eMedicine Specialties > General Surgery > Abdomen

Hepatic Cysts: Workup

Author: Heidi Holman Jackson, MD, Staff Physician, Department of Surgery, University of Utah School of Medicine
Coauthor(s): Sean J Mulvihill, MD, Chief, Professor, Department of Surgery, University of Utah School of Medicine
Contributor Information and Disclosures

Updated: Sep 9, 2009

Workup

Laboratory Studies

  • The evaluation of a patient with a simple liver cyst involves carefully recording patient history and performing a physical examination plus an imaging study, such as an abdominal CT scan, to define the anatomy of the cyst. The clinician can minimize the cost of evaluation by obtaining only key studies that may alter the treatment plan.
  • Patients with simple hepatic cysts require little preoperative laboratory workup. Liver function test results, such as transaminases or alkaline phosphatase, may be mildly abnormal, but bilirubin, prothrombin time, and activated partial thromboplastin times are usually within the reference range.
  • In the setting of PCLD, greater abnormalities in liver function test results are found, but liver failure is uncommon. Renal function test results, including blood urea nitrogen and creatinine levels, are often abnormal and should be performed on initial evaluation.
  • In the presence of hydatid cysts, eosinophilia is noted in approximately 40% of patients, and echinococcal antibody titers are positive in nearly 80% of patients.
  • As with simple cysts, liver function test results are normal with cystic tumors. There may be mild abnormalities in some patients. Carbohydrate antigen (CA) 19-9 levels are elevated in some patients. Cyst fluid can be sent for CA 19-9 testing at the time of surgery as a marker for cystadenoma and cystadenocarcinoma.
  • Patients with hepatic abscesses can usually be easily identified by the clinical presentation. Leukocytosis is generally present.
  • The enzyme immunoassay (EIA) test detects specific antibodies to E histolytica.

Imaging Studies

  • Before the widespread availability of abdominal imaging techniques, including ultrasonography and CT scans, liver cysts were diagnosed only when they grew to an enormous size and became apparent as an abdominal mass or as an incidental finding during laparotomy. Today, imaging studies often reveal asymptomatic lesions incidentally.
  • The clinician has a number of options for imaging the liver in patients with hepatic cysts. Ultrasonography is readily available, noninvasive, and highly sensitive (see first image below and Image 2). Computed tomography scan is also highly sensitive and is easier for most clinicians to interpret, particularly for treatment planning (see second image below and Image 3).1,2 MRI, nuclear medicine scanning, and hepatic angiography have a limited role in the evaluation of hepatic cysts.
  • Simple cysts have a typical radiographic appearance. They are thin walled with a homogenous low-density interior.
  • PCLD is confirmed by ultrasound or CT scan with multiple liver cysts identified at the time initial of evaluation (see third image below and Image 4).
  • Hydatid cysts can be identified by the presence of daughter cysts within a thick-walled main cavity (see fourth image below and Image 5).
  • In patients who are jaundiced with hydatid disease, endoscopic retrograde cholangiopancreatography (ERCP) should be performed to determine if the cyst has ruptured into the bile duct.
  • Central necrosis of large solid neoplasms can mimic cystic hepatic tumors, as this area of necrosis appears cystic.
  • Cystadenoma and cystadenocarcinoma usually appear multiloculated with internal septations, heterogeneous density, and irregularities in the cyst wall (see fifth image below and Image 6).
  • Unlike many tumors, calcifications are rare in cystadenoma and cystadenocarcinoma.
  • A practical problem in the evaluation of a patient with a cystic hepatic lesion is differentiating cystic neoplasms from simple cysts.
    • Cystic neoplasms tend to have thicker, irregular, hypervascular walls, whereas simple cysts tend to be thin walled and uniform.
    • Simple cysts tend to have homogenous low-density interiors, whereas neoplastic cysts usually have heterogeneous interiors with septa and papillary extrusions.
  • Abscesses of the liver appear cystic on imaging studies but can usually be diagnosed from the overall clinical presentation.


Ultrasonographic appearance of a patient with a l...

Ultrasonographic appearance of a patient with a large simple hepatic cyst.

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Ultrasonographic appearance of a patient with a l...

Ultrasonographic appearance of a patient with a large simple hepatic cyst.



Computed tomography (CT) scan appearance of a lar...

Computed tomography (CT) scan appearance of a large hepatic cyst.

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Computed tomography (CT) scan appearance of a lar...

