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Hepatic Cysts Workup

Updated: Jun 12, 2018
Author: Robert E Glasgow, MD; Chief Editor: John Geibel, MD, MSc, DSc, AGAF more...

WORKUP

Approach Considerations
The evaluation of a patient with a simple liver cyst involves carefully recording the patient history and
performing a physical examination plus an imaging study (eg, abdominal computed tomography [CT])
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.

Before the widespread availability of abdominal imaging techniques, including ultrasonography and
CT, 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.

Laboratory Studies
Little preoperative laboratory workup is required for these patients. Liver function test (LFT) results,
such as transaminases or alkaline phosphatase, may be mildly abnormal, but bilirubin, prothrombin
time (PT), and activated partial thromboplastin time (aPTT) are usually within the reference range.

In the setting of polycystic liver disease (PCLD), greater abnormalities in LFT results are found,
but liver failure is uncommon. Renal function test results, including blood urea nitrogen (BUN) 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.

With cystic tumors, as with simple cysts, LFT results are normal. 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 on the basis of the clinical
presentation. Leukocytosis is generally present.
The enzyme immunoassay (EIA) test detects specific antibodies to E histolytica.

Imaging Studies
The clinician has a number of options for imaging the liver in patients with hepatic cysts.
Ultrasonography is readily available, noninvasive, and highly sensitive. CT (see the image below) is
also highly sensitive and is easier for most clinicians to interpret, particularly for treatment planning.
Magnetic resonance imaging (MRI), nuclear medicine scanning, and hepatic angiography have a
limited role in the evaluation of hepatic cysts.

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

Simple cysts have a typical radiographic appearance. They are thin-walled with a homogenous
low-density interior.

PCLD is confirmed by means of ultrasonography or CT (see the image below), with multiple liver
cysts identified at the time initial of evaluation.

Computed tomography (CT) scan of polycystic liver disease curiously limited to right liver.
Hydatid cysts can be identified by the presence of daughter cysts within a thick-walled main cavity
(see the image below).

Hepatic cysts. Sagittal magnetic resonance imaging (MRI) reconstruction in patient with 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 whether the cyst has ruptured into the bile duct.

Central necrosis of large solid neoplasms can mimic cystic hepatic tumors, in that this area of
necrosis appears cystic.

Cystadenoma (see the image below) and cystadenocarcinoma usually appear multiloculated with
internal septations, heterogeneous density, and irregularities in the cyst wall. Unlike many
tumors, cystadenoma and cystadenocarcinoma are rarely associated with calcifications.
Computed tomography (CT) appearance of biliary cystadenoma.

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 (see the image below) but can usually be
diagnosed from the overall clinical presentation.

Ultrasonographic appearance of large simple hepatic cyst.

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.

Treatment & Management