From the Guidelines
The diagnostic workup for hepatic cysts should begin with ultrasound as the first-line imaging modality, due to its accessibility, lack of radiation, and high sensitivity and specificity for diagnosing cystic liver lesions 1. The choice of ultrasound is supported by its ability to explore content and wall thickness, with a sensitivity and specificity of about 90% for the diagnosis of cystic liver lesions 1.
Key Points to Consider
- Ultrasound is the recommended initial imaging technique for diagnosing simple hepatic cysts and polycystic liver disease (PLD) 1.
- For complex cysts or those with atypical features, further evaluation using additional imaging such as MRI or CT may be necessary to characterize the cysts and rule out malignancy 1.
- MRI is particularly useful for identifying hemorrhagic or proteinaceous contents and wall enhancement, and is superior to ultrasound and CT for detecting small cysts in young individuals 1.
- Laboratory tests, including liver function tests and serology for echinococcal infection, should also be performed as part of the diagnostic workup.
Imaging Modalities
- Ultrasound: first-line imaging modality for simple hepatic cysts and PLD 1.
- MRI: useful for characterizing complex cysts and detecting small cysts in young individuals 1.
- CT: may be used to evaluate the distribution of cysts in the liver and detect complications such as hepatic or portal vein compression 1.
Special Considerations
- Polycystic liver disease: diagnosis is made in the presence of >10 hepatic cysts, and MRI is preferred over CT for evaluating the distribution of cysts and detecting small cysts 1.
- Echinococcal cysts: require specific management with albendazole before and after surgical or percutaneous intervention to prevent recurrence and anaphylaxis.
From the Research
Diagnostic Workup for Hepatic Cysts
The diagnostic workup for hepatic cysts typically involves imaging modalities such as:
- Ultrasonography (US) as the first-line imaging modality 2, 3, 4, 5, 6
- Computed Tomography (CT) for further characterization and diagnosis 2, 3, 4, 5, 6
- Magnetic Resonance Imaging (MRI) for differentiation of simple and complex cysts 2, 3, 4, 5, 6
- Contrast-enhanced ultrasound for non-invasive evaluation in real-time 4
Characteristics of Hepatic Cysts
Hepatic cysts can be characterized as:
- Simple cysts: typically saccular, thin-walled masses with fluid-filled epithelial lined cavities 2
- Complex cysts: include septae, mural consistency, calcifications, and quality of cystic fluid 4
- Cysts with irregular walls, septations, calcifications, or daughter cysts on US should be evaluated with enhanced CT or MRI 2
Diagnostic Algorithm
The diagnostic algorithm for hepatic cysts involves:
- Stratifying risk by differentiating simple and complex cysts 4
- Using serodiagnostic tests and microbubble contrast-enhanced ultrasound (CEUS) to differentiate complicated cysts, echinococcosis, and cystadenoma/cystadenocarcinoma 6
- Considering the patient's comorbidities and clinical and laboratory data when interpreting imaging studies 5
Treatment Modalities
Treatment modalities for hepatic cysts include: