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A study on clinical profile of parasitic hepatic cyst compare with other hepatic cyst in Bangladesh

Introduction: Cystic lesion of the liver is not an uncommon condition. These conditions are increasingly being diagnosed because of improved diagnostic facilities. Hepatic cysts may be non-parasitic and parasitic. The nonparasitic cysts may be simple, polycystic liver disease and neoplastic. The incidence of simple liver cyst is approximately 5% of the general population, and most of them are asymptomatic, diagnosed incidentally during imaging study for other abdominal conditions or at laparotomy. These cysts may again produce symptoms due to pressure on adjacent organs. The parasitic cyst caused by the larval stage of Teniaechinococcus. Echinococcosis is wide-spread, and it is not confined to sheep-raising countries. Increasing migration, high mobility of troops and a growing incidence of world travel make hydatidosis a global problem of increasing importance. In Bangladesh the exact incidence of cystic lesions of the liver is not known, but these conditions are increasingly being diagnosed and treated Materials & Methods: A prospective study was carried out form September, 2000 to May, 2005 in the Dept. of Surgery, Bangabandhu Sheikh Mujib Medical University (BSMMU, Dhaka and Islamic Bank Central Hospital (IBCHK), Dhaka. The study was carried out on patients of cystic disease of the liver who underwent operative treatment in 136 patients This study revealed the cystic lesions of the liver are not uncommon. Because of improved diagnostic technologies a good number of cases are now seen. This study was mainly done to find out the common causes. In several countries, parasitic aetiology is common because of obvious reasons. Results: Of the total of 124 patients evaluated 92 patients were female and 32 patients male. Therefore, female-male ratio was 3:1. The incidence of cystic lesion of the liver in different age groups showed mean age 36.7±9.8 years range 17-61 years. Majority (42.8%) of the patients in the age group 30-39 years and 2nd highest (30.2%) in the age of group 40-49 years. Among hepatic cysts, Neoplastic 8(6.46%), Parasitic 62(50%) Simple 40(32.25%), Polycystic 14(11.29%). The neoplastic cysts were cystic degeneration in malignant tumor. Conclusion: This study proved that parasitic (hydatid) disease is the common cause of hepatic cysts in our country. Improved diagnostic technologies were also helped by the surgical procedures e.g. hepatic resection, excision of the cyst, deroofing etc. followed by histopathological confirmation. These were possible, because of special interest in hepatobiliary surgery, use of CUSA and above all.


Introduction
Cystic lesion of the liver is not an uncommon condition. These conditions are increasingly being diagnosed because of improved diagnostic facilities. Hepatic cysts may be non-parasitic and parasitic. The non-parasitic cysts may be simple, polycystic liver disease and neoplastic. The incidence of simple liver cyst is approximately 5% of the general population, and most of them are asymptomatic, diagnosed incidentally during imaging study for other abdominal conditions or at laparotomy. These cysts may again produce symptoms due to pressure on adjacent organs . [1,2] The parasitic cyst caused by the larval stage of Teniaechinococcus. Echinococcosis is widespread, and it is not confined to sheep-raising countries. Increasing migration, high mobility of troops and a growing incidence of world travel make hydatidosis a global problem of increasing importance . [3] In Bangladesh the exact incidence of cystic lesions of the liver is not known, but these conditions are increasingly being diagnosed and treated because of availability of modem diagnostic facilities and development of expertise. The simple hepatic cyst may have a complicated course. The standard surgical management has been to operate when patients are symptomatic or when cysts cause complications, such as mpture, hemorrhage, infection, portal hypertension, obstmctive jaundice, torsion and malignant degeneration . [4] Similarly hepatic hydatid disease may give rise to obstructive jaundice, suppuration and anaphylactic shock due to mpture-which is life threatening . [5] In Beahrs and Weiland 1973 has pin pointed the problem of cystic lesion of parasitic origin, with a new dimension of thinking, and more number of scientific workers have involved them to find out more facts in this concern. [6] As we know, so far no such study was carried out till date in Bangladesh, so it has become the demand of time to know about the state of problem of parasitic disease of the liver in our population. Keeping this priority in mind, we have decided to carry on this scientific work to find out the causes of symptomatic cystic lesions of the liver.

