) 107 Diagnosis treatment disease liver Xu Ming-qian Department Surgery, The People's General Hospital Xinjiang Uighur Autonomous Region Hydatid disease liver is a common endemic parasitic condition which prevails in areas world where pastoral industry is well developed, allegealy affects both animals man. It is commonly found in northwestern provinces China. A total nine hundred patients unilocular disease had been treated by surgical operation in our hospital between , se, 650 were cases cysts in liver. The diagnosis treatment series 650 cases is briefly described as follows. Clinical background Of 650 cases, minority nationalities accounted for 348 (53.6%) ; males constituted 52.2% (339 cases) females 47.8% (311 cases) ; 433 (66.6%) were single cyst in liver, 105 (16.2%) multiple cysts, 112 (17.2%) multiple cysts in both liver or viscera ; 556 (85.60) harbored cysts in right lobe liver, 49 (7.500) in left lobe, 45(6.9%) in both lobes. Diagnostic criteria 1. History contact Echinococcosis generally has a high prevalence in pastoral areas where diseased organs are discarded to dogs. A history contact dogs or ir contaminated environment is, refore, suggestive. But rapid development communication in recent years ' disease is not confined to pastoral areas, 26.6,00 our series patients were urban inhabitants. 2. Subjective symptoms Because basic lesion hepatic echinococcosis is space-occupying cystic pressure ectocysts s interfere absorption toxic proteins cystic fluid, patient may ten have no distinct subjective symptoms in early stage liver function is usually not significantly altered. In our series 650 cases, 103 (15.8%) were this type. The slow growth cysts in liver led to a sense bearingdown bursting occult pain in liver region (70.5%), inappetence (60.9%), wasting (55.400) anemia (38.3%). Present address : Department Surgery, The People's General Hospital Xinjiang Uighur Autonomous Region, 91, Heaven Lake Road, Urumqi, Xinjiang, China

2 108(108) 3. Local signs The parasitism development cysts caused liver to move downwards left, enlarged liver being senting sign (89.4%). to ten first pre- When site cysts was in middle or lower part liver, enlarged liver /or large cysts projecting under liver be palpable (77.3%), characteristic signs being a regular margin, a definite limit, a smooth surface, a hemispherical mass moving up down respiration, no manifest ness in absence complications. tender- Because thicker wall ectocysts higher tension cystic fluid, cysts felt hard elastic on pressing, knocking. but pliable had " Based on this feature, thrill" disease could be distinguished from or tumors. With cysts in upper part liver, diaphragm be elevated distended borderline hepatic moved upwards on Fig. 1 A boy right into thoracic cavity The dullness swelling significantly on (22.7%). percussion In children, when enough to be palpable or visible as an abdominal swelling, huge lobe right lower may cyst in liver. chest abdominal be seen. a liver cyst became right hypochondrium large be swollen up cyst projected over costal margin (8.2%a) (Fig. 1). 4. Complications There were 220 cases ten concurrently (1) Hydatid like in this or consecutively One hundred symptoms (38.8%) in two series or more in which various complications occurred, forms. cyst infection twelve hepatopostema upon infiltration cases (17.2%) ; but thicker inflammation into developed cystic hepatic wall tissues, cyst infection, have symptoms provoking a great being influence milder than hepatopostema. (2) Hydatid cyst rupture There were 53 cases (8.1%) rupture into biliary tract, cyst. With rupture fragments cyst rupture. (1) cases were this being common cause secondary infection liver into larger be liberated Twenty-four hepatic duct, into biliary tract, structive jaundice complicating, cystic fluid, daughter cysts cyst causing acute cholecystalgia for most part, secondary acute /or obstructive ob pyogenic cholangitis, griping pain, chilly feeling, fever jaundice more prominent in latter case. (2) Seventeen cases had rupture into abdominal cavity, cystic fluid escaping into peritoneal cavity, producing acute diffuse peritonitis anaphylactic reaction.

