Diagnosis and treatment
Liver hydatid disease: Still a problem
Hidatidosis hepática: todavía un problema
Victoria Busto Bea
, Jesús Barrio Andrés, Carolina Almohalla Álvarez
Corresponding author
Servicio de Aparato Digestivo, Hospital Universitario Río Hortega, Valladolid, Spain
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"<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">CT scan: large hydatid cyst occupying the left hepatic lobe.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Echinococcosis is an infection caused by the <span class="elsevierStyleItalic">Echinococcus</span> parasite, a cestodes genus (band-like worms) of which 4 species are capable of producing disease in humans, although two of them are responsible for the vast majority of cases: the <span class="elsevierStyleItalic">Echinococcus granulosus</span> and <span class="elsevierStyleItalic">Echinococcus alveolar</span>, which cause cystic and alveolar echinococcosis respectively.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">1</span></a> Cystic echinococcosis, which is the predominant form in our country, has almost a worldwide distribution, being mostly prevalent in underdeveloped regions, particularly in rural areas with livestock, especially in Central and South America, Sub-Saharan Africa, the Mediterranean, Russia and China. However, it is not limited to underdeveloped countries; in fact, the arrival of immigrants from endemic areas, among other factors, is turning this condition into a re-emerging problem in Europe,<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">2</span></a> which highlights the importance of knowing how to diagnose it and treat it. <span class="elsevierStyleItalic">E. granulosus</span> infection in Spain has been endemic and remains a problem: losses attributable to human and animal cystic echinococcosis in Spain in 2005 were estimated at €148,964,534.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">3</span></a> Cystic echinococcosis is characterized by the development of one or more hydatid cysts (HC) inside which survives the parasite and, although the HC can settle in any organ, cystic echinococcosis of the liver or hepatic hydatid disease (HHD) is the most common form of manifestation (70–80% of infected patients).</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Clinical signs and symptoms</span><p id="par0010" class="elsevierStylePara elsevierViewall">HHD is often asymptomatic, up to 50% of cases and, if it produces clinical symptoms, these are derived from the compression of adjacent structures or the rupture of the HC, it is not specific to the parasite.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">4</span></a> The early years of infection are asymptomatic, as HC growth is slow (1–50<span class="elsevierStyleHsp" style=""></span>mm/year) and, in fact, latent periods of over 50 years have been described.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">5</span></a> When the HC exceed 10<span class="elsevierStyleHsp" style=""></span>cm, these can lead to various manifestations, summarized in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. Especially problematic is its rupture, which can cause anaphylactic reactions (10% of rupture cases<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">5</span></a>) and peritonitis.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The prognosis depends mainly on the stage of the disease, but, as an approximation, we can mention the result of a 1999 study conducted in Argentina<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">6</span></a> which evaluated the natural history of 33 asymptomatic patients with HHD: at 10 years of diagnosis, only 15% had been operated on, and of the remaining 85%, which received no treatment of any kind, 75% remained asymptomatic. Cystic echinococcosis mortality in the world is estimated at 0.2 per 100,000 population, with a case lethality rate of 2.2–5%.<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">7</span></a> The figure is lower in developed countries (e.g. Spain has reported a 1.94% case fatality rate for cystic echinococcosis).</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Diagnosis</span><p id="par0020" class="elsevierStylePara elsevierViewall">The established diagnosis of HHD is only possible after evidence of protoscoleces in the cystic fluid, macroscopic visualization of the HC during surgery or development of degenerative changes in the HC in imaging tests after antiparasitic treatment.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">8</span></a> However, in clinical practice, the diagnosis is usually based on a combination of clinical-epidemiological, radiological and serologic findings.<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">5,8,9</span></a> Thus, we should suspect HHD in all cases, whether symptomatic or not, with one or several hepatic cysts and compatible epidemiology (coming from an endemic area, affected relatives of ecchinococcosis, contact with dogs, etc.).<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">8,10</span></a> In suspected subjects, evidence of typical characteristics of hydatid disease in the cysts in imaging tests or positive results in a high sensitivity serological test confirmed by another a high specificity serological test are considered sufficient to confirm the diagnosis of HHD and suggest treatment.<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">8,10</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Lab test results may show a nonspecific abnormal liver profile, mild eosinophilia (if cyst fluid leakage), leukopenia and thrombocytopenia.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">9</span></a> As for imaging, ultrasound is the main technique: it has high sensitivity (90–95%) and specificity (93–100%) and is non-invasive and inexpensive.<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">9,11</span></a><a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> shows the ultrasound image of a multivesicular infected HC. The long term ultrasonographic study of HHD patients showed that HC can be found in different stages of development discernible through ultrasound and was the basis for the development of various ultrasound classification systems, starting Gharbi in 1981. In 2003, WHO established a standardized ultrasound classification (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>) that takes into account the natural history of HC and is, today, essential for treatment decision making.