Week 6 - F - Focal liver lesions (1) - Benign -> Hemangioma, F.N.H, adenoma, cystic (simple/hydatid, P.C.L.D/Abscess/Amoebiasis)

Question 1

Primary hepatic tumours are rare and they may be benign or malignant More commonly, liver tumours are secondary tumours from metastases (90%) What are the common primary malignancies that metastasize to the liver?

Answer 1

Common primaries - breast, pancreas, stomach, colon, lung

Question 2

Primary liver tumours as said can be benign or malignant What are different examples of both benign and malignant primary liver tumours?

Answer 2

Benign liver tumours * Hemangioma * Focal nodular hyperplasia * Hepatocellular adenoma * Liver cysts Malignant liver tumour - primary * Hepatocellular carcinoma * Cholangiocarcinoma

Question 3

BENIGN LIVER TUMOURS What is the commonest liver tumour? If you are able to see it clinically, what does it look like?

Answer 3

Hemangioma’s are the commonest liver tumour Clinically they appear as a well demarcated reddish-purple hypervascular lesions

Question 4

Hemangiomas are usually asymptomatic and are found on scans of the liver for other reasons How do they appear on ultrasound scan? How do they appear on CT scan?

Answer 4

On USS * Hemangiomas typically appear as a well demarcated, echogenic spot On CT * Hemangiomas typically show venous enhancement from periphery to center

Question 5

What is the treatment of liver hemangiomas? Why is biopsy avoided?

Answer 5

There is usually no need for treatment and no need to biopsy Biopsy is avoided due to the risk of haemorrhage.

Question 6

Focal nodular hyperplasia (FNH) is a benign tumor of the liver (hepatic tumor), which is the second most prevalent tumor of the liver (the first is hepatic hemangioma). What causes focal nodular hyperplasia?

Answer 6

Focal nodular hyperplasia is not thought to be a true neoplasm but instead a localised hyperplastic hepatocyte response to abnormal blood flow in the liver - a congenital vascular anomaly usually

Question 7

Focal nodular hyperplasia consists of normal liver constituents in an abnormally organized pattern What is the typical growth pattern of focal nodular hyperplasia?

Answer 7

The typical growth pattern is described as a central scar containing a large artery, with radiating branches to the periphery - this is known as a stellate pattern/scar The stellate scar can have central necrosis if large

Question 8

Which sex are both hemangiomas and focal nodular hyperplasia more common? What are the typical symptoms? What is their malignant potential?

Answer 8

Both hemangiomas and focal nodular hyperplasia are more commonly found in females Both are typically asymptomatic Both have no malignant potential

Question 9

How is focal nodular hyperplasia diagnosed? How is it managed?

Answer 9

On USS - nodle with varying echogenicity CT scan shows a hypervascular mass with central scar - stellate pattern (or spoke wheel sign) No treatment is necessary

Question 10

Hepatocellular adenoma What cells are hepatic adenomas composed from? What are the associated causes with this and therefore which sex are they more commonly found in?

Answer 10

Hepatocellular adenomas are composed purely from normal hepatocytes - no portal tract, central veins or bile ducts They are more common in females and associated with anabolic steroid use, oral contracetpive pill and pregnancy

Question 11

Hepatocellular adenomas are normally asymptomatic but how/what age may they present?

Answer 11

Normally asymptomatic May present with rupture, haemorrhage, RUQ pain Usually present in third to fifth decade

Question 12

Most hepatic adenomas are solitary lesions found incidentally on imaging but as said -pain, bleeding and rupture are symptoms that can occur How are they diagnosed? Why is it important to make a definitive diagnosis if suspicious of hepatocellular adenoma?

Answer 12

On US scan - mixed echoicty On CT scan, most lesions are hypodense and then have diffuse arterial enhacnment when contrast is administered Definitive diagnosis is made via FNA/biopsy - important because they have a small malignant transformation risk

Question 13

What is the difference in treatment of hepatocellular adenomas in males and females?

Answer 13

Females (more common) - stop hormones, weight loss 5cm or increasing in size/symptoms - surgical excision IN males, irrespective of size - surgically excise as malignant transformation rates are higher

Question 14

Cystic lesions of the liver * Simple cysts * Hydatid * Polcystic liver lesion * Polyctsic kidney disease * Abscess Simple hepatic cysts are common benign liver lesions and have no malignant potential. They can be diagnosed with ultrasound, CT, or MRI. What is a simple liver cyst? Symptoms?

Answer 14

Simple liver cyst is a liquid collection lined by an epithelium that is solitary and uniloculated Most of the time is it asymptomatic

Question 15

Do simple hepatic cysts have any biliary tree communication? How do they appear on ultrasound scan?

Answer 15

Simple hepatic cysts are benign developmental lesions that do not communicate with the biliary tree On USS they are round/ovoid, well demarcated and have no internal vascularity

Question 16

What is the management of a simple liver cyst? What if you are uncertain of the diagnosis?