3 (109)109 (3) Rupture into lungs occurred in 8 cases. This appeared in situations where cysts at top liver adhered to diaphragm bottom lungs follow - ing complicating secondary bacterial infection ruptured into lungs owing to penetration diaphragm by inflammatory infiltration, resulting in pulmonary abscess bronchial fistula, daughter cysts cyst fragments in purulent sputum coughed out. (4) Two cases had rupture into thoracic cavity, formation pleural effusion anaphylactic reaction. (5) Two cases developed rupture into pericardium, leading to symptoms pericardial plugging. (6) One case was rupture out abdominal wall, forming auto- "marsupialization". (3) Anaphylactic shock It occurred in 10 patients (1.5%), 9 whom were cyst rupture into abdominal 1 into thoracic cavity, but in none 34 cases rupture into biliary tract or bronchus. (4) Disseminated implantation Of 17 cases cyst rupture into abdominal cavity, 14 developed scolex implantations, development new peritoneal cysts. 5. (.asoni intracutaneous test The intracutaneous test using clear fluid, drawn by surgical operation diluted to 1 : 100 after inactivation by autoclaving, as antigen was made on 628 patients, 582 se showed positive reactions, giving a positive rate 92.7%. Negative reactions were obtained in 46 patients (7.3%), relative value in excluding presence infection. A positive reaction still remain significant for several years after removal endocysts. Of 582 patients positive skin reactions, 146 were strong positive form. Four patients developed flush, edema pruritus all over arm following intracutaneous injection antigen. 23 cases were delayed hypersensitivity, local eryma or edema appearing several hours later. In presence complications rupture or infection or both, re was a tendency for positive reaction to increase. As for false negative reactions,! such factors as a single cyst, a short history, small cysts, no daughter cysts or scolices as well as low titre cystic fluid antigen used be concerned ; in addition, too long a disease history, old feeble degenerative cysts decrease in biologic activity loss antigenicity, or interruption absorption antigen by thick calcified wall ectocysts were also factors that gradually turn a positive reaction into negative. False positive reactions were encountered rarely, it was found that hepatocarcinoma tuberculosis showed positive reaction. 6. Laboratory findings (1) Complement fixation test It gave 84 percent positive reactions in our series patients, but had cross-reactions

4 110(110) helminth-like endocysts, diseases. It became negative about one year after surgical removal so was significant in judging rapy or recurrence. (2) Indirect haemagglutination It gave 80 to 94 percent bination (3) specific Eosinophilic reactions, test granulocytosis It temporarily rose had high (Casoni) averaged after specificity, was used in com- as screening ,96, rupture or but operation go as high as 2500 took place, but was in a non- reaction. 7. Ultrasound 1) Type examination A ultrasound As sound saturated out high (2) cysts passed were through formed, reflection. or when thick between Wave train Type a central fluid dark isolated Radioisotope Radioisotope smooth was appear from that cyst wall, a flat two clear segment in presence concentrated after regular cystic fluid a multitude complication hepatocarcinoma. B ultrasound a round cysts, m cystic fluid had become this was to be differentiated It revealed daughter wave waves sound wave daughter infection, 8. positive intracutaneous some cases. test or oval structure space forms scanning regular could nuclide scanning margin entire thick cyst wall definite limit. coarse surface In presence be found. roentgenography showed leftward Fig. 2 Pneumoroentgenogram cyst in right lobe liver. It shows elevated diaphragm a hemispherical projection into thoracic cavity. downward Fig. 3 Lateral disfigured view displacement same case in Fig. 2.

