The Puncture, Aspiration, Injection and Re-aspiration (PAIR) Technique of Hepatic Hydatid Cyst: A Case Report and Review of Literature

Abstract

Hydatid disease, caused by Echinococcus granulosus, commonly affects the liver and can lead to complications such as rupture, secondary infection, and anaphylaxis. While surgery is the traditional treatment for complicated cases, minimally invasive techniques are emerging as viable alternatives. We report a case of a 27-year-old female with a history of gastritis and a pancreatic cyst who presented with acute diffuse abdominal pain and nausea. Imaging revealed an 11.8×8.8×5.2 cm cystic structure in the left hepatic lobe, consistent with a hydatid cyst, with free intraperitoneal fluid concerning for an impending or near rupture. The patient underwent percutaneous drainage of the cyst (puncture, aspiration, injection, and re-aspiration, PAIR technique), yielding 300 cc of serosanguinous fluid. She was started on albendazole therapy and closely monitored. Over nine days of hospitalization, her condition improved, drainage output decreased, and she was discharged in stable condition with a structured follow-up plan. Our report demonstrates that percutaneous drainage with adjunctive albendazole therapy is a feasible and effective alternative to surgery in hemodynamically stable patients with ruptured hepatic hydatid cysts. Further studies are warranted to refine patient selection criteria and optimize long-term outcomes.

Keywords: albendazole; echinococcus; extrahepatic; hepatic hydatid cyst; pair technique ruptured cyst.

Figure 1. Abdominal ultrasound

Abdominal ultrasound demonstrating a complex cystic structure in the left hepatic lobe measuring 11.6×8×8 cm (red arrow), consistent with a hydatid cyst. The size and morphology, along with the patient's clinical history, raised concern for potential rupture, guiding the decision for PAIR intervention. PAIR - puncture, aspiration, injection, and re-aspiration

Figure 2. CT abdomen and pelvis status after percutaneous drainage of hepatic cyst

CT abdomen and pelvis status post percutaneous drainage of hepatic cyst, showing an interval decrease in size of the collection in the left lobe of liver (green arrow), with a pigtail drainage catheter (red arrow) seen within the collection. The collection had decreased from the prior measurement of 11.8x8.8 cm to a 10x7 cm.