Hydatid Cyst of the Liver Presenting with Right Upper Quadrant Abdominal Pain – A Case Report

Abstract

Hydatid disease, also known as cystic echinococcosis, is a zoonotic parasitic infection caused primarily by the larval stage of Echinococcus granulosus. The liver is the most commonly affected organ, accounting for approximately 60–70% of cases, followed by the lungs. The disease remains endemic in many developing countries where livestock farming and close contact with dogs are common. Clinical manifestations vary depending on the size, location, and complications of the cyst. Many patients remain asymptomatic for years, while others may present with abdominal pain, hepatomegaly, jaundice, or cyst rupture.

We report the case of a 35-year-old woman who presented with intermittent right upper abdominal pain and abdominal fullness for six months. Ultrasonography and contrast-enhanced computed tomography revealed a large hydatid cyst in the right lobe of the liver. Serological testing supported the diagnosis. The patient underwent surgical management combined with antihelminthic therapy using albendazole, resulting in successful recovery without recurrence during follow-up. This case highlights the importance of early recognition, appropriate imaging, and timely intervention in the management of hepatic hydatid disease.

Introduction

Hydatid disease is a chronic parasitic infection caused by cestodes belonging to the genus Echinococcus. Humans serve as accidental intermediate hosts after ingesting parasite eggs shed in the feces of infected dogs and other canines.

Following ingestion, the embryos penetrate the intestinal mucosa and enter the portal circulation, where they are commonly trapped in the liver. Over time, the larvae develop into fluid-filled hydatid cysts containing daughter cysts and protoscolices.

Hydatid cyst disease remains a significant public health concern in endemic regions including parts of Asia, Africa, South America, the Middle East, and the Mediterranean region.

Risk factors include:

• Close contact with dogs
• Livestock farming
• Sheep and cattle rearing
• Poor sanitation
• Consumption of contaminated food or water
• Residence in endemic areas

Common clinical manifestations include:

• Right upper quadrant abdominal pain
• Abdominal fullness or mass
• Nausea and vomiting
• Hepatomegaly
• Jaundice (in complicated cases)
• Fever due to secondary infection

Early diagnosis and treatment are important to prevent complications such as cyst rupture, anaphylaxis, biliary obstruction, and secondary dissemination.

Case Report

Patient History

A 35-year-old woman presented to the general surgery outpatient department with complaints of:

• Dull aching pain in the right upper abdomen for six months
• Intermittent abdominal discomfort
• Sensation of fullness after meals
• Occasional nausea

The pain was non-radiating and gradually increasing in intensity over the preceding three months.

The patient reported living in a rural area and having frequent contact with domestic dogs and livestock.

Past medical history was unremarkable.

There was no history of:

• Tuberculosis
• Chronic liver disease
• Viral hepatitis
• Diabetes mellitus
• Previous abdominal surgery

Family history was non-contributory.

Clinical Examination

General examination revealed:

• Conscious and oriented patient
• Mild discomfort on abdominal palpation
• No pallor, cyanosis, or edema

Vital signs were stable:

• Pulse rate: 84 beats/minute
• Blood pressure: 124/78 mmHg
• Respiratory rate: 18 breaths/minute
• Temperature: Afebrile

Abdominal examination revealed:

• Mild hepatomegaly
• Tenderness in the right hypochondrium
• No guarding or rigidity
• No ascites

Other systemic examinations were within normal limits.

Clinical Evaluation

Differential Diagnosis

The following conditions were considered:

• Hydatid cyst of liver
• Simple hepatic cyst
• Liver abscess
• Hepatic hemangioma
• Biliary cystadenoma
• Hepatocellular carcinoma

Investigations

Radiological Evaluation

Ultrasonography

Abdominal ultrasonography demonstrated:

• A well-defined cystic lesion measuring approximately 10 × 8 cm in the right hepatic lobe
• Internal septations and daughter cysts
• Detached endocyst membrane appearance

These findings strongly suggested hepatic hydatid disease.

Contrast-Enhanced Computed Tomography (CECT)

CECT abdomen revealed:

• Large cystic lesion in segment VII of the liver
• Multiple daughter cysts within the mother cyst
• Characteristic “wheel spoke” appearance
• No evidence of rupture

The imaging findings were consistent with a hepatic hydatid cyst.