Answer 16

There is no follow ip necessary for a diagnosis of a simple liver cyst If in doubt, imaging in 3-6 months or consider surgical intervention

Question 17

Hydatid cyst What causes the condition known as - hydatid liver cysts?

Answer 17

A hydatid liver cyst is an infection in the liver or other parts of the body due to the tapeworm (a type of helminth infection - these are parasitic worms) of the genus Echinococcus

Question 18

What is the route of transmission of Hydatid cysts? Which organs are typically affected due to the ingestion of the parasite eggs?

Answer 18

Humans ingest parasite (echinococcus) eggs via food/water contaminated by animal faeces or by handling animals which are infected with the taprwarom Disease is due to development of cyst-like larvae in viscera - usually liver / lungs

Question 19

Why countries are patients who present with hydatid cysts likely to have travelled?

Answer 19

Central/Sout america Middle east/north africa Eastern europe

Question 20

What is the clinical presentation of a patient with hydatid cysts affecting the liver?

Answer 20

Typically presents with malaise and right upper quadrant pain Also hepatomegaly Maybe obstructive jaunidce

Question 21

How are hydatid cysts diagnosed?

Answer 21

USS/CT/MRI shows avascular fluid filled cysts +/- calcification Carry out seological tests for anti-echniococcus antibodies if this is seen

Question 22

What is the treatment of hydatid cysts of the liver?

Answer 22

Surgery Treatment is usually by surgery combined with anti-parasitic agent eg mebendazole or albendazole

Question 23

Polycystic liver disease What other condition does polycystic liver disease normally occur with?

Answer 23

Polycystic liver disease (PLD) usually describes the presence of multiple cysts scattered throughout normal liver tissue PLD is commonly seen in association with autosomal-dominant polycystic kidney disease,

Question 24

Polyctstic liver disease much more commonly occurs due to the autosomal dominant, polycystic kidney disease However, rarely, polycstic liver disease can occur alone with no renal disease * What is the inheritance of this type? * What genes are associated with this?

Answer 24

Polycystic liver disease comes in two forms as autosomal dominant polycystic kidney disease (with kidney cysts) and autosomal dominant polycystic liver disease (liver cysts only). The genes PRKCSH and SEC63 have been identified in association with autosomal dominant polycsytic liver disease

Question 25

Most patients are asymptomatic What is the presentation of patients with polycstic liver disease if they do have symptoms?

Answer 25

Abdominal pain Abdominal distension Atypical symptoms due to voluminous cysts resulting in compression of adjacent tissue or failure of the affected organ

Question 26

What is the treatment of polycystic liver disease?

Answer 26

Conservative treatment is recommended to halt cyst growth to allow abdominal decompression and ameliorate symptoms * Somatostatin anologues eg ocreotide are given for symptoms relief and liver volume reduction Surgery is given only in selective patients or liver failure

Question 27

Liver abscesses What is the presentation of a liver abscess? What is often the history from the patient?

Answer 27

Patient presents with high fever, leukocytosis, abdominal pain and a complex liver lesion when a scan is carried out Jaundice may be seen Patient often says they previously had * an abdominal infection (haemategnous spread through portal venous system) * or biliary tract infection * or a dental procedure

Question 28

What are the two main types of liver abscess? What type of organism is implicated in the different causes?

Answer 28

Pyogenic liver abscess, which is most often polymicrobial, accounts for the majority of cases Amoebic liver abscess due to a protozoan parasite accounts for 10% of cases.

Question 29

What is the protozoan parasite species implicated in amoebiasis infections? How is it spread? What does it usually cause?

Answer 29

Amoebiasis is causes by the protozoan - entamoeba histolyca It is spread via the faecal oral route and normally will cause a gastroenteritis type picture Rarely can cause an amoebic liver abscess

Question 30

How does intestinal amoebiasis tend to present? How is intestinal amoebiasis diagnosed?

Answer 30

Presents with * Abdo pain * Fever * Bloody diarrhoea - can perforate bowel * Toxic and unwell Diagnosed by stool microscopy (parasites anywhere usually require microscopy)

Question 31

How is a liver abscess (pyogenic or amoebic) diagnosed?

Answer 31

Ultrasound will usually show a fluid filled cavity, hyperechoic walls may be seen in chronic abscesses IN amoebic disease, can detect amoebic antibodies

Question 32

What is the treatment of a pyogenic liver abscess? What is the treatment of an amoebiasis / amoebic liver abscess?

Answer 32

Pyogenic abscess * Initial empiric broad spectrum antibiotics * Aspiration / drainage percutaneously Ameobiasis / amoebic liver abscess * Metronidazole or tinadazole * Lumenal amoebicide to prevent reinvasion of tissues by amoebae still in the intestines - eg diloxanide duroate * Aspiration if liver abscess