Figure 1
Teaching Case
SectionAbdominal imaging
Case TypeClinical Cases
AuthorsJoão Abrantes1, Catarina Lima Vieira2, Clara Fernandes1, João Granadeiro1
Connected authors
86 years, male
A 86 years-old man, with a previous history of hypertension, coronary artery disease and known hydatid disease, presents with a history of long term dyspepsia and epigastric pain. Laboratory evaluation revealed a normochromic, normocytic anemia (Hb 6.9).
Hydatid cyst rupture with cysto-gastric fistula
Hepatic abscess
Cystic tumor
Cystic hepatic metastasis
Admission abdominal CT revealed a partially collapsed calcified hepatic cyst in the left liver lobe, adjacent to the gastric wall and with a endoluminal air-fluid level. There is a fistulous tract to the small curvature of the stomach.
Upper gastrointestinal endoscopy (performed because of dyspepsia, epigastric pain and anemia) demonstrated mucosal ulceration associated with a patent fistulous tract in the small curvature of the gastric body.
Previous abdominal CT (3 years earlier) showed a partially calcified hepatic hydatid cyst in the left liver lobe, measuring 4.9 cm. No evidence of rupture or other complications.
Upper gastrointestinal endoscopy (performed because of dyspepsia, epigastric pain and anemia) demonstrated mucosal ulceration associated with a patent fistulous tract in the small curvature of the gastric body.
Previous abdominal CT (3 years earlier) showed a partially calcified hepatic hydatid cyst in the left liver lobe, measuring 4.9 cm. No evidence of rupture or other complications.
Hydatid disease (HD) is a zoonosis caused by tapeworms, with the Echinococcus granulosus parasite being the most commonly involved in human infection [1]. HD has a worldwide geographic range and affects patients on all continents [2].
The diagnosis of HD is based on clinical findings, serologic values, and imaging features. Hydatid cysts have been classified into five types according to their characteristics in the ultrasound examination, and these criteria have been extrapolated to CT and MR imaging findings [3]:
I - Unilocular cystic lesion with visible wall
II – Multivesicular multiseptated lesion with daughter cysts
III– Heterogeneous with low-level debris, sparse daughter cysts and detached membranes
IV–Heterogeneous cyst with no daughter cysts and scattered calcifications
V– Lesion with thick calcified wall
When the imaging findings suggest the presence of a nonviable (type V) cyst, expectant management can be pursued [4].
The majority of HD involvement occurs in the liver (59–75%) [5], with pulmonar and pleural disease seen in 10%–30% of all cases of HD in adult humans [6]. Hydatid disease of peritoneal cavity accounts for 10% to 16% of the described cases in the literature, mainly resulting from liver cyst rupture [7].
The spleen is site to hydatid cysts in up to 4% of all abdominal cases and urinary tract involvement is seen in less than 5% of cases [8, 9]. A very low percentage of patients can also present with adrenal, cardiac, skeletal and cerebral HD [10–13].
Complications of hydatid cysts include rupture, infection, exophytic growth and portal venous system involvement, with a purposed classification into three types of complication [14]:
1-Contained rupture
2-Communicationg rupture with involvement of the biliary tree
3-Direct rupture into peritoneal cavity, pleural cavity, abdominal wall and hollow viscera.
Spontaneous rupture of a hydatid cyst into hollow viscera, such as in the presented case, is an extremely rare complication, with an estimated frequency of 0.5% [15].
Preoperative diagnosis of gastric fistula of hydatid disease can be made with radiological studies, the presence of air-fluid levels and determination of the site of communication in computed tomography are helpful features for the diagnosis [16].
The management of HD historically involved an open surgical approach, however, as effective antihelminthic agents were developed, the use of the percutaneous, minimally invasive, image-guided approach was introduced and can be used to treat active disease before major complications develop [17].
Written informed patient consent for publication has been obtained.
The diagnosis of HD is based on clinical findings, serologic values, and imaging features. Hydatid cysts have been classified into five types according to their characteristics in the ultrasound examination, and these criteria have been extrapolated to CT and MR imaging findings [3]:
I - Unilocular cystic lesion with visible wall
II – Multivesicular multiseptated lesion with daughter cysts
III– Heterogeneous with low-level debris, sparse daughter cysts and detached membranes
IV–Heterogeneous cyst with no daughter cysts and scattered calcifications
V– Lesion with thick calcified wall
When the imaging findings suggest the presence of a nonviable (type V) cyst, expectant management can be pursued [4].
The majority of HD involvement occurs in the liver (59–75%) [5], with pulmonar and pleural disease seen in 10%–30% of all cases of HD in adult humans [6]. Hydatid disease of peritoneal cavity accounts for 10% to 16% of the described cases in the literature, mainly resulting from liver cyst rupture [7].