<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">12</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Computed tomography (CT) and magnetic resonance imaging (MRI) have greater sensitivity than ultrasound (>95%)<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">11,13</span></a> but are not first-choice techniques, rather they are reserved for cases in which more anatomical detail is needed, for example, when it is necessary to establish the presence of daughter vesicles, when complications are suspected or in cases where the ultrasound is not able to differentiate the HC from other space-occupying lesions.<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">11</span></a> In addition, they are indicated for HCs that are difficult to access by ultrasound, such as subdiaphragmatic or extraabdominal, in disseminated hydatid disease and presurgical evaluation.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">8</span></a> The typical CT image is that of a hypodense, multivesicular or univesicular lesion with a clearly identifiable thick wall; <a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a> shows the CT image of a large HC occupying the left hepatic lobe. On MRI, the HC is hypointense on T1-weighted sequences and hyperintense on T2-weighted sequences. MRI does not seem to offer advantages over CT, except a better delimitation of the HC wall and the assessment of the biliary system and the hepatic venous system.<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">9,14</span></a> MRI cholangiography or endoscopic retrograde cholangiopancreatography is indicated to assess the biliary tract in patients with obstructive jaundice or prior to surgery.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">8</span></a></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Serology can be useful for both diagnosis and follow-up after treatment.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">4</span></a> However, despite the wide variety of serologic tests available, it still constitutes a limited sensitivity and specificity tool, primarily relegated to complement the imaging tests.<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">11</span></a> This is due to various reasons. On the one hand, its sensitivity is directly proportional to the degree of HC antigen release, which is lower when the thickness of its wall is greater.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">5</span></a> Thus, only 60–80% of those infected become seropositive subjects and 10–15% of false negative serological tests are due to a greater HC wall thickness. Furthermore, the sensitivity of serological tests also depends on clinical factors: for example, children and pregnant women have negative serology more often, also, liver HCs trigger an antibody response more often than lung HCs (90 vs 65%).<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">15</span></a> Furthermore, their specificity is also limited due to cross-reactions with helminths or other cestodes such as <span class="elsevierStyleItalic">E. multilocularis</span> and <span class="elsevierStyleItalic">Taenia solium</span> or the presence of anti-P1 antibodies, neoplasms, cirrhosis or immunological disorders.<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">15</span></a> Finally, the lack of serologic test standardization is another contributing factor that limits its usefulness.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Some authors recommend the combination of tests as a way to overcome these disadvantages, an initial high sensitivity test as screening, followed by a high specificity confirmation test in those patients whose first test was positive.<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">16</span></a> The screening test often uses “raw” antigens, extracted from hydatid fluid or protoscoleces; its sensitivity is high and its specificity is acceptable.<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">4,15</span></a> IgG detection by ELISA appears to be the most sensitive (sensitivity around 95%) and, together with indirect hemagglutination, it is the most commonly used screening test.<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">4,5</span></a> Confirmation tests using specific parasite antigens: Antigen 5 and, particularly, antigen B are considered the most specific for <span class="elsevierStyleItalic">Echinococcus</span>, although they are not completely specific for <span class="elsevierStyleItalic">E. granulosus</span><a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">16</span></a>; these tests have greater specificity at the expense of lower sensitivity and use techniques such as Western blot or immunoelectrophoresis.<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">16</span></a> In recent years there has been attempts to improve the diagnostic accuracy of serological tests by detecting IgG subclasses<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">17</span></a> or by using recombinant or synthetic antigens or subunits of these.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">4</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">As for microbiological testing, in cases where diagnostic doubts persist (e.g. cysts suspected of being hydatid but small and with negative serology, or when it is not possible to distinguish whether a lesion is a HC, an abscess or a tumour) the fine-needle biopsy can be useful<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">5</span></a>: the presence of protoscoleces or antigens of <span class="elsevierStyleItalic">E. granulosus</span> in the aspirate confirms the diagnosis. This technique should be reserved only for dubious cases, as there is associated risk of anaphylaxis and dissemination. Detection of <span class="elsevierStyleItalic">E. granulosus</span> antigens in serum is also diagnostic, but only half of infected patients have circulating antigens. Finally, the detection of the parasite's DNA by polymerase chain reaction or in situ hybridization is still experimental.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">4</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Treatment</span><p id="par0050" class="elsevierStylePara elsevierViewall">We have 3 accepted treatment options for HHD: surgery, percutaneous techniques and antiparasitic drugs (besides watchful waiting), and, in recent years, other options have been considered, such as radiation or high intensity ultrasound.<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">18</span></a> There are no high-quality studies comparing their results, therefore, the recommendations we present are based largely on expert opinion. The choice of treatment should be based on patient and HC characteristics and the availability of different therapeutic alternatives. The attitude recommended by the consensus document of WHO's Echinococcosis Working Group is shown in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">8</span></a></p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Surgical treatment</span><p id="par0055" class="elsevierStylePara elsevierViewall">Its aim is to evacuate the HC and obliterate the residual cavity, being the form of treatment that offers the highest chance of reaching a definitive cure. The recurrence rate ranges between 2 and 25% depending on the series. Its main causes are inadequate HC removal or the presence of an HC which was not initially identified.