5 (111)111 liver configuration, on a larger discrete defects area, presenting spherical space-occupying changes regular margin definite limit. Roentgenography revealed an enlarged Hydatid cysts at outline liver. according top to size cysts, a wavy swelling or a hemispherical thoracic cavity in diaphragm part. from liver provoked, lung projection into corresponding right This could be differentiated cysts by artificial pneumo- peritoneum (Fig. 2, 3). Larger cysts produced a pressure on diaphragm, causing it to be raised its degree movement respiration decreased. Huge Fig. cysts in right lobe liver not only 4 caused right diaphragm to be raised but Calcified ectocyst right lobe liver. Irregular shadows mass calcification refore be liable to be taken as cysts in right lung. middle or lower portion liver grew towards peritoneal cavity, that re ectocysts 9. that gastrointestinal were pressure traces in gastric pit. not only were occupation on roentgenograms Rupture hypertrophic (Fig. in can be seen. also forced heart to be moved leftwards, following barium meal showed cyst but tract was Cysts in roentgenoscopy pushed to left With a long history disease, displayed different degrees calcium 4). hepatic cysts into peritoneal or thoracic cavity or bronchus Scolices or hooklets could be found in ascites, pleural fluid or sputum. Treatment Surgical is to clean operation recurrence to prevent management 1. (1) has hirto endocyst, caused secondary to prevent by principal The method cystic fluid from scolex implantation, infection. residual been to eliminate treatment comprised treatment. outflow to get rid residual Its principle anaphylaxis loculi ectocysts removal endocysts loculi ectocysts. Removal endocysts Removal endocysts by puncturing It is method most commonly used. After exposing surface liver, ml cystic fluid was first drawn by puncturing for use antigen, n an equal volume a 10% formalin was injected to kill scolices, cystic fluid was rapidly aspirated by a needle a large bore ; as soon as ectocyst collapsed, endocyst

6 112(112) was detached from ectocyst, at this time endocyst daughter cysts (re were no daughter cysts in approximately half cases) were removed by lifting incising ectocyst, wall ectocyst was cleaned formalin hydrogen peroxide solution. In performing se procedures, guidelines "non-tumor operation procedures" were followed. Owing to fibrous wall ectocyst formed by liver tissues, re was no boundary layer between m, ectocyst could not be denuded its wall re be no need for performing an ablation. (2) Removal intact endocysts This is suitable for cysts which project over surface liver. A crucial incision was carefully performed on ectocyst wall, being as long as diameter cyst incisures were pulled to make entire content endocyst escape slowly. The endocyst being vulnerable to rupture, close precautions Should be taken. 2. Management residual loculi ectocysts According to size residual loculi, thickness cyst wall, presence or absence infection or biliary fistula, following procedures were used in surgical treatment : (i) Closed ectocyst suture, in 514 cases (73.70). (ii) Closed greater omentum filling, in 73 cases (10.5%). (iii) Ectocyst "marsupialization", in 51 cases (7.3%). It was adopted in early years now is in disfavour. (iv) Closed drainage a rubber cater in residual loculus, in 25 cases (3.690'). (v) Liver lobectomy or resection, in 18 cases '(2.6%). (vi) Mass resection ectocysts residual loculi open, in 11 cases (1.60). (vii) Drainage "Roux-en-Y" method, in 5 cases (0.7%). In our series 650 cases, 697 operations were performed, 6 deaths.(0.920). The author wishes to extend his sincere thanks for : advices critical reading manuscript Pr. Akiro Shirota, The First Department Surgery Pr. HirOshi Shimizu, Department Radiology, Nippon Medial School. References 1) Xu, M.Q.: Hydatid disease. Xinjiang People's Press, Urumgi, ) Xu, M.Q.: Diagnosis treatment pulmonary echinococcosis. Chin. J. Surg., 6, 1358, ) Xu, M.Q. et al.: Diagnosis complications disease. Chin. J. Surg., 14, 88, ) Chen, W.Q. et al.: Diagnosis management disease liver. Chin. J. Surg., 17, 476, ) Xu, M.Q.: Roentgenodiagnosis disease. Chin. J. Radiol., 14, 95, ) Xu, M.Q.: Diagnosis treatment disease liver. Chin. J. Infect. Dis., 1, 83, ) Xu, M.Q.: Complications disease liver. J. Practical Surg., 3, 201, (Received for publication, January 6, 1984)