Liver cystic disease

Question 1

Cause of benign liver cysts (4)

Answer 1

genetic
acquired
infectious
parasitic

Question 2

majority of liver cysts are (2)

Answer 2

non infectious
and
non neoplastic

Question 3

Most common neoplastic liver cysts

Answer 3

cystadenomas

cystadenocarcinomas

Question 4

Simple cyst

Answer 4

• asymptomatic, may develop symptom with pregnancy
• well defined, unilocular, low fluid density
• less than 3cms
• Hypo in T1, Hyper in T2
• more common in right lobe of liver
  TTT :
• none unless symptomatic
• alcohol sclerotherapy
• laparoscopic fenestration

Question 5

Ciliated foregut cyst

Answer 5

• Pain although y 5cm
• unilocular, subcapsular, single, near falciform in segm IV, 4 layered wall on ultrasound
• resection if > 4 cm

Question 6

Polycystic liver disease

Answer 6

• multiple cysts on liver + kidney
• autosomal dominant
• open fenestration, liver resection, orthotopic liver transplantation

Question 7

Amebic abscess

Answer 7

• complext cyst with double target appearance

- metronidazole

Question 8

Pyogenic liver abscess

Answer 8

• complex cyst with rim enhancment
• percutaneous drainage and antibiotics
• surgery if refractory

Question 9

Traumatic cyst

Answer 9

• variable density and intensity, density layering shifts with movement
• no treatment unless symptomatic or complications

Question 10

Cystadenoma

Answer 10

• more common in females
• complex, multilocular cyst with septations, microcalcification, nodules, contrast enhancement of septations
  TTT :
• enucleation
• partial hepatectomy or lobectomy

Question 11

IPMN-B (Intraductal papillary mucininous neoplasm of the bile ducts)

Answer 11

• complex, multilocular, septation, calcification, biliary communication on ERCP or IOC, bile duct dilatation distal of tumor.
  TTT : partial hepatectomy or lobectomy with IOC +/- extrahepatic biliary resection and portal lymphadenectomy

Question 12

Cystadenocarcinoma

Answer 12

• more common in females
• complex, multilocular cyst with septations, microcalcification, nodules, contrast enhancement of septations
  TTT :
• partial hepatectomy
• lobectomy

Question 13

Cystic HCC

Answer 13

• history of HBV, HCV or corrhosis
• complex hypervascular cystic lesion with portal venous washout
  TTT :
• RFA
• TACE (transarterial chemoembolisation)
• Partial hepatectomy or lobectomy
• Liver transplantation

Question 14

Liver tests

Answer 14

usually normal unless compressing hepatic structures

Question 15

Fever (2)

Answer 15

• superinfected cyst

- pyogenic liver ascess

Question 16

Fever + travel or livestock (2)

Answer 16

• Serology for Echinococcus

- Stool studies for Entamoeba

Question 17

Cyst aspiration (3)

Answer 17

• rarely helps in benign vs neoplastic, no marker
• avoid if Echinococcus : anaphylaxis
• if cystadenocarcinoma : peritoneal spread

Question 18

Debris within cysts (3)

Answer 18

• parasitic
• neoplastic
• hemorrage in simple cyst

Question 19

Mural calcification or daughter cyst

Answer 19

Echinococcal disease (can appear later)

Question 20

Echinococcus (types)

Answer 20

alveolar : E. multilocularis - fox (EU, CH, north heimsphere)
cystic = hydatid : E. granulosus - dog (EU, mediteranea, tropical zone)
polycsystic (E. vogeli, E oligarthrus, seldom south america
)

Question 21

Alveolar form (multilocularis)
Survival at 5 years without treatment
At 10 years with treatment

Answer 21

40%

80% if inoperable

Question 22

Alveolar Echinococcal Disease

Answer 22

• radical surgery (partial hepatectomy) if possible (30% of cases)
• liver transplantation
• if cholangitis or abscess : percutaneous, endoscopic
• Albendazole
  
  • for 2 years after surgery
  • lifelong for non operative cases

Question 23

Simple cyst can become symptomatic if:

Answer 23

• size > 5cm (pressure, pain)
• ruptured
• hemorrhage
• infected

Question 24

Rapidly growing simple cyst

Answer 24

increased risk of malignancy

Question 25

Imaging for simple cyst

Answer 25

Ultrasound should do | if septa, CT

Question 26

Choledocus Cyst

Answer 26

``` very rare children intermittent icterus complications as adult: - cholangitis - pancreatitis - portal hypertension - liver abscess pathophysiology : - long common channel theory - oddi dysfunction - Oligogangliosis (gallway Hirschsprung) ttt: - resection and reconstruction - OLT ```

Question 27

Hemangioma Diagnosis

Answer 27

US | CT (iris phenomenon, filling from peripher to central)

Question 28

Hemangioma indication for surgery (3)

Answer 28

> 15cm symptomatic rapid growth Kasabach-Merritt syndrome (thrombopenia, consummation coagulopathy, hypofibrinogen)

Question 29

FNH Focal Nodular Hyperplasia - ranking of non malignant tumor - female male ratio - age - typical morphology - size - % asymptomatic

Answer 29

- second most common non malignant tumor - female (9:1) - 20-50 years of age - typical vascular anomaly in the the center of the nodule - associated with Rendu Osler and therefore likely congenital - < 5cm in 90% of cases - 75% asymptomatic

Question 30

FNH Diagnosis

Answer 30

- Dx with 4 phase CT or MRI

Question 31

FNH indication

Answer 31

> 8cm | unclear if FNH or other

Question 32

Hepatocellular adenoma indication

Answer 32

> 5cm (risk of bleeding and malignancy) No biopsy !! < 5cm, no absolute indication but surveillance

Question 33

Hepatocellular adenoma

Answer 33

associated with estrogen and contrapective pill can cause pain in 25% of cases avoidance of hormonal contraception is recommended