<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">19,20</span></a> There are different techniques. These can be classified as radical or conservative, and today, we have no good prospective studies that indicate which is the most effective and safe,<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">21</span></a> therefore it needs to be individualized according to patient and HC characteristics, surgeon experience, etc. Their indications, contraindications, morbidity and mortality<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">8</span></a> are collected in <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>. Conservative techniques are easier and require fewer resources. The radical ones, however, are more complex, requiring more equipment and experience in hepatobiliary surgery and have traditionally been considered to be associated with increased morbidity and mortality. However, there are many studies showing that radical techniques, always in expert hands, apart from achieving better results in terms of recurrence (0–4.65 against 4.65–25% for conservative techniques, depending on the series), they have lower rates of complications, especially biliary fistulas and infection of the residual cavity, which makes them techniques of choice, as long as they are available.<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">19,20</span></a> Laparoscopy is an increasingly popular alternative in recent years, although there are no trials comparing them to open surgery.</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">The possibility of spreading the parasite needs to be minimized in all cases of HHD surgery, protecting the surrounding tissues with gauzes impregnated in a protoscolecidal agent (usually saline 20%) and, if the HC is going to be opened, injecting the protoscolecidal agent inside it about 15<span class="elsevierStyleHsp" style=""></span>min before.<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">8,20</span></a> In addition, treatment with albendazole is recommended for a week before surgery until a month later (although the most appropriate time and duration regarding its administration has not been established).<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">8,21</span></a> If leakage of cystic fluid becomes evident during surgery, peritoneal lavage should be performed with hypertonic saline and albendazole treatment for 3–6 months after surgery, combined with praziquantel during the first week.<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">22</span></a> The presence of cystobiliary fistula (present in up to 80% of cases) should also be ruled out, preferably before surgery, by Cholangio-MRI or endoscopic retrograde cholangiopancreatography, or intraoperatively, by radiological contrast injection. If found, it should be repaired, otherwise it can lead to persistent biliocutaneous fistula (most common complication), biliary obstruction, bacterial cholangitis and even biliary cirrhosis. HC size is a major risk factor for the development of biliary cystic fistulas: it is estimated that with 7.5<span class="elsevierStyleHsp" style=""></span>cm the probability is 80%.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">8</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Percutaneous techniques</span><p id="par0065" class="elsevierStylePara elsevierViewall">There are 2 types of percutaneous techniques: <span class="elsevierStyleItalic">puncture-aspiration-injection-reaspiration</span> (PAIR) and modified catheterization techniques. The PAIR is aimed at destroying the germinal layer with protoscolicidal agents and consists of 4 steps<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">8,23</span></a>: Ultrasound or CT-guided puncture, aspiration of its contents, injecting a protoscolecidal agent (between a third and half of the aspirate volume) and re-aspiration of the cyst fluid (which must be examined again, because the presence of viable protoscoleces in it requires to repeat the injection of protoscolecidal agent and the reaspiration of cystic fluid). Saline 20% or 95% ethanol are generally used as protoscolecidal agents; formalin has been associated with the development of sclerosing cholangitis and is not recommended. It is mandatory rule out biliary fistula before injecting the protoscolecidal agent to avoid a chemical cholangitis. PAIR indications, contraindications, morbidity and mortality are shown in <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">8</span></a> The cure rate with PAIR in appropriate HCs is greater than 95%, with recurrence in 0–3% of cases.<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">9,24</span></a> The combination of PAIR and albendazole seems more effective than either of the two separately,<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">21</span></a> so albendazole should be administered 4<span class="elsevierStyleHsp" style=""></span>h before the puncture until a month after it or, if not available or contraindicated, mebendazole 4 <span class="elsevierStyleHsp" style=""></span>h before until 3 months later.<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">8,23</span></a> As for the comparison between PAIR and surgery, it seems that its efficacy, when the indication is correct, is comparable. There are even studies showing a lower morbidity with PAIR; however, a Cochrane systematic review in 2006 established that while PAIR seems promising, there is insufficient evidence to support or stop recommending it to other therapeutic alternatives.<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">25</span></a> PAIR variants have been developed in recent years intended to improve results and reduce morbidity, for example, the Örmeci technique, where only a small amount of intracystic fluid is aspirated, the protoscolecidal agent injected is a mixture of alcohol and polidocanol and there is no re-aspiration. This technique could be associated with a lower incidence of biliary fistula.<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">26</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Modified catheterization techniques are reserved for multivesicular HCs (types 2 and 3a) in an attempt to avoid surgery and its goal is to eliminate all endocyst and daughter vesicles using large-calibre catheters and cutting and aspiration tools.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">8</span></a> Data on long-term results are limited and there are no comparative studies with surgery.