Hepatic Cysts Workup

  • Author: Heidi Holman Jackson, MD; Chief Editor: John Geibel, MD, DSc, MA   more...
 
Updated: Mar 11, 2010
 

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.
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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. Computed tomography scan (see image below) is also highly sensitive and is easier for most clinicians to interpret, particularly for treatment planning. MRI, nuclear medicine scanning, and hepatic angiography have a limited role in the evaluation of hepatic cysts. Computed tomography (CT) scan appearance of a largComputed tomography (CT) scan appearance of a large hepatic cyst.
  • 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, as depicted in the image below. Computed tomography (CT) scan of polycystic liver Computed tomography (CT) scan of polycystic liver disease curiously limited to the right lobe.
  • Hydatid cysts can be identified by the presence of daughter cysts within a thick-walled main cavity, which are clear in the MRI below. Hepatic cysts. Sagittal magnetic resonance imagingHepatic cysts. Sagittal magnetic resonance imaging (MRI) reconstruction in a patient with a large echinococcal cyst; note daughter cysts in interior.
  • 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. The image below is a CT scan of biliary cystadenoma. Computed tomography (CT) scan appearance of biliarComputed tomography (CT) scan appearance of biliary cystadenoma.
  • 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, as shown in the image below, but can usually be diagnosed from the overall clinical presentation. Ultrasonographic appearance of a patient with a laUltrasonographic appearance of a patient with a large simple hepatic cyst.
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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.
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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.

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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  Chairman, 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 Hepato-Pancreato-Biliary Association, American Pancreatic Association, American Society for Gastrointestinal Endoscopy, American Surgical Association, Association for Academic Surgery, International Hepato-Pancreato-Biliary Association, Society for Surgery of the Alimentary Tract, and Society of University Surgeons

Disclosure: Nothing to disclose.

Specialty Editor Board

Brian James Daley, MD, MBA, FACS, FCCP, CNSC  Professor, Associate Program Director, Department of Surgery, Division of Trauma and Critical Care, University of Tennessee Health Science Center College of Medicine

Brian James Daley, MD, MBA, FACS, FCCP, CNSC 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.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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.

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 Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director, 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 Consulting; ARdelyx Ownership interest Board membership

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Histology demonstrating biliary epithelium lining simple cyst.
Ultrasonographic appearance of a patient with a large simple hepatic cyst.
Computed tomography (CT) scan appearance of a large hepatic cyst.
Computed tomography (CT) scan of polycystic liver disease curiously limited to the right lobe.
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 biliary cystadenoma.
Resection of involved liver in polycystic liver disease.
Laparoscopic view of the initial hepatic cyst puncture, before unroofing. The lesion is located high in the right lobe of the liver near the diaphragm.
Laparoscopic view of the beginning of unroofing a large simple hepatic cyst near the dome of the right lobe of the liver.
Drawing of final result of laparoscopic unroofing of a large simple hepatic cyst in the right lobe of the liver.
Initial penetration of hepatic cyst with drainage of cyst fluid.
Unroofing of hepatic cyst.
Omentum sutured to excised margin.
Table. Series of Patients Undergoing Laparoscopic Unroofing of Liver Cysts
First Author (Year) Institution Number of Patients Success Rate, Simple Cysts Success Rate, Polycystic Liver Disease
Morino (1994)[10] University of Torino, Italy17100%40%
Krahenbuhl (1996)University of Bern, Switzerland8100%N/A
Hansen (1997)[11] University of California, San Francisco, United States1994%0%
Emmerman (1997)Eppendorf University, Hamburg, Germany1889%N/A
Fabiani (1997)[12] University of Nice, France10100%N/A
Martin (1998)[13] Royal Infirmary, Edinburgh, Scotland3892%39%
Katkhouda (1999)[14] University of Southern California, United States25100%89%
Zacherl (2000)[15] University Clinic of Surgery, Vienna, Austria1186%N/A
Fiamingo (2003)[16] University Hospital, Via Giustiniani, Italy1589%50%
Robinson(2004)[17] University of Colorado, United States11N/A45%
Konstadoulakis(2005)[18] Athens University, Greece9N/A78%
Fabiani (2005)[19] University Nice, France3896%*N/A
*Clinicoradiologic recurrence
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