Hepatic Cysts Guidelines

Updated: Aug 10, 2022
  • Author: Robert E Glasgow, MD; Chief Editor: John Geibel, MD, MSc, DSc, AGAF  more...
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EASL Guidelines on Cystic Liver Disease

In June 2022, the European Association for the Study of the Liver (EASL) published guidelines on management of cystic liver disease. [18] Recommendations included the following.

Hepatic cysts

The number of lesions (solitary vs multiple) and architecture (simple vs complex cyst) are essential in the characterization of hepatic cyst(s).

Use ultrasonography (US) as the first imaging modality for diagnosing simple hepatic cysts and polycystic liver disease (PCLD), with additional imaging for hepatic cysts with complex features such as atypical cyst wall or content, either solitary or in patients with PCLD. For diagnosis of biliary hamartomas, use magnetic resonance imaging (MRI) with heavily T2-weighted sequences and MR cholangiography sequences.

Do not use the tumor markers carcinoembryonic antigen (CEA) or carbohydrate antigen 19-9 (CA19-9) in blood or cyst fluid to distinguish between hepatic cysts (solitary or in PCLD) and mucinous cystic neoplasms (MCNs) of the liver.

Patients with symptomatic simple hepatic cysts without biliary communication should receive the best volume-reducing therapy available locally.

Hepatic cyst infection should be viewed as definite when accompanied by neutrophil debris and/or microorganisms in cyst aspirate with evidence of infection, and it should be viewed as likely when accompanied by features including fever for more than 3 days with no other detectable source, gas in a cyst found on computed tomography (CT) or MRI, tenderness near the liver, and increased C-reactive protein (CRP).

Fluoroquinolones and third-generation cephalosporins should be used for empiric first-line antibiotic therapy for hepatic cyst infection; antibiotics should be given for 4-6 weeks.

CT should not be used for diagnosis of cyst hemorrhage.

Temporarily stop anticoagulants in patients with hepatic cyst hemorrhage.

Polycystic liver disease

Stop exogenous estrogen in female patients with PCLD.

Treatment for PCLD should be given to symptomatic patients only.

Before pregnancy, patients with PCLD should be counseled about the risk of giving PCLD to the newborn but should not be advised against pregnancy.

Caroli disease

Patients with multiple segmental cystic or saccular dilatations of bile ducts should be evaluated for congenital hepatic fibrosis to distinguish Caroli disease from Caroli syndrome.

Consider referral for liver transplantation in patients with Caroli disease or Caroli syndrome who have recurrent cholangitis and either bilobar involvement or monolobar involvement with liver fibrosis or portal hypertension when liver resection is not possible.