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Systemic antiparasitic drugs</span><p id="par0075" class="elsevierStylePara elsevierViewall">Benzimidazoles are the antiparasitic drugs of choice for the treatment of <span class="elsevierStyleItalic">E. granulosus</span> infection, which inhibit the parasite's microtubule assembly thus impeding the absorption of glucose through its wall.<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">9,27</span></a> Its indications, contraindications and side effects are listed in <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">8</span></a> Their efficacy depends on the size and location of the HC and host characteristics. HC resolution has been described in approximately 30% of cases (size reduction, separation of membranes, calcification, etc.) and clinical and radiological improvement in 30–50%, with worse outcomes in the elderly and long-standing infections.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">9</span></a> However, more recent studies indicate a lower efficacy, and also underline the not so inconsiderable rate of relapse of 25% in initial treatments and 60% in retreatment<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">28</span></a> after reaching a dormant stage under treatment. Their effect on high volume cysts is very slow, so they are not recommended as the only treatment on HCs bigger than 5<span class="elsevierStyleHsp" style=""></span>cm.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">8</span></a> A recent systematic review established that the HC size and stage are essential in predicting the likelihood of response to antiparasitic agents.<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">28</span></a> All patients treated with these drugs should be subject to monitoring due to the possibility of adverse effects: lab tests including blood count and liver function every 15 days for 3 months and then monthly is recommended; an increase in aminotransferase 5 times over the normal upper limit forces to stop treatment. Albendazole is the benzimidazole of choice for <span class="elsevierStyleItalic">E. granulosus</span> infection; it is preferred over mebendazole due to its greater in vitro activity, efficacy, pharmacokinetics and bioavailability, which allows to use it in a shorter regimen. It is administered orally at a dose of 10–15<span class="elsevierStyleHsp" style=""></span>mg/kg/day divided in 2 doses, with a high fat meal to increase its bioavailability (maximum dose of 400<span class="elsevierStyleHsp" style=""></span>mg/day).<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">8</span></a> Although the optimal treatment duration has not been established, 3–6 months is the recommended length, without the monthly breaks typical in the 1980s (implemented due to the limited information available on long term drug safety); however, the duration is often dependent on the response observed by ultrasound monitoring; retreatment<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">28</span></a> is common. If albendazole is unavailable or is not tolerated, the best alternative is mebendazole at 40–50<span class="elsevierStyleHsp" style=""></span>mg/kg/day, divided into 3 doses.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">8</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Praziquantel acts by increasing the absorption of calcium in the protoescoleces cell membrane, causing its paralysis. It has higher and faster protoscolecidal in vitro activity than benzimidazoles, but its efficacy in vivo is variable, so it is not recommended as a sole treatment<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">27</span></a>; however, combined with albendazole appears to be more effective than albendazole in monotherapy.<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">29</span></a> New drugs have been investigated in recent years for the treatment of HHD, both new benzimidazole formulations as well as new molecules.<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">30</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Observations</span><p id="par0085" class="elsevierStylePara elsevierViewall">It is the recommended strategy in the uncomplicated inactive HC (types 4 and 5).<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">8</span></a></p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Follow up</span><p id="par0090" class="elsevierStylePara elsevierViewall">HHD recurrence can happen after any kind of treatment, so follow up is essential. The best way to do this has not been defined, but a valid scheme could involve performing an imaging test (usually ultrasound) every 3–6 months until the findings indicate inactivity and are stable and then every year until 5 years have been completed; after those 5 years, in principle, the follow-up can then stop. Serology is also useful for monitoring, as antibodies usually disappear within two years of effective treatment and reappear in case of recurrence.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">9</span></a> However, exceptions to this rule are numerous, and indeed, it seems that the serology status after treatment may depend on the sensitivity of the test used (the most sensitive test can remain positive over 10 years). There are no recommendations as to which is the most appropriate test or the most adequate protocol. Finally, nowadays there is more interest in the search for viability markers that could facilitate patient monitoring.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conflict of interest</span><p id="par0095" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:8 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Clinical signs and symptoms" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Diagnosis" ] 3 => array:3 [ "identificador" => "sec0020" "titulo" => "Treatment" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Surgical treatment" ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Percutaneous techniques" ] 2 => array:2 [ "identificador" => "sec0035" "titulo" => "Systemic antiparasitic drugs" ] 3 => array:2 [ "identificador" => "sec0040" "titulo" => "Observations" ] ] ] 4 => array:2 [ "identificador" => "sec0045" "titulo" => "Follow up" ] 5 => array:2 [ "identificador" => "sec0050" "titulo" => "Conflict of interest" ] 6 => array:2 [ "identificador" => "xack232410" "titulo" => "Acknowledgement" ] 7 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-09-11" "fechaAceptado" => "2015-12-01" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Please cite this article as: Busto Bea V, Barrio Andrés J, Almohalla Álvarez C. Hidatidosis hepática: todavía un problema. Med Clin (Barc). 2016;146:367–371.