The disseminated intra-peritoneal hydatid disease is a very rare finding. A case of disseminated intra abdominal hydatid disease is presented along with a review of literature and various therapeutic modalitie

Kaushal, Satinder Singh

Mahesh, DM

Mokta, Jitender K

Raina, Rajiv

Raina, Sujeet

Sood, Vivek

English

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Published Quarterly
Mangalore, South India
ISSN 0972-5997
Volume 7, Issue 2; Apr-Jun 2008
Giant intra-abdominal hydatid cysts with multivisceral locations   
Authors
Sujeet Raina, Senior Resident,
Mahesh DM, PG student
Vivek Sood, PG student
Jitender K Mokta, Assistant Professor
Rajiv Raina, Associate Professor
Satinder Singh Kaushal, Professor & Head,
Department of Medicine, Indira Gandhi Medical College, Shimla - 171001 (Himachal Pradesh)
Address For Correspondence
Dr Sujeet Raina,
Fire Officers Building,
Stokes Place,,
Shimla (H.P) 171002
E-mail: sujeetrashmishera@yahoo.co.in
Citation
Raina  S,  Mahesh  DM,  Sood  V,  Mokta  JK,  Raina  R,  Kaushal  SS.  Giant  intra-abdominal  hydatid  cysts  with 
multivisceral locations. Online J Health Allied Scs. 2008;7(2):10
URL
http://www.ojhas.org/issue26/2008-2-10.htm
http://ojhas.org 1
OJHAS  Vol 7 Issue 2(10) Raina S et al Giant intra-abdominal hydatid cysts with multivisceral locations. 
 Case Report
Submitted: April 18, 2008; Accepted: June 20, 2008; Published: July 21, 2008
Abstract:
The disseminated intra-peritoneal hydatid disease is a very rare finding. A case of disseminated intra abdominal hydatid 
disease  is  presented  along  with  a  review  of  literature  and  various  therapeutic  modalities.
Key Words: Hydatid cyst, peritoneal hydatosis, rectovesical hydatid cyst
Introduction:
Hydatid disease is a parasitic infection caused by the larval 
stage of the cestode, Echinococcus granulosus. It is endem-
ic in many parts  of the world,  including India.  Most fre-
quently  it  affects  the liver and lung.  Involvement of  the 
peritoneal cavity is uncommon, accounting for 13% of ab-
dominal echinococcosis. Unusual locations as well as multi-
ple primary or secondary hydatid disease pose special ther-
apeutic  challenges.(1)  We report  a  case  of  disseminated 
abdominal  hydatosis  who presented with features of ob-
structive uropathy and investigations revealed hydatid cyst 
in rectovesical pouch besides liver, spleen and peritoneum.
Case Report:
A 28 year male shepherd presented with a dull aching pain 
and gradually increasing lump in the right hypochondrium 
and epigastric region over six months. There was history of 
acute retention of urine thrice in the past twelve days for 
which patient was catheterized. Anorexia and weight loss 
were  associated  complaints.  History  of  constipation  was 
also present. There was no history of jaundice. He was op-
erated upon for hepatic hydatic disease seven years back. 
Examination revealed multiple cystic swellings in abdomen. 
Hepatospleenomegally was present. Both liver and spleen 
were having irregular surface with multiple, nontender cys-
tic masses palpable over the surface. Soft irregular masses 
were also felt in the umbilical and hypogastric regions. On 
per rectal examination, a mass was felt from anterior rectal 
wall but rectal mucosa was free. Review of other systems 
was  normal.  On  laboratory  investigations  hemogram  re-
vealed  mild  increase  in  the  eosinophil  count  (3%)  and 
raised ESR (55mm at  the end of  1 hour)  ,  Biochemistry 
screen revealed normal  investigations  including a normal 
liver  function  profile.  Test  for  antibodies  against 
Echinococcus granulosus was 15.99 U/ml and was positive. 