The spleen is site to hydatid cysts in up to 4% of all abdominal cases and urinary tract involvement is seen in less than 5% of cases [8, 9]. A very low percentage of patients can also present with adrenal, cardiac, skeletal and cerebral HD [10–13].
Complications of hydatid cysts include rupture, infection, exophytic growth and portal venous system involvement, with a purposed classification into three types of complication [14]:
1-Contained rupture
2-Communicationg rupture with involvement of the biliary tree
3-Direct rupture into peritoneal cavity, pleural cavity, abdominal wall and hollow viscera.
Spontaneous rupture of a hydatid cyst into hollow viscera, such as in the presented case, is an extremely rare complication, with an estimated frequency of 0.5% [15].
Preoperative diagnosis of gastric fistula of hydatid disease can be made with radiological studies, the presence of air-fluid levels and determination of the site of communication in computed tomography are helpful features for the diagnosis [16].
The management of HD historically involved an open surgical approach, however, as effective antihelminthic agents were developed, the use of the percutaneous, minimally invasive, image-guided approach was introduced and can be used to treat active disease before major complications develop [17].
Written informed patient consent for publication has been obtained.
References
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[2] Eckert J, Conraths FJ, Tackmann K. (2000) Echinococcosis: an emerging or re-emerging zoonosis?. Int J Parasitol 30(12-13):1283-94 (PMID: 11113255)
[3] WHO Informal Working Group. (2003) International classification of ultrasound images in cystic echinococcosis for application in clinical and field epidemiological settings. Acta Trop 85(2):253-61 (PMID: 12606104)
[4] Brunetti E, Kern P, Vuitton DA (2010) Expert consensus for the diagnosis and treatment of cystic and alveolar echinococcosis in humans. Acta Trop 114(1):1-16 (PMID: 19931502)
[5] Beggs I (1985) The radiology of hydatid disease. AJR Am J Roentgenol 145(3):639-48 (PMID: 3895873)
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[7] Hamamci EO, Besim H, Korkmaz A (2004) Unusual locations of hydatid disease and surgical approach. ANZ J Surg 74(5):356-60 (PMID: 15144257)
[8] Rasheed K, Zargar SA, Telwani AA (2013) Hydatid cyst of spleen: a diagnostic challenge. N Am J Med Sci 5(1):10-20 (PMID: 23378949)
[9] Ishimitsu DN, Saouaf R, Kallman C, Balzer BL (2010) Renal Hydatid Disease. Radiographics 30(2):334-7 (PMID: 20228320)
[10] Balik AA, Celebi F, Başglu M, Oren D, Yildirgan I, Atamanalp SS (2001) Intra-abdominal extrahepatic echinococcosis. Surg Today 31(10):881-4 (PMID: 11759882)
[11] Díaz-Menéndez M, Pérez-Molina JA, Norman FF, Pérez-Ayala A, Monge-Maillo B, Fuertes PZ, López-Vélez R. (2012) Management and outcome of cardiac and endovascular cystic echinococcosis. PLoS Negl Trop Dis 6(1):e1437 (PMID: 22235354)
[12] Raj DH, Dash PK (2015) Hydatid disease of bone: a dangerous crippling disease. BMJ Case Rep bcr2015211697 (PMID: 26294362)
[13] Tüzün M, Altinörs N, Arda IS, Hekimoğlu B (2002) Cerebral hydatid disease CT and MR findings. Clin Imaging 26(5):353-7 (PMID: 12213372)
[14] Lewall DB (1998) Hydatid disease: biology, pathology, imaging and classification. Clin Radiol 53(12):863-74 (PMID: 9867269)
[15] Moguillanski SJ, Gimenez CR, Villavicencio RL (1999) Radiologia de la hidatidosis abdominal. Lippincott, Williams and Wilkins 2:47-72
[16] Yildiz SY, Berkem H, Hengirmen S (2010) A rare complication of intraabdominal hydatid disease: gastric fistula and recurrent gastric bleeding. Am J Surg 200(5):e59-60 (PMID: 20850708)
[17] Smego RA Jr, Bhatti S, Khaliq AA, Beg MA (2003) Percutaneous aspiration-injection-reaspiration drainage plus albendazole or mebendazole for hepatic cystic echinococcosis: a meta-analysis. Clin Infect Dis 37(8):1073-83 (PMID: 14523772)
Case information
| URL: | https://eurorad.org/case/16178 |
| DOI: | 10.1594/EURORAD/CASE.16178 |
| ISSN: | 1563-4086 |
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Figure 2
Department of Gastroenterology, Centro Hospitalar Barreiro Montijo, Barreiro, Portugal.