</p>" ] ] "multimedia" => array:6 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 585 "Ancho" => 995 "Tamanyo" => 56074 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Ultrasound: infected multivesicular hydatid cyst of the liver.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 671 "Ancho" => 850 "Tamanyo" => 88379 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">CT scan: large hydatid cyst occupying the left hepatic lobe.</p>" ] ] 2 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">Clinical manifestations of hepatic hydatid disease \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">-Low-grade fever<br>-Nausea and vomiting<br>-Pain in right upper quadrant<br>-Hepatomegaly painful on palpation<br>-Compression of blood or lymph vessels, which can lead to portal hypertension, Budd-Chiari syndrome or hepatic atrophy of the corresponding lobe<br>-Bile duct compression<br>-Neighbouring organs compression<br>-Bacterial superinfection<br>-Rupture towards different locations, the most common being: bile duct (biliary fistulas are the most common complication of hepatic hydatid disease: occur in 40–60% of cases depending on the series, and can lead to jaundice, biliary colic, cholangitis and acute pancreatitis), peritoneum (peritonitis, anaphylactic reactions) and transdiaphragmaticly to the lungs (bronchial fistula, pulmonary hydatid disease)<br>-Allergic reactions (resulting from cystic fluid coming out of the cyst gradually, through small fissures, or after the abrupt rupture the cyst) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1137001.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Clinical manifestations of hepatic hydatid disease.</p>" ] ] 3 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">HC: hydatid cyst.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Cyst type \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Characteristics \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Undifferentiated cystic lesion \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Unilocular cyst, with no identifiable wall and fully anechoic. Since this is the description of a simple hepatic cyst, an ultrasound image is not enough to determine whether an injury of this type is a HC; if it is, it would be an active cyst, but not fertile \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Type 1 HC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Unilocular cyst with identifiable wall and fully anechoic or small mobile echoes similar to snowflakes called “hydatid sand” which correspond to capsules where protoscoleces are generated. It is active and fertile \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Type 2 HC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Multiseptated or multivesicular (by the presence of daughter vesicles inside), which can confer a wheel, rosette or honeycomb aspect, and a clearly identifiable wall. It is active and fertile \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Type 3 HC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Transitional cyst that is beginning to deteriorate, so unlike the above, it is generally oval rather than spherical, as the fluid pressure inside decreases. There are 2 types:<br>-HC Type 3a: unilocular, with identifiable wall and the detached laminated membrane, which produces the “lilac water sign”<br>-Type 3b HC: unilocular, consisting of ruptured membranes and daughter vesicles still viable (anechoic areas) or degenerate, giving it an aspect of complex mass, most of it solid \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Type 4 HC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Solid heterogeneous mass, usually hypoechoic, without daughter vesicles and sometimes looking like a ball of yarn due to the curved appearance of degenerate membranes. It is inactive and infertile \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Type 5 HC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Thick wall lesion wholly or partially calcified; calcium often deposits in an arch-like shape, causing a rear cone-shaped acoustic shadow. It is inactive and infertile \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1137002.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Standardized WHO ultrasound classification.</p>" ] ] 4 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">PAIR: <span class="elsevierStyleItalic">puncture-aspiration-injection-reaspiration</span>; HC: hydatid cyst; MoCaT: modified catheterization technique.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">HC 1 and 3a (unilocular) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><5<span class="elsevierStyleHsp" style=""></span>cm: albendazole (if not available or no follow-up possibility, PAIR)<br>>5<span class="elsevierStyleHsp" style=""></span>cm: albendazole<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>PAIR (if albendazole is unavailable or no possibility of follow-up, only PAIR) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">HC 2 and 3b<br>(Multilocular) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Albendazole<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>[MoCaT or surgery] (if albendazole is unavailable or there is no follow-up possibility, only MoCaT or surgery) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">HC 4 and 5<br>(Inactive) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Observations \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cystic lesions undifferentiated \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Do not treat unless parasitic origin is proven. If the epidemiology, clinical features, radiology and serology indicate hydatid nature, treat as HC 1 and 3a \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1136999.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Treatment recommended by WHO according to the type of hydatid cyst.</p>" ] ] 5 => array:8 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at4" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">PAIR: <span class="elsevierStyleItalic">puncture-aspiration-injection-reaspiration</span>; HC: hydatid cyst.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Indications \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Contraindications \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Morbidity, mortality and side effects<br> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">-Multivesicular HC (types 2 and 3b)<br>-HC >10<span class="elsevierStyleHsp" style=""></span>cm<br>-Surface HC (could break spontaneously or after trauma)<br>-Complicated HC (infected, ruptured, bleeding, etc.)