Ultrasound  examination  of  the  abdomen  and  pelvis  re-
vealed multiple, thin walled cystic lesions of variable size in 
the liver and spleen with cartwheel appearance. The peri-
toneum and the pelvis were studded with similar cystic le-
sions. Plain CT scan of the abdomen revealed multiple, well 
defined cystic lesions throughout the abdomen.(Fig-1) The 
cysts were multi loculated with multiple internal septations 
suggestive of hydatid disease. Liver and spleen appear to 
be replaced by the multiseptated cysts.(Fig-2) A large cyst 
is seen in the pelvic cavity producing a pressure affect on 
surrounding structures but not invading them.(Fig-3) A di-
agnosis of secondary echinococcosis was made on clinical 
features and investigations. Patient was started on albenda-
zole (15mg/kg/day) and follow up was advised. Patient has 
been lost in the follow up.  
Figure-1 CT abdomen showing peritoneal hydatid cyst
Figure-2 CT abdomen showing hydatid cyst in liver and 
spleen
Figure-3 CT  abdomen  showing  hydatid  cyst  in  rec-
tovesical pouch
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OJHAS  Vol 7 Issue 2(10) Raina S et al Giant intra-abdominal hydatid cysts with multivisceral locations. 
Discussion:
Hydatid disease is a parasitic disease caused by the larval 
stage of Echinococcus granulosus. Hydatid disease remains 
a continuous public health problem in endemic countries 
including India.  The most frequently involved organs  are 
the liver (55-70%) followed by the lung (18-35%); these two 
organs affected simultaneously in about 5-13% of cases, the 
spleen (5%) and other organs (5%).(1-2 ) Apart from com-
mon sites such as liver and lungs in humans, hydatid cysts 
can present in unusual sites which include peritoneum, kid-
ney, muscle, adrenal gland, ovary, pancreas, thyroid gland, 
pleura, diaphragm, uterus and brain.(1) The peritoneal hy-
datid disease represents an uncommon occurrence with an 
overall frequency of peritoneal disease in cases of abdomi-
nal echinococcus at approximately 13%. Peritoneal hydati-
dosis  is  almost  always  secondary  to  hepatic  disease,  al-
though some unusual cases of primary peritoneal hydati-
dosis have been described. Peritoneal involvement is usual-
ly undetected unless cysts are large enough to cause symp-
toms. Most of the cases of peritoneal hydatid disease are 
secondary to previous surgery for liver hydatidosis; howev-
er, spontaneous microrupture of a hepatic cyst into peri-
toneum has also been reported. Intraperitoneal rupture of 
hepatic or splenic cysts results in release of brood’s cap-
sule, scolices and daughter cysts which implant and devel-
op  independently  leading  to  multiple  disseminated  in-
traperitoneal  hydatid  disease.  This  phenomenon is  called 
secondary echinococcosis.(3)
Peritoneal hydatid disease may grow and occupy the entire 
peritoneal  cavity,  simulating  a  multilobulated  mass.  This 
pathological condition is known as encysted peritoneal hy-
datidosis. Peritoneal hydatid disease represents an uncom-
mon occurrence and its diagnosis is more accurate today 
due to the new imaging techniques.(4) A double contrast 
CT  scan  is  90-100%  accurate  for  diagnosing  secondary 
echinococcosis and is superior to USG in identifying addi-
tional  extrahepatic  intra  abdominal  cysts.(3)  CT  is  the 
modality  of  choice for these patients  because it  permits 
imaging of the entire abdomen and pelvis.(5)  
The goal  of treatment is to prevent secondary complica-
tions of the disease. In cases of disseminated systemic dis-
ease, inoperable cases, cyclic therapy with a benzimidazole 
compound is preferred and has been found to cure disease 
in 10-30% of cases, to slow progression in 50%-70% and to 