Methodology
Study Type: A Prospective study method was followed to carry out the study.

Results
Of the total of 124 patients evaluated 92 patients were female and 32 patients male. Therefore, female-male ratio was 3:1. The incidence of cystic lesion of the liver in different age groups showed mean age 36.7±9.8 years range 17-61 years. Majority (42.8%) of the patients in the age group 30-39 years and 2nd highest (30.2%) in the age of group 40-49 years. So the peak incidence was in 4th and 5th decades of life.       Table-7 shows the location of cysts in the different lobes of liver. Among the parasitic cysts, highest percentage of cysts was found in right lobe and among the non-parasitic cysts, similar pattern was observed. Location of cysts does not have any relation with aetiology in this study.

Discussion
In the field of abdominal surgery liver cyst though not very common, but patient often presents with symptoms. It is necessary to establish the cause of liver cyst for proper management.
Since establishment in 1965 the then IPGM&R presently known as BSMMU, serves as a tertiary referral hospital in our country. As expert surgical teams are working in this hospital and availability of modem investigative and operative equipments like C. Remembering this need, we have chosen to bear on this logical work to discover the reasons for symptomatic cystic injuries of the liver. It was found that no statistically significant mean age difference was found between male and female patients (p>0.05). It was found that no statistically significant mean age difference was found between male and female patients (p>0.05). Among hepatic cysts Neoplastic 8(6.46%) Parasitic 62(50%) Simple 40 (32.25%), Polycystic 14(11.29%). The neoplastic cysts were cystic degeneration in malignant tumor. In parasitic (hydatid) hepatic cyst female-male ratio 2.1:1, indicates females were more sufferer which match with the sex distribution of the study done by Sayek, Yalin&Sanac (1989) but did not match with Sanfelippo, Beahrs &Weiland (1974). [6] It also found that the symptomatic hepatic hydatid cysts were common in 4th and 5th decades of life which almost match with the observation of Papadimitriou and Mandrekas, (1970). [7] In polycystic liver disease (33.3%) case was associated with polycystic kidney disease. Among the simple cyst one (8.33%) patient was associated with gallstone disease. Similar findings were observed by . [8] Symptoms responsible for surgical exploration were varying depending on the nature of the cysts.  (2000), but our finding does not conform with the finding of Langer et al. (1984). [10] Ultrasonography (USG) has become the screening test for the diagnosis of the space occupying lesions of the liver. It was done in all 124(100%) cases as initial investigation. CT Scan was done in selected cases, where USG could not delineate the nature and exact location of the cysts. Non-parasitic cyst was solitary in 124(100%) patients. It was located in right lobe of the liver 50(82.4) and left lobe 2(5.9).Non-parasitic cyst was multiple in 2(11.8)cases and situated in the both lobes of the liver. Our findings consistent with the finding of Letwin et al. (1987). [11] Parasitic cyst were found in the right lobe 56(73.7),left lobe 6 (15.8%) and both lobes 8 (10.5) patients. This findings consistent with Langer et al. (1984), but not with the finding of Witzleben, et.al.(1996). [12] Russell, et.al.(2000). Preoperative diagnosis was evaluated with the preoperative & histopathological findings and the final diagnosis was established in every cases. Our study shows that parasitic cysts 54 (47.2%) and non-parasitic cysts 70(50.8%). This indicates that parasitic (hydatid) disease is the common cause of symptomatic cysts of the liver.

Conclusion
This study proved that parasitic (hydatid) disease is the common cause of hepatic cysts in our country. Improved diagnostic technologies were also helped by the surgical procedures e.g. hepatic resection, excision of the cyst, deroofing etc. followed by histopathological confirmation. These were possible, because of special interest in hepatobiliary surgery, use of CUSA and above all To find out the alarming incidence of hydatid disease in our environment needs extensive study in different institutes, is my humble submission.