<br>-Extrahepatic HC<br>-When percutaneous techniques would be of choice but are not available \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">-Inactive asymptomatic HC<br>-Very small HC<br>-Inaccessible HC<br>-High surgical risk \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">-Radical techniques:<br>-Mortality: 0–2.1%<br>-Morbidity: 5.5%<br>-Conservative techniques:<br>-Mortality: 0–2.9%<br>-Morbidity: 12.6% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">PAIR \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">-Unilocular HC (types 1 and 3a)<br>-Recurrence after drug treatment<br>-No availability, rejection or contraindication to surgery or recurrence after it \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">-Inactive HC<br>-Solid HC<br>-Multivesicular HC<br>-Surface HC (risk of rupture to peritoneum)<br>-Presence of biliary cystic fistula \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">-Mortality: 2.5%<br>-Morbidity:<br>-Major complications: 1.4%<br>-Minor complications: 13.7% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Drugs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">-Unilocular HC (types 1 and 3a) <5<span class="elsevierStyleHsp" style=""></span>cm<br>-Multiple HC<br>-Peritoneal HC<br>-Various organs involvement<br>-No availability, rejection or contraindication to surgery or percutaneous techniques<br>-Prophylaxis during and after surgery and percutaneous techniques \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">-Inactive HC<br>-HC >10<span class="elsevierStyleHsp" style=""></span>cm<br>-Multivesicular HC<br>-HC with risk of rupture<br>-Follow up impossibility<br>-Early pregnancy early<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a><br>-Myelosuppression<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a><br>-Chronic liver disease<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">-Hepatotoxicity (slight increase in aminotransferases: 10–20%)<br>-Myelosuppression (Leukopenia: 1%)<br>-Alopecia<br>-Headache<br>-Nausea and vomiting<br>-Abdominal pain<br>-Diarrhoea \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1137000.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Relative contraindication.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Therapeutic alternatives in hepatic hydatid disease.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:30 [ 0 => array:3 [ "identificador" => "bib0155" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cestodos" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "P.R. Murray" 1 => "K.S. Rosenthal" 2 => "G.S. Kobayashi" 3 => "M.A. Pfaller" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "LibroEditado" => array:5 [ "titulo" => "Microbiología médica" "paginaInicial" => "748" "paginaFinal" => "750" "edicion" => "4th ed." "serieFecha" => "2004" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0160" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Emergence/re-emergence of <span class="elsevierStyleItalic">Echinococcus</span> spp. – a global update" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "D.J. Jenkins" 1 => "T. Romig" 2 => "R.C. Thompson" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.ijpara.2005.07.014" "Revista" => array:6 [ "tituloSerie" => "Int J Parasitol" "fecha" => "2005" "volumen" => "35" "paginaInicial" => "1205" "paginaFinal" => "1219" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16157340" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0165" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Analysis of the economic impact of cystic echinococcosis in Spain" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "C. Benner" 1 => "H. Carabin" 2 => "L.P. Sánchez-Serrano" 3 => "C.M. Budke" 4 => "D. Carmena" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.2471/BLT.09.066795" "Revista" => array:6 [ "tituloSerie" => "Bull World Health Organ" "fecha" => "2010" "volumen" => "88" "paginaInicial" => "49" "paginaFinal" => "57" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20428353" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0170" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Molecular tools for the diagnosis of cystic and alveolar echinococcosis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "M.M. Siles-Lucas" 1 => "B.B. Gottstein" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Trop Med Int Health" "fecha" => "2003" "volumen" => "6" "paginaInicial" => "463" "paginaFinal" => "475" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11422961" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0175" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Hepatic echinococcosis: clinical and therapeutic aspects" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "G. Nunnari" 1 => "M.R. Pinzone" 2 => "S. Gruttadauria" 3 => "B.M. Celesia" 4 => "G. Madeddu" 5 => "G. Malaguarnera" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.3748/wjg.v18.i13.1448" "Revista" => array:6 [ "tituloSerie" => "World J Gastroenterol" "fecha" => "2012" "volumen" => "18" "paginaInicial" => "1448" "paginaFinal" => "1458" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22509076" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0180" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Long-term outcome of asymptomatic liver hydatidosis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "B. Frider" 1 => "E. Larrieu" 2 => "M. Odriozola" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Hepatol" "fecha" => "1999" "volumen" => "30" "paginaInicial" => "228" "paginaFinal" => "231" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10068100" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0185" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Echinococcosis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "D.P. McManus" 1 => "W. Zhang" 2 => "J. Li" 3 => "P.B. Bartley" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/S0140-6736(03)14573-4" "Revista" => array:6 [ "tituloSerie" => "Lancet" "fecha" => "2003" "volumen" => "362" "paginaInicial" => "1295" "paginaFinal" => "1304" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/14575976" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0190" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Writing panel for the WHO-IWGE2. Expert consensus for the diagnosis and treatment of cystic and alveolar echinococcosis in humans" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "E. Brunettia" 1 => "P. Kernb" 2 => "D.A. Vuittonc" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.actatropica.2009.11.001" "Revista" => array:6 [ "tituloSerie" => "Acta Trop" "fecha" => "2010" "volumen" => "114" "paginaInicial" => "1" "paginaFinal" => "16" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19931502" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0195" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The liver involvement of the hydatid disease: a systematic review designed for the hepato-gastroenterologist" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "D. Touma" 1 => "T. Sersté" 2 => "R. Ntounda" 3 => "J.P. Mulkay" 4 => "M. Buset" 5 => "Y. van