Laboratory Evaluation

Routine investigations showed:

• Hemoglobin: 12.8 g/dL
• Total leukocyte count: 8,200/mm³
• Platelet count: 290,000/mm³
• Eosinophil count: Mildly elevated
• ESR: Elevated

Liver function tests revealed:

• Total bilirubin: Normal
• AST: Normal
• ALT: Normal
• Alkaline phosphatase: Mildly elevated

Serological testing:

• Enzyme-linked immunosorbent assay (ELISA) for Echinococcus antibodies: Positive

Diagnosis

Based on clinical presentation, imaging findings, and positive serological testing, a diagnosis of: Hydatid Cyst of the Liver (Cystic Echinococcosis) was established.

Management and Outcome

Medical Treatment

The patient was initiated on:

• Albendazole 400 mg twice daily
• Supportive therapy
• Liver function monitoring

Albendazole therapy was administered for four weeks before surgery to reduce cyst viability and minimize the risk of dissemination.

Surgical Management

Considering the large size of the cyst and symptomatic presentation, the patient underwent elective surgical intervention.

Intraoperative findings included:

• Large hydatid cyst in the right lobe of the liver
• Multiple daughter cysts within the cavity
• No communication with the biliary tree

The cyst contents were carefully evacuated and the residual cavity managed appropriately after instillation of a scolicidal agent.

The procedure was completed successfully without complications.

Follow-Up

At 1 Month

Clinical assessment revealed:

• Complete relief of abdominal pain
• Improved appetite
• No postoperative complications

At 3 Months

Follow-up ultrasonography showed:

• Reduction of residual cavity size
• No evidence of recurrence

At 6 Months

The patient remained asymptomatic with:

• Normal liver function tests
• No radiological evidence of recurrent disease
• Good quality of life

Discussion

Hydatid disease is caused by infection with the larval stage of Echinococcus granulosus. Humans become infected through accidental ingestion of parasite eggs present in contaminated food, water, or soil.

After entering the portal circulation, the larvae are most commonly filtered by the liver, explaining why hepatic involvement is observed in the majority of cases.

Clinical Features

The clinical manifestations depend largely on cyst size, location, and complications.

Common symptoms include:

• Right upper quadrant pain
• Abdominal swelling
• Nausea
• Hepatomegaly
• Loss of appetite

Complications may include:

• Cyst rupture
• Secondary bacterial infection
• Biliary obstruction
• Anaphylactic reactions
• Peritoneal dissemination

Many patients remain asymptomatic for years because hydatid cysts grow slowly.

Diagnostic Evaluation

Imaging plays a central role in diagnosis.

Ultrasonography is the preferred initial investigation because it can identify:

• Daughter cysts
• Floating membranes
• Hydatid sand
• Internal septations

CT scanning provides better anatomical definition and is particularly useful for surgical planning.

Serological tests such as ELISA assist in confirming the diagnosis, although sensitivity may vary depending on cyst location and stage.

Treatment

Management depends on cyst characteristics and patient factors.

Treatment options include:

• Albendazole therapy
• Percutaneous aspiration, injection, and re-aspiration (PAIR)
• Surgical excision
• Combined medical and surgical therapy

Albendazole remains the cornerstone of pharmacological treatment and is often used both preoperatively and postoperatively.

Surgery remains the preferred option for:

• Large cysts
• Symptomatic lesions
• Complicated cysts
• Cysts at risk of rupture

Successful treatment requires complete removal or inactivation of the parasite while preventing spillage of cyst contents.

Prevention

Hydatid disease can be prevented through:

• Regular deworming of dogs
• Proper disposal of animal carcasses
• Improved sanitation practices
• Health education in endemic communities
• Washing fruits and vegetables before consumption
• Avoiding feeding raw offal to dogs

Public health measures remain crucial for reducing disease transmission.

Prognosis

The prognosis of hepatic hydatid disease is generally favorable when diagnosed early and treated appropriately. Advances in imaging techniques, antihelminthic therapy, and surgical management have significantly improved patient outcomes. Most patients experience complete recovery following successful treatment, although recurrence may occur if daughter cysts are not completely eradicated or if intraoperative spillage takes place. Long-term follow-up with imaging studies is therefore recommended. Early diagnosis and timely intervention help prevent potentially life-threatening complications such as cyst rupture, secondary infection, biliary obstruction, and anaphylactic reactions. Patient education regarding preventive measures is equally important in reducing the risk of reinfection in endemic areas.

Conclusion

Hydatid cyst of the liver is an important parasitic disease that should be considered in patients presenting with chronic right upper quadrant abdominal pain, particularly in endemic regions. Characteristic imaging findings and positive serological tests facilitate diagnosis. Combined medical and surgical management can provide excellent outcomes and minimize recurrence. Early recognition and appropriate treatment remain essential for preventing complications and improving patient quality of life.

References

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