A RARE CAUSE OF CHRONIC ABDOMINAL PAIN DR
A RARE CAUSE OF CHRONIC ABDOMINAL PAIN DR ANISHA BHAGWANANI DR MANIL CHOUHAN PROF PETER CHIODINI DR ZAHIR AMIN UNIVERSITY COLLEGE LONDON HOSPITAL
44 Lithuanian v PC: Intermittent epigastric pain and swelling for 5 years v HPC: 2 -3 attacks/year lasting up to 10 days no fevers/night sweats v PMHx: Nil relevant v O/E: palpable epigastric mass v Bloods: Normal LFTs, αFP, hepatitis screen CRP 11, ESR 41
Differential Diagnosis from referring hospital Giant cavernous haemangioma Chronic liver abscess Liver tumour
Impression: “features more in keeping with a benign lesion with plan for liver biopsy”
Histology v Mass: Entirely necrotic material without viable liver tissue Numerous small cystic lesions Multiple fragments of laminated membranes – bright PAS positivity No protoscolices and no hooklets v Background Liver: Minimal inflammation consistent with SOL effect Normal liver architecture Final diagnosis: ALVEOLAR HYDATID (Echinococcus multilocularis)
UCLH MDT v CT/MRI: Involvement of middle hepatic vein Obliteration of left portal vein and biliary tree Indentation of right portal vein and right hepatic artery v Not suitable for radical resection v Non-radical resection unsuitable – risk of incomplete resection and residual disease v Lifelong albendazole (parasitostatic) v Annual MR follow up
Alveolar Hydatid v Metacestode (larval) form of tapeworm Echinococcus multilocularis v Rare form of hydatid disease (6 cases per 100, 000 persons/year in endemic areas) v Transmission via consumption of parasite eggs from faeces of foxes and dogs v Disseminated disease possible via haematogenous and lymphatic spread v Invariably fatal if left untreated
Alveolar Hydatid v Diagnosis relies on a combination of radiology + positive serology and histology Imaging Features Infiltrative tumour-like mass Irregular borders Heterogenous Calcification Cystic foci No contrast enhancement
Cystic Hydatid (Echinococcus granulosus) v More common form of hydatid disease (50 cases per 100, 000 persons/year) Imaging Features Well defined mass Cystic/multi-cystic Calcification cyst wall Internal septa No enhancement
Management of Alveolar Hydatid v Complete surgical resection is treatment of choice + albendzole for 2 years v Rarely liver transplantation in very advanced cases v Long-term albendzole for inoperable patients v Image-guided percutaneous procedures for complications
Learning Points v Increasing cases in UK due to migration from endemic countries v Consider in patients with a rural and animal exposure and appropriate travel history v Imaging features – irregular heterogeneous mass with infiltrative features, cystic change, calcification, no enhancement v Can mimic liver tumours e. g. HCC, cholangiocarcinoma, hepatic metastases
- Slides: 11