Laethem" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Acta Gastroenterol Belg" "fecha" => "2013" "volumen" => "76" "paginaInicial" => "210" "paginaFinal" => "218" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23898558" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0200" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Enfermedades infecciosas. Hidatidosis. Diagnóstico de hidatidosis. Guía para el equipo de salud" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "M. Moral" 1 => "Ministerio de Salud de la Nación de República Argentina" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:3 [ "fecha" => "2012" "editorial" => "Dirección de Epidemiología" "editorialLocalizacion" => "Buenos Aires" ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0205" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Diagnostics in cystic echinococcosis: serology versus ultrasonography" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J. Wuestenberg" 1 => "B. Gruener" 2 => "S. Oeztuerk" 3 => "R.A. Mason" 4 => "M.M. Haenle" 5 => "T. Graeter" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.5152/tjg.2014.7112" "Revista" => array:6 [ "tituloSerie" => "Turk J Gastroenterol" "fecha" => "2014" "volumen" => "25" "paginaInicial" => "398" "paginaFinal" => "404" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25254522" "web" => "Medline" ] ] ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib0210" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "International classification of ultrasound images in cystic echinococcosis for application in clinical and field epidemiological settings" "autores" => array:1 [ 0 => array:2 [ "colaboracion" => "WHO Informal Working Group" "etal" => false ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Acta Trop" "fecha" => "2003" "volumen" => "85" "paginaInicial" => "253" "paginaFinal" => "261" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12606104" "web" => "Medline" ] ] ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib0215" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Sonographic findings in hydatid disease of the liver: comparison with other imaging methods" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "Z. Suwan" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Ann Trop Med Parasitol" "fecha" => "1995" "volumen" => "89" "paginaInicial" => "261" "paginaFinal" => "269" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7668917" "web" => "Medline" ] ] ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib0220" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Hydatid cyst of the liver: comparison of CT and MRI" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "P. Taourel" 1 => "B. Marty-Ane" 2 => "S. Charasset" 3 => "M. Mattei" 4 => "P. Devred" 5 => "J.M. Bruel" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Comput Assist Tomogr" "fecha" => "1993" "volumen" => "17" "paginaInicial" => "80" "paginaFinal" => "85" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8419444" "web" => "Medline" ] ] ] ] ] ] ] ] 14 => array:3 [ "identificador" => "bib0225" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Laboratory diagnosis of cystic hydatic disease" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "M.F. Biava" 1 => "A. Dao" 2 => "B. Fortier" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "World J Surg" "fecha" => "2001" "volumen" => "25" "paginaInicial" => "10" "paginaFinal" => "14" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11213147" "web" => "Medline" ] ] ] ] ] ] ] ] 15 => array:3 [ "identificador" => "bib0230" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "An update on immunodiagnosis of cystic echinococcosis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "E. Ortona" 1 => "R. Riganò" 2 => "B. Buttari" 3 => "F. Delunardo" 4 => "S. Ioppolo" 5 => "P. Margutti" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Acta Trop" "fecha" => "2003" "volumen" => "85" "paginaInicial" => "165" "paginaFinal" => "171" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12606093" "web" => "Medline" ] ] ] ] ] ] ] ] 16 => array:3 [ "identificador" => "bib0235" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Contribution of specific anti-hydatid IgG subclasses in the diagnosis of echinococcosis primary infection and relapses" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "M. Benabid" 1 => "Y. Galai" 2 => "R. Nouira" 3 => "S. Bouchoucha" 4 => "A. Bouratbine" 5 => "K. Aoun" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Clin Lab" "fecha" => "2013" "volumen" => "59" "paginaInicial" => "293" "paginaFinal" => "298" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23724617" "web" => "Medline" ] ] ] ] ] ] ] ] 17 => array:3 [ "identificador" => "bib0240" "etiqueta" => "18" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Suppression of <span class="elsevierStyleItalic">E. multilocularis</span> hydatid cysts after ionizing radiation exposure" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "X. Zhou" 1 => "Y. Zhao" 2 => "R. Zhou" 3 => "H. Zhang" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1371/journal.pntd.0002518" "Revista" => array:5 [ "tituloSerie" => "PLoS Negl Trop Dis" "fecha" => "2013" "volumen" => "7" "paginaInicial" => "e2518" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24205427" "web" => "Medline" ] ] ] ] ] ] ] ] 18 => array:3 [ "identificador" => "bib0245" "etiqueta" => "19" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Long term results after complete or incomplete surgical resection of liver hydatid disease" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "R. Chautems" 1 => "L. Buhler" 2 => "B. Gold" 3 => "M. Chilcott" 4 => "P. Morel" 5 => "G. Mentha" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "2003/17/smw-10168" "Revista" => array:6 [ "tituloSerie" => "Swiss Med Wkly" "fecha" => "2003" "volumen" => "133" "paginaInicial" => "258" "paginaFinal" => "262" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12833196" "web" => "Medline" ] ] ] ] ] ] ] ] 19 => array:3 [ "identificador" => "bib0250" "etiqueta" => "20" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Hepatic hydatidosis. Radical vs. conservative surgery: 22 years of experience" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "P. Priego" 1 => "J. Nuño" 2 => "P. López Hervás" 3 => "A. López Buenadicha" 4 => "R. Peromingo" 5 => "J. Díe" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Rev Esp Enferm Dig" "fecha" => "2008" "volumen" => "100" "paginaInicial" => "82" "paginaFinal" => "85" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18366265" "web" => "Medline" ] ] ] ] ] ] ] ] 20 => array:3 [ "identificador" => "bib0255" "etiqueta" => "21" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Treatment of hydatid cyst of the liver: where is the evidence?