Andy Kuo's List: eMedicine case

• The CT scan of the abdomen reveals a fluid-filled cystic mass with an irregular margin in the fourth segment of the liver. The mass communicates with the gallbladder and is associated with a small amount of free fluid around the liver and in the peritoneal cavity. These imaging findings in the setting of eosinophilia, an associated allergic reaction, and a history of acutely worsening abdominal pain with sudden pressure applied to the abdomen, are consistent with a ruptured hydatid cyst.
• After humans ingest the eggs, they hatch into embryos in the small intestine. The embryos penetrate the intestinal mucosa, enter the portal circulation, and are carried to the liver.^[3,4] Some are destroyed in the liver while others form into hydatid cysts. A small percentage of the eggs may pass through the liver and form cysts in other parts of the body, including the lungs, central nervous system (CNS), spleen, and pancreas.
• Surgery is the traditional treatment of choice for hydatid cysts; however, a number of cysts are now treated with PAIR (percutaneous aspiration, infusion of scolicidal agents, and reaspiration). PAIR may be a reasonable approach for treating patients with inoperable disease, and it is typically performed while patients are on antihelminthic therapy to decrease the risk of cyst dissemination.
• PAIR is contraindicated for superficially located cysts, cysts communicating with the biliary tree, and cysts with multiple internal septal divisions. Surgery is still preferred for complicated cysts under these conditions. Care must be made to remove cysts without contaminating the surrounding tissues, as anaphylaxis and dissemination of infectious protoscolices may result.
• Albendazole and mebendazole are used for the medical treatment of echinococcosis in patients with contraindications for surgery.
• Albendazole is the preferred agent because of its greater absorption from the gastrointestinal tract, which results in higher serum levels.

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