Hepatic hydatid disease — DTM&H MCQ

Correct answer: E — Albendazole pre-treatment followed by PAIR

The correct answer is E, albendazole pre-treatment followed by PAIR (puncture, aspiration, injection, re-aspiration). A 15 cm well-defined cyst with daughter cysts corresponds to a WHO-IWGE CE2 or large CE1/CE3a morphology; for cysts of this size, PAIR under albendazole cover is the recommended minimally invasive first-line approach rather than surgery, provided the cyst is accessible and not at high risk of complication. Albendazole is started several days before the procedure and continued afterwards to reduce protoscolex viability and the risk of secondary echinococcosis if spillage occurs during puncture. This combined approach achieves cure rates comparable to surgery with lower morbidity and shorter hospital stay. Why the other options are wrong: C. Immediate surgical excision without medical therapy: surgery without perioperative albendazole increases the risk of peritoneal seeding and recurrence if cyst fluid leaks intraoperatively; surgery is reserved for complicated, multiloculated, or superficially ruptured cysts, not routinely for straightforward large cysts. A. Observation with serial ultrasound: appropriate only for inactive, calcified CE4 or CE5 cysts with no daughter cysts; an active cyst with daughter vesicles and positive serology requires active intervention. D. Praziquantel 40 mg/kg daily for 14 days alone: praziquantel is not the standard monotherapy for cystic echinococcosis; it lacks proven protoscolicidal efficacy comparable to albendazole and is not recommended as sole treatment. B. Percutaneous drainage without scolicidal agent: puncturing a hydatid cyst without prior albendazole cover and without instilling a scolicidal agent risks anaphylaxis and peritoneal dissemination of viable protoscoleces. Key point: Large active hydatid cysts with daughter cysts (CE1 or CE2/CE3a) are managed with albendazole started before, and continued after, PAIR, not surgery or unprotected drainage.

Reference: WHO Informal Working Group on Echinococcosis (WHO-IWGE) staging and treatment algorithm for cystic echinococcosis, as summarised in: Percutaneous treatment of liver hydatid cysts (PAIR + albendazole), PMC3354352, https://pmc.ncbi.nlm.nih.gov/articles/PMC3354352/