yield no change in 20%- 30%.(6) Albendazole seems to be 
more effective owing to better penetration and absorption. 
These agents have actually been used in several studies as 
a conservative treatment, leading to some decrease or sta-
bilization  of  the  cyst  size,  especially  in  cases  with  small 
cysts.  Albendazole  is  combined  with  surgery  to  prevent 
postoperative recurrence.(2) After medical therapy, follow 
up is advisable with USG or CT scan. After medical treat-
ment,  hydatid  cysts  shows gradual  reduction in cyst size 
and number. The cyst becomes poorly defined and denser. 
Daughter cysts may disappear or may rupture and the lam-
inated membrane may separate from the pericyst and col-
lapse. Thickening and calcification of the cyst wall can be 
taken as therapeutic response if it was absent before treat-
ment. Cyst disappearance should be regarded as the crite-
ria with most promising prognostic value.
Surgical removal of the cyst is customized to each patient 
depending on the patient's general condition, the number 
and localization of cysts, and the surgeon's expertise.(1-2) 
Recurrence  of  hydatid  disease  after  after  radical  proce-
dures is very low, but not zero and the possibility of recur-
rence always remains.(2) PAIR( puncture, aspiration, instil-
lation  of  scolicidal  agents  and  reaspiration)  technique  is 
also  possible  in  cysts  relapsing  after  surgery  or  failed 
chemotherapy.  However  PAIR  is  contraindicated  in  cysts 
that  communicate  with  biliary  tree,  superficial  cysts  and 
cysts with thick internal septal divisions.(7)
The purpose of reporting this case is to highlight the un-
common presentation of hydatid disease due to multivis-
ceral and peritoneal locations.
References:
1. Syed Abdullah Iqbal, Masood Jawaid, Fareya Us-
mani: Disseminated Intra-Abdominal Hydatidosis: 
A Very Rare Presentation. The Internet Journal of  
Surgery. 2007;11:1.
2. Safioleas MC, Misiakos EP, Kouvaraki M, et al. 
Hydatid Disease of the Liver. Arch  
Surg. 2006;141:1101-8
3. Sahu SK, Singh P, Sachan PK,et al. Secondary 
echinococcosis. Indian J Surg 2006;68:334-5.
4. Tarcoveanu E, Dimofte G, Bradea C,et al. Multi-
ple Peritoneal Hydatid Disease after Rupture of a 
Multivesicular Hepatic Hydatid Cyst. Case report. 
J Gastrointestin Liver Dis 2006;15:301-5
5. Yuksel M, Demirpolat G, Sever A, et al. Hydatid 
disease involving some rarelocations in the body: 
a pictorial essay. Korean J Radiol 2007;8:531-40
6. Karmali S, Thompson SK, McKinnon G, et al. A 
37-year-old woman with fever and abdominal-
pain. CMAJ 2005;172:1683. 
7. White CA, Weller PF. Cestodes. In: Kasper DL, 
Braunwald E, Fauci SA, Hauser SL, Longo DL, 
Jameson JL, eds. Harrison′s Principles of Internal 
Medicine. 16th ed. New York. McGraw-Hill.2005. 
pp 1275-76
http://ojhas.org 3
OJHAS  Vol 7 Issue 2(10) Raina S et al Giant intra-abdominal hydatid cysts with multivisceral locations. 


A 37-year-old woman with fever and abdominalpain.

Fareya Usmani: Disseminated Intra-Abdominal Hydatidosis: A Very Rare Presentation. The Internet Journal of Surgery.

Hydatid disease involving some rarelocations in the body: a pictorial essay.

Multiple Peritoneal Hydatid Disease after Rupture of a Multivesicular Hepatic Hydatid Cyst. Case report.

Sachan PK,et al. Secondary echinococcosis.

Giant intra-abdominal hydatid cysts with multivisceral locations

Sujeet Raina

Mahesh DM

Vivek Sood

Jitender K Mokta

Rajiv Raina

Satinder Singh Kaushal

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Giant intra-abdominal hydatid cysts with multivisceral locations

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