Computed tomography (CT) scan appearance of a large hepatic cyst.



Computed tomography (CT) scan of polycystic liver...

Computed tomography (CT) scan of polycystic liver disease curiously limited to the right lobe.

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Computed tomography (CT) scan of polycystic liver...

Computed tomography (CT) scan of polycystic liver disease curiously limited to the right lobe.



Hepatic cysts. Sagittal magnetic resonance imagin...

Hepatic cysts. Sagittal magnetic resonance imaging (MRI) reconstruction in a patient with a large echinococcal cyst; note daughter cysts in interior.

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Hepatic cysts. Sagittal magnetic resonance imagin...

Hepatic cysts. Sagittal magnetic resonance imaging (MRI) reconstruction in a patient with a large echinococcal cyst; note daughter cysts in interior.



Computed tomography (CT) scan appearance of bilia...

Computed tomography (CT) scan appearance of biliary cystadenoma.

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Computed tomography (CT) scan appearance of bilia...

Computed tomography (CT) scan appearance of biliary cystadenoma.

Other Tests

  • Other tests are generally not necessary in the evaluation of hepatic cysts. Percutaneous aspiration should be avoided because the laboratory and cytologic evaluation of the simple cyst fluid is nondiagnostic, and a small risk exists of inducing anaphylaxis from leakage from the hydatid cyst or of causing abscess formation in a previously sterile cyst.

Histologic Findings

Histologic assessment of the excised cyst wall should be routinely undertaken to identify the presence of an unsuspected neoplasm, such as cystadenoma. In simple cysts, histology of the cyst wall generally reveals a layer of simple cuboidal epithelium.

More on Hepatic Cysts

Overview: Hepatic Cysts
Workup: Hepatic Cysts
Treatment: Hepatic Cysts
Follow-up: Hepatic Cysts
Multimedia: Hepatic Cysts
References
Further Reading
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References

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Keywords

hepatic cyst, liver cyst, simple cysts, cysts liver, liver lesions, liver tumor, liver surgery, liver mass, liver lesion, hydatid cyst, cyst on liver, cysts on liver, solitary nonparasitic cysts of the liver, polycystic liver disease, echinococcosis, PCLD, parasitic cysts, hydatid cysts, echinococcal cysts, cystic tumors, abscesses, Echinococcus granulosus, cystic hepatic lesions, cystadenoma, cystadenocarcinoma, polycystic kidney disease, PKD, autosomal dominant polycystic kidney disease, AD-PKD, jaundice, cholangitis, anaphylactic shock

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Contributor Information and Disclosures

Author

Heidi Holman Jackson, MD, Staff Physician, Department of Surgery, University of Utah School of Medicine
Heidi Holman Jackson, MD is a member of the following medical societies: American College of Surgeons, American Medical Women's Association, and Southwestern Surgical Congress
Disclosure: Nothing to disclose.

Coauthor(s)

Sean J Mulvihill, MD, Chief, Professor, Department of Surgery, University of Utah School of Medicine
Sean J Mulvihill, MD is a member of the following medical societies: American College of Surgeons, American Gastroenterological Association, American Pancreatic Association, American Society for Gastrointestinal Endoscopy, Association for Academic Surgery, Society for Surgery of the Alimentary Tract, and Society of University Surgeons
Disclosure: Nothing to disclose.

Medical Editor

Brian James Daley, MD, MBA, FACS, Associate Program Director, Professor, Department of Surgery, Division of Trauma and Critical Care, University of Tennessee School of Medicine
Brian James Daley, MD, MBA, FACS is a member of the following medical societies: American Association for the Surgery of Trauma, American College of Chest Physicians, American College of Surgeons, American Medical Association, Association for Academic Surgery, Association for Surgical Education, Eastern Association for the Surgery of Trauma, Shock Society, Society of Critical Care Medicine, Southeastern Surgical Congress, and Tennessee Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

BS Anand, MD, Professor, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine
BS Anand, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy
Disclosure: Nothing to disclose.

CME Editor

Paolo Zamboni, MD, Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy
Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences
Disclosure: Nothing to disclose.

Chief Editor

John Geibel, MD, DSc, MA, Vice Chairman, Professor, Department of Surgery, Section of Gastrointestinal Medicine and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital
John Geibel, MD, DSc, MA is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, and Society for Surgery of the Alimentary Tract
Disclosure: AMGEN Royalty Other

 
 
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