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TABLE 4 World Health Organization – Informal Working Groups on Echinococcosis (WHO-IWGE) Classification of the Hydatid Cyst 3
Stage Echographic aspect according to WHO-IWGE classification
CL Anechogenic uniloculated cyst, with no echoes or internal sepsis
CE 1 Anechogenic cyst with fine echoes inside, representing the hydatic sand - active cyst
CE 2 Cyst with multiple septae at the interior, giving it a multivesicular (“honeycomb”) aspect, with a uniloculated primary cyst –
active cyst
CE 3 Uniloculated cyst with decolated proligere membrane (“waterlilly sign”) (CE3a) or daughter vesicles associating hypo/
hyperechogenic images (CE3b) – cyst in transition phase
CE 4 Cyst with mixed content, hypo/hyperechogenic, without daughter vesicles - “wool clew” aspect – cyst in the degenerative phase
CE 5 Cyst with partial or totally calcified wall – inactive cyst
CE = cystic echinococcosis; CL = cystic lesion.

TABLE 5 Therapy Protocol for Hydatid Cyst 3
Stage and size First-option treatment Alternative treatment
Refusal of intervention or contraindications ABZ (6 mo)
for invasive treatment
CE 1, CE 3a
Small Only ABZ (6 mo) PAIR + ABZ (1 mo)
Medium Surgery + ABZ (1–6 mo) PAIR + ABZ (1 mo)
Large Surgery + ABZ (1–6 mo) MoCaT + ABZ (1 mo)
CE 2, CE 3b
Small Only ABZ (6 mo) MoCaT + ABZ (1 mo)
Medium Surgery tx + ABZ (1–6 mo) MoCaT + ABZ (1 mo)
Large Surgery tx + ABZ (1–6 mo) MoCaT + ABZ (1 mo)
CE 4, CE 5 “Watch and wait” “Watch and wait”
Complicated cysts, no matter what stage Surgery (+/– interventional endoscopy in Surgery in case of rupture; percutaneous
case of rupture into the biliary tract) + ABZ drainage in case of infection + ABZ
(6 mo) (1 month)
ABZ = antibiotics; albendazole (adult dose: 400mg twice daily; pediatric dose: 15mg/kg/d (max 800mg) ; CE = cystic echinococcosis; MoCaT =
4
modified catheterization technique; PAIR = puncture, aspiration, injection, re-aspiration technique (injection of 95% ethanol or hypertonic
saline).

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