History and Physical Examination
Simple cysts
Simple cysts generally cause no symptoms but may produce dull right-upper-quadrant pain if large in size. Patients with symptomatic simple liver cysts may also report abdominal bloating and early satiety. Occasionally, a cyst is large enough to produce a palpable abdominal mass. Jaundice caused by bile duct obstruction is rare, as are cyst rupture and acute torsion of a mobile cyst. Patients with cyst torsion may present with an acute abdomen. When simple cysts rupture, patients may develop secondary infection, leading to a presentation similar to a hepatic abscess with abdominal pain, fever, and leukocytosis.
Polycystic liver disease
Polycystic liver disease (PCLD) rarely arises in childhood. These cysts are observed at the time of puberty and increase in adulthood. They occur as part of a congenital disorder associated with polycystic kidney disease (PKD). Women are more commonly affected, and an increase in cyst size and number is correlated with estrogen level. In PCLD, hepatomegaly may be prominent, and patients occasionally progress to hepatic fibrosis, portal hypertension, and liver failure. Complications (eg, rupture, hemorrhage, and infection) are rare. However, patients do present with abdominal pain as the cysts enlarge.
Neoplastic cysts
Cystadenoma most often occurs in middle-aged women. However, cystadenocarcinoma equally affects both men and women. Most patients are asymptomatic or have vague abdominal complaints of bloating, nausea, and fullness. These patients, like all those with hepatic cysts, eventually present with abdominal pain. Rarely, they present with evidence of biliary obstruction.
Hydatid cysts
Patients with hydatid cysts, like those with simple cysts, are most often asymptomatic, but pain may develop as the cyst grows. Larger lesions typically cause pain and are more likely to develop complications than simple cysts. At presentation, patients generally have a palpable mass in the right upper quadrant.
Cyst rupture is the most serious complication of hydatid cysts. Cysts may rupture into the biliary tree, through the diaphragm into the chest, or freely into the peritoneal cavity. Rupture into the biliary tree may result in jaundice or cholangitis. Free rupture into the peritoneal cavity may cause anaphylactic shock. As with simple cysts, patients with hydatid cysts may develop secondary infection and subsequent hepatic abscesses.
Hepatic abscesses
Patients with hepatic abscesses present with abdominal pain, fever, and leukocytosis. Typically, symptoms are vague and relatively nonspecific, and as a result, diagnosis is often delayed. Clinical history is important because of associated illnesses. Those patients with amebiasis can have a history of diarrhea and weight loss, though some may be asymptomatic. Pyogenic abscesses often present with cholangitis, abdominal infections, or sepsis. Rarely, abscesses will rupture, and patients present with peritonitis.
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Histology demonstrating biliary epithelium lining simple cyst.
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Ultrasonographic appearance of large simple hepatic cyst.
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Computed tomography (CT) scan appearance of large hepatic cyst.
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Computed tomography (CT) scan of polycystic liver disease curiously limited to right liver.
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Hepatic cysts. Sagittal magnetic resonance imaging (MRI) reconstruction in patient with large echinococcal cyst; note daughter cysts in interior.
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Computed tomography (CT) appearance of biliary cystadenoma.
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Resection of involved liver in polycystic liver disease.
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Laparoscopic view of initial hepatic cyst puncture, before unroofing. Lesion is located high in right liver near the diaphragm.
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Laparoscopic view of beginning of unroofing of large simple hepatic cyst near dome of right liver.
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Drawing of final result of laparoscopic unroofing of a large simple hepatic cyst in right liver.
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Initial penetration of hepatic cyst with drainage of cyst fluid.
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Unroofing of hepatic cyst.
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Omentum sutured to excised margin.
Tables
First Author (Year) |
Institution |
Number of Patients |
Success Rate, Simple Cysts |
Success Rate, Polycystic Liver Disease |
Morino (1994) [7] |
University of Torino, Italy |
17 |
100% |
40% |
Krahenbuhl (1996) |
University of Bern, Switzerland |
8 |
100% |
N/A |
Hansen (1997) [8] |
University of California, San Francisco, United States |
19 |
94% |
0% |
Emmerman (1997) |
Eppendorf University, Hamburg, Germany |
18 |
89% |
N/A |
Fabiani (1997) [9] |
University of Nice, France |
10 |
100% |
N/A |
Martin (1998) [10] |
Royal Infirmary, Edinburgh, Scotland |
38 |
92% |
39% |
Katkhouda (1999) [11] |
University of Southern California, United States |
25 |
100% |
89% |
Zacherl (2000) [12] |
University Clinic of Surgery, Vienna, Austria |
11 |
86% |
N/A |
Fiamingo (2003) [13] |
University Hospital, Via Giustiniani, Italy |
15 |
89% |
50% |
Robinson (2004) [14] |
University of Colorado, United States |
11 |
N/A |
45% |
Konstadoulakis (2005) [15] |
Athens University, Greece |
9 |
N/A |
78% |
Fabiani (2005) [16] |
University Nice, France |
38 |
96%* |
N/A |
*Clinicoradiologic recurrence |
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