Liver Cysts Flashcards
How are liver cysts commonly found?
Incidentally on routine imaging
Explain simple liver cyst
Fluid-filled epithelial-lined sacs
They are most commonly found in the right lobe
Are quite common and increasing incidence with age.
Cause of simple cysts
Congenitally malformed bile duct cells that fail to connect to the extrahepatic ducts.
Clinical features of simple cysts.
Asymptomatic
Usually discovered incidentally.
10-15% may experience symptoms…
Abdo pain, nausea and early satiety.
Lab tests in simple cysts
LFTs usually normal
Some patients might have raised GGT
CEA and CA19-9 tumour markers may also be elevated in some cases
Imaging modality of choice in simple cysts
USS
USS findings in simple cysts
Anechoic
Well-defined
Thin-walled
Oval/spherical lesions with no septations
Strong posterior wall acoustic enhancement
General management of simple cysts.
Usually no management is needed.
> 4cm in size should have follow-up USS at 3, 6 and 12 months
If the size of the cyst remains unchanged after 2-3 years no further scans are needed
Managment in symptomatic patients with simple cysts.
Ultrasound-guided aspiration or laparoscopic de-roofing (cysts have blue hue on this)
Define polycystic liver disease
Presence of 20 or more cysts within the liver parenchyma each of which is 1 cm or more in size.
Caused by usually one of the two following conditions…
Autosomal dominant polycystic kidney disease (ADPKD)
Autosomal dominant polycystic liver disease (ADPLD)
Explain ADPKD
Caused by mutations in the PKD1 and PKD2 genes
10-60% patients will develop liver cysts as well as it is a common extra-renal manifestation
Explain ADPLD
Mutation in the PRKCSH or SEC63 gene
There will be no renal involvement in ADPLD
Pathophysiology of polycystic liver disease
The mutations in the genes lead to aberrant ductal plate configuration during liver embryogenesis.
This means that the structures are not connected to the intrahepatic bile duct
This means that they cannot drain -> dilatation and cyst formation of bile-like fluid.
Clinical features polycystic liver disease
Majority are asymptomatic
Abdominal pain can arise as the cysts grow in size
Hepatomegaly
Concurrent renal disease with urinary tract symptoms
Liver cirrhosis and portal HTN
Lab tests in polycystic liver disease
Usually normal LFTs
ALP can be raised sometimes
Renal function should also be assessed
Definitive diagnosis of polycystic liver disease
Ultrasound imaging with multiple of cysts (>20)
Management of asymptomatic patients of polycystic liver disease
Can be left alone and monitored
Many patients will eventually require some sort of intervention as they are progressive diseases.
Short-term benefit for somatostatin analogues in symptomatic relief might be trialled
This is because it acts to reduce cyst volume
Indications for surgery polycystic liver disease
Intractable symptoms
Inability to rule out malignancy on imaging alone
Prevention of malignancy
Surgical approach polycystic liver disease
US-guided aspiration
Laparoscopic de-roofing of cysts
Explain US guided aspiration in polycystic liver disease
Provides temporary relief
It is not routinely perfored as fluid usually accumulates again
Explain laparoscopic de-roofing of cysts in polycystic liver disease
Preferred technique
Where there are particular liver segments that are heavily affected resection may be preferred
Extreme cases transplantation might even be preferred
Explain cystic neoplasms of the liver
Quite rare and account for <5% of liver cysts
Most of them are cystadenomaswhich arepremalignant lesionsthat can lead tocystadenocarcinomas in around 10% of cases
Clinical features of cystic neoplasms
Most commonly asymptomatic
Since the neoplasms grow slowly, symptoms may present slowly as well.
Abdo pain, anorexia
Nausea, fullness and bloating
Lab tests cystic neoplasms
LFTs usually normal
ALP, CEA and CA19-9 can all be elevated
Imaging of cystic neoplasms
USS can distinguish between simple cysts and cystic neoplasms
CT imaging with contrast should be performed in all patients where cystic neoplasms is suspected
CT for staging as well
When should you do an aspiration or biopsy of cystic neoplasms
Should be avoided
This is because it can result in potential peritoneal seeding of malignancy
Imaging features suggestive of malignancy
Septations
Wall enhancement
Nodularity
Imaging features suggestive of abscess
Debris within lesion
Loculation (can also suggest malignancy)
Imaging features suggestive of hydatid cyst.
Calcification
Daughter cysts around main lesion
Management of cystic neoplasms
Liver lobe resection for both cystadenomas and cystadenocarcinomas
Samples are sent for histopathology as well to confirm diagnosis
Explain hydatid cysts
Result from infection by the tapeworm Echinococcus granulosus.
Explain pathophysiology of hydatid cysts
Eggs from tapeworm are passed by faeco-oral route.
The larvae invade their hosts’ GI tract and then pass via hepatic portal to liver where it starts to grow.
Epidemiology of hydatid cysts
Global distribution
Highest prevalence in South america, north africa and central asia
Clinical features of hydatid cysts
Only grow a few millimetres per year
This means they may remain asymptomatic and undetected for many years
Most common presentation is vague abdo pain caused by mass effect on surrounding structures or due to rupture
Jaundice, cholangitis, vomiting, dyspepsia and early satiety can also happen
Rarely anaphylaxis can happen if a cyst ruptures into thorax or intraperitoneally.
Lab tests of hydatid cysts
LFTs are often normal unless there is also associated cholangitis
FBC = Eosinophilia
Echinococcal antibody titres +ve
Imaging of hydatid cysts
USS
CT with contrast can be done as well
USS findings hydatid cysts
Calcified spherical lesions with multiple septations
Anechoic or snow-flake like inclusions
CT imaging findings hydatid cysts
Similar to USS with calcified spherical lesions with mutiple septations
Daughter lesions can be found near main lesion as well
Primary treatment of hydatid cysts
Surgical by cyst de-roofing
What other surgical intervention might be done in hydatid cysts
Radiological drainage and injection of scolecidal agent
Aspiration is not recommended due to risk of rupture and anaphylactic reaction
Medical management of hydatid cysts
If the cysts are asymptomatic and inactive monitoring might be done.
Medical management is used as an adjunct to surgical therapy
Especially in those with widely disseminated hydatid disease or if unfit for surgery
Albendazole, mebendazole and/or praziquantel is normally given
