Liver cystic disease Flashcards
Cause of benign liver cysts (4)
genetic
acquired
infectious
parasitic
majority of liver cysts are (2)
non infectious
and
non neoplastic
Most common neoplastic liver cysts
cystadenomas
cystadenocarcinomas
Simple cyst
- 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
Ciliated foregut cyst
- Pain although y 5cm
- unilocular, subcapsular, single, near falciform in segm IV, 4 layered wall on ultrasound
- resection if > 4 cm
Polycystic liver disease
- multiple cysts on liver + kidney
- autosomal dominant
- open fenestration, liver resection, orthotopic liver transplantation
Amebic abscess
- complext cyst with double target appearance
- metronidazole
Pyogenic liver abscess
- complex cyst with rim enhancment
- percutaneous drainage and antibiotics
- surgery if refractory
Traumatic cyst
- variable density and intensity, density layering shifts with movement
- no treatment unless symptomatic or complications
Cystadenoma
- more common in females
- complex, multilocular cyst with septations, microcalcification, nodules, contrast enhancement of septations
TTT : - enucleation
- partial hepatectomy or lobectomy
IPMN-B (Intraductal papillary mucininous neoplasm of the bile ducts)
- 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
Cystadenocarcinoma
- more common in females
- complex, multilocular cyst with septations, microcalcification, nodules, contrast enhancement of septations
TTT : - partial hepatectomy
- lobectomy
Cystic HCC
- 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
Liver tests
usually normal unless compressing hepatic structures
Fever (2)
- superinfected cyst
- pyogenic liver ascess
Fever + travel or livestock (2)
- Serology for Echinococcus
- Stool studies for Entamoeba
Cyst aspiration (3)
- rarely helps in benign vs neoplastic, no marker
- avoid if Echinococcus : anaphylaxis
- if cystadenocarcinoma : peritoneal spread
Debris within cysts (3)
- parasitic
- neoplastic
- hemorrage in simple cyst
Mural calcification or daughter cyst
Echinococcal disease (can appear later)
Echinococcus (types)
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
)
Alveolar form (multilocularis)
Survival at 5 years without treatment
At 10 years with treatment
40%
80% if inoperable
Alveolar Echinococcal Disease
- 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
Simple cyst can become symptomatic if:
- size > 5cm (pressure, pain)
- ruptured
- hemorrhage
- infected
Rapidly growing simple cyst
increased risk of malignancy
Imaging for simple cyst
Ultrasound should do
if septa, CT
Choledocus Cyst
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
Hemangioma Diagnosis
US
CT (iris phenomenon, filling from peripher to central)
Hemangioma indication for surgery (3)
> 15cm
symptomatic
rapid growth
Kasabach-Merritt syndrome (thrombopenia, consummation coagulopathy, hypofibrinogen)
FNH Focal Nodular Hyperplasia
- ranking of non malignant tumor
- female male ratio
- age
- typical morphology
- size
- % asymptomatic
- 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
FNH Diagnosis
- Dx with 4 phase CT or MRI
FNH indication
> 8cm
unclear if FNH or other
Hepatocellular adenoma indication
> 5cm (risk of bleeding and malignancy)
No biopsy !!
< 5cm, no absolute indication but surveillance
Hepatocellular adenoma
associated with estrogen and contrapective pill
can cause pain in 25% of cases
avoidance of hormonal contraception is recommended
