What imaging finding is classic for hepatic hydatid disease and what precaution is essential during surgical removal?

• A. Cysts with calcifications; avoid puncture to prevent spillage.
• B. Cysts with daughter cysts on ultrasound/CT; risk of anaphylaxis if ruptured; use scolicidal agents during removal.
• C. Liver abscess with pus; surgical drainage is contraindicated.
• D. Gallbladder stones with cholecystitis; antibiotic prophylaxis is essential.

Answer: (B)

In hepatic echinococcosis, the imaging hallmark is a liver cyst that contains multiple internal daughter cysts, giving a multilocular or “wheel-within-a-wheel” appearance on ultrasound or CT. This pattern is classic and highly suggestive of hydatid disease. The danger with these cysts is that if they rupture, the hydatid fluid is highly antigenic and can trigger a serious allergic reaction, including anaphylaxis, and it can also release protoscoleces that seed new cysts in the liver or elsewhere. Because of that, the main precaution during surgical removal is to prevent rupture and spillage of the cyst contents. Surgeons achieve this by carefully handling the cyst and using scolicidal agents (such as hypertonic saline or povidone-iodine) to irrigate and sterilize the field, minimizing the risk of dissemination and recurrence.