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "C. Dziri" 1 => "K. Haouet" 2 => "A. Fingerhut" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00268-004-7516-z" "Revista" => array:6 [ "tituloSerie" => "World J Surg" "fecha" => "2004" "volumen" => "28" "paginaInicial" => "731" "paginaFinal" => "736" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15457348" "web" => "Medline" ] ] ] ] ] ] ] ] 21 => array:3 [ "identificador" => "bib0260" "etiqueta" => "22" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Combination chemotherapy is more effective in postspillage prophylaxis for hydatid disease than either albendazole or praziquantel alone" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "D.H. Taylor" 1 => "D.L. Morris" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Br J Surg" "fecha" => "1989" "volumen" => "76" "paginaInicial" => "954" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2804596" "web" => "Medline" ] ] ] ] ] ] ] ] 22 => array:3 [ "identificador" => "bib0265" "etiqueta" => "23" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Puncture, aspiration, injection, re-aspiration. An option for the treatment of cystic echinococcosis. Document WHO/CDS/SPH/2001.6" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "World Health Organization (WHO)" 1 => "Informal Working Group on Echinococcosis" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:5 [ "fecha" => "2001" "paginaInicial" => "1" "paginaFinal" => "40" "editorial" => "WHO" "editorialLocalizacion" => "Ginebra, Suiza" ] ] ] ] ] ] 23 => array:3 [ "identificador" => "bib0270" "etiqueta" => "24" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Percutaneous drainage of echinococcal cysts (PAIR – puncture, aspiration, injection, reaspiration): results of a worldwide survey for assessment of its safety and efficacy. WHO Informal Working Group on Echinococcosis-Pair Network" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "C. Filice" 1 => "E. Brunetti" 2 => "R. Bruno" 3 => "F.G. Crippa" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Gut" "fecha" => "2000" "volumen" => "47" "paginaInicial" => "156" "paginaFinal" => "157" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10917754" "web" => "Medline" ] ] ] ] ] ] ] ] 24 => array:3 [ "identificador" => "bib0275" "etiqueta" => "25" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Percutaneous needle aspiration, injection, and re-aspiration with or without benzimidazole coverage for uncomplicated hepatic hydatid cysts" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "S. Nasseri-Moghaddam" 1 => "A. Abrishami" 2 => "A. Taefi" 3 => "R. Malekzadeh" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/14651858.CD003623.pub3" "Revista" => array:5 [ "tituloSerie" => "Cochrane Database Syst Rev" "fecha" => "2011" "volumen" => "1" "paginaInicial" => "CD003623" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21249654" "web" => "Medline" ] ] ] ] ] ] ] ] 25 => array:3 [ "identificador" => "bib0280" "etiqueta" => "26" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "PAIR vs. Örmeci technique for the treatment of hydatid cyst" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "N. Ormeci" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.5152/tjg.2014.13018" "Revista" => array:6 [ "tituloSerie" => "Turk J Gastroenterol" "fecha" => "2014" "volumen" => "25" "paginaInicial" => "358" "paginaFinal" => "364" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25254515" "web" => "Medline" ] ] ] ] ] ] ] ] 26 => array:3 [ "identificador" => "bib0285" "etiqueta" => "27" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Anthelminthic treatment: AN adjuvant therapeutic strategy against <span class="elsevierStyleItalic">Echinococcus granulosus</span>" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "M. Stamatakos" 1 => "C. Sargedi" 2 => "C.H. Stefanaki" 3 => "C. Safioleas" 4 => "I. Matthaiopoulou" 5 => "M. Safioleas" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.parint.2009.01.002" "Revista" => array:6 [ "tituloSerie" => "Parasitol Int" "fecha" => "2009" "volumen" => "58" "paginaInicial" => "115" "paginaFinal" => "120" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19272345" "web" => "Medline" ] ] ] ] ] ] ] ] 27 => array:3 [ "identificador" => "bib0290" "etiqueta" => "28" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Treatment response of cystic echinococcosis to benzimidazoles: a systematic review" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M. Stojkovic" 1 => "M. Zwahlen" 2 => "A. Teggi" 3 => "K. Vutova" 4 => "C.M. Cretu" 5 => "R. Virdone" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1371/journal.pntd.0000524" "Revista" => array:5 [ "tituloSerie" => "PLoS Negl Trop Dis" "fecha" => "2009" "volumen" => "3" "paginaInicial" => "e524" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19787039" "web" => "Medline" ] ] ] ] ] ] ] ] 28 => array:3 [ "identificador" => "bib0295" "etiqueta" => "29" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Combined albendazole and praziquantel versus albendazole alone in the treatment of hydatid disease" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "A.E. Mohamed" 1 => "M.I. Yasawy" 2 => "M.A. Al Karawi" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Hepatogastroenterology" "fecha" => "1998" "volumen" => "45" "paginaInicial" => "1690" "paginaFinal" => "1694" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9840130" "web" => "Medline" ] ] ] ] ] ] ] ] 29 => array:3 [ "identificador" => "bib0300" "etiqueta" => "30" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Scolicidal effects of black cumin seed (<span class="elsevierStyleItalic">Nigella sativa</span>) essential oil on hydatid cysts" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "H. Mahmoudvand" 1 => "E.S. Dezaki" 2 => "F. Kheirandish" 3 => "B. Ezatpour" 4 => "S. Jahanbakhsh" 5 => "M.F. Harandi" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.3347/kjp.2014.52.6.653" "Revista" => array:6 [ "tituloSerie" => "Korean J Parasitol" "fecha" => "2014" "volumen" => "52" "paginaInicial" => "653" "paginaFinal" => "659" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25548417" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack232410" "titulo" => "Acknowledgement" "texto" => "<p id="par0100" class="elsevierStylePara elsevierViewall">Thanks to Dr. Agustin Caro-Patón Gomez for his help in preparing this article.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/23870206/0000014600000008/v1_201607210236/S238702061630290X/v1_201607210236/en/main.assets" "Apartado" => array:4 [ "identificador" => "44144" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Diagnosis and treatment" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23870206/0000014600000008/v1_201607210236/S238702061630290X/v1_201607210236/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S238702061630290X?idApp=UINPBA00004N" ]
