What are the recommended interventions for hepatic (liver) cysts?

Management of Hepatic Cysts

Volume-reducing therapies for hepatic cysts should only be performed in symptomatic patients, as asymptomatic cysts do not require treatment or follow-up. 1

Diagnostic Approach

• Ultrasound should be the first imaging modality used to diagnose simple hepatic cysts and polycystic liver disease (PLD) 1
• For cysts demonstrating complex features (atypical cyst wall or content), additional evaluation using MRI or CT is required 1
• MRI with heavily T2-weighted sequences is recommended for diagnosing biliary hamartomas 1

Treatment Algorithm for Simple Hepatic Cysts

Asymptomatic Cysts

• No treatment or follow-up is required for asymptomatic simple hepatic cysts 1, 2
• Routine follow-up with imaging after procedures is not recommended 1

Symptomatic Cysts

• Symptomatic simple hepatic cysts without biliary communication should be treated with volume-reducing therapy 1
• Treatment options include:
  1. Percutaneous aspiration sclerotherapy: Cyst is drained and temporarily exposed to a sclerosing agent (100% ethanol, 20% saline, tetracycline, or polidocanol) 1
     • Volume reduction is slow in onset (may take 6+ months)
     • Volume reductions range between 76-100%
     • Symptom relief in 72-100% of cases
  2. Laparoscopic fenestration/deroofing: Involves drainage and resection of the extrahepatic cyst wall 1, 3
     • Associated with low recurrence rate (<8%)
     • Preferred over laparotomy due to shorter procedural time and reduced postoperative hospital stays 1
     • High success rate and low invasiveness 2

Management of Infected Hepatic Cysts

Diagnosis of Infection

• Definitive diagnosis: Cyst aspiration showing neutrophil debris and/or microorganisms 1, 4
• Likely infection criteria: Fever >38.5°C for >3 days, CT/MRI detecting gas in cyst, increased CRP, leukocytosis, tenderness in liver area 1

Treatment of Infected Cysts

• Antibiotic therapy should be administered as soon as possible 1

  • Fluoroquinolones (ciprofloxacin) and third-generation cephalosporins are the standard of care 1, 4
  • Recommended duration is 4-6 weeks 1

• Drainage considerations:

  • Drainage should be considered for infected cysts in the following scenarios 1, 4:
    • Persistence of temperature >38.5°C after 48 hours on empirical antibiotics
    • Isolation of pathogens unresponsive to antibiotic therapy
    • Severely compromised immune system
    • CT or MRI detecting gas in a cyst
    • Large infected hepatic cysts (>5 cm)
  • Combined drainage and antibiotics are more effective than antibiotics alone 1, 4
  • Caution is advised when draining infected cysts in PLD patients as infection may spread to adjacent cysts 1, 4

• Secondary prophylaxis for hepatic cyst infection is not recommended 1

Complications and Special Considerations

Cyst Hemorrhage

• Imaging (ultrasound or MRI) should be performed in patients with sudden and severe abdominal pain to detect intracystic hemorrhage 1
• Temporary interruption of anticoagulants is recommended in hepatic cyst hemorrhage 1
• Anticoagulants may be resumed between 7-15 days after onset of hemorrhage 1

Mucinous Cystic Neoplasms (MCNs)

• MRI should be used to characterize hepatic cysts with worrisome features 1
• Surgical resection is the gold standard for suspected MCNs of the liver 1
• Tumor markers (CEA, CA19-9) in blood or cyst fluid cannot reliably discriminate between simple hepatic cysts and MCNs 1

Outcomes

• Laparoscopic management of hepatic cysts has shown excellent clinical results with minimal morbidity 3
• Complete resolution of symptoms occurs in approximately 69.4% of patients following laparoscopic intervention 3
• Reintervention for cyst recurrence may be required in about 9.4% of cases 3