What are the guidelines for managing hepatic cysts?

Management of Hepatic Cysts

Asymptomatic simple hepatic cysts require no treatment and no follow-up imaging regardless of size, while symptomatic cysts should be treated with volume-reducing therapy (laparoscopic fenestration or aspiration sclerotherapy) based on local expertise. 1, 2

Diagnostic Approach

Initial Imaging

• Ultrasound is the first-line diagnostic modality for suspected hepatic cysts, with approximately 90% sensitivity and specificity for diagnosis 1, 3
• Simple hepatic cysts appear as round or oval-shaped, anechoic lesions with sharp, smooth borders, thin walls, and strong posterior acoustic enhancement 3, 4
• Once a simple cyst is confirmed on ultrasound, no further imaging (CT or MRI) is indicated 1, 3

Complex Features Requiring Advanced Imaging

• Hepatic cysts demonstrating complex features require further evaluation using MRI or CT 1
• Complex features include: septations, mural thickening or nodularity, debris-containing fluid, wall enhancement, or calcifications 3, 5
• MRI should be used to characterize hepatic cysts with worrisome features (100% consensus) 1
• Contrast-enhanced ultrasound (CEUS) can identify vascularized septation or wall enhancement to distinguish malignant from benign lesions 3, 6

Key Diagnostic Elements

• The number of lesions (solitary vs. multiple) and architecture (simple vs. complex) are key elements in describing hepatic cysts 1
• Biliary hamartomas should be diagnosed by MRI with heavily T2-weighted sequences and MR cholangiography sequences 1

Laboratory Testing

When Bloodwork is NOT Needed

• No bloodwork is required for asymptomatic simple hepatic cysts, as these are benign developmental anomalies 3
• Tumor markers (CEA and CA19-9) in blood or cyst fluid cannot be used to discriminate between hepatic cysts and mucinous cystic neoplasms 1, 7
• TAG-72 in cyst fluid may help distinguish between simple hepatic cysts and mucinous cystic neoplasms, though evidence is limited 1

When Bloodwork IS Indicated

• If clinical features suggest infected hepatic cyst, obtain complete blood count and C-reactive protein to assess for leukocytosis and inflammation 3

Follow-Up Recommendations

Simple Hepatic Cysts

• It is not recommended to follow asymptomatic patients with simple hepatic cysts, biliary hamartomas, or peribiliary cysts (96% consensus) 1, 2
• Simple hepatic cysts are benign lesions that typically follow an indolent course without significant changes in size over time 1, 7
• If symptoms develop, ultrasound should be the first diagnostic modality used to assess size and look for complications or compression 1, 2

Post-Treatment Follow-Up

• Routine follow-up with imaging after aspiration sclerotherapy or surgical procedures is not recommended (92% consensus) 1, 7
• Treatment success is defined by symptom relief, not by volume reduction of hepatic cysts 1, 7

Treatment Indications and Options

Symptomatic Simple Cysts

• Symptomatic simple hepatic cysts without biliary communication should be treated with the best locally available volume-reducing therapy (100% consensus) 1, 7
• Laparoscopic fenestration is recommended because of its high success rate and low invasiveness 4
• Operative techniques include fenestration, fenestration with decapitation, decapitation alone, or excision 8
• Complete resolution of symptoms occurs in approximately 69% of patients at median 7-month follow-up 8
• Reintervention for cyst recurrence occurs in approximately 9% of cases 8

Infected Hepatic Cysts

• Fluoroquinolones and third-generation cephalosporins are recommended as empirical first-line antibiotics (90% consensus) 1, 7
• The recommended duration of antibiotic therapy is 4-6 weeks (100% consensus) 1, 7
• Secondary prophylaxis for hepatic cyst infection is not recommended (92% consensus) 1
• Drainage of infected hepatic cysts may be pursued when: cysts >5-8 cm, fever persisting >48 hours despite antibiotics, pathogens unresponsive to antibiotic therapy, immunocompromise, hemodynamic instability or sepsis, or intracystic gas on imaging 1, 7

Intracystic Hemorrhage

• Imaging to detect intracystic hemorrhage may be performed in patients with sudden and severe abdominal pain (96% consensus) 1
• Ultrasound (showing sediment or mobile septations) and/or MRI (heterogeneous and intense signal on both T1- and T2-weighted sequences) may be used to diagnose cyst hemorrhage (96% consensus) 1
• CT is not recommended to diagnose cyst hemorrhage (91% consensus) 1
• Intracystic hemorrhage typically resolves spontaneously and does not require treatment 7
• Temporary interruption of anticoagulants in hepatic cyst hemorrhage is recommended (96% consensus), with resumption between 7-15 days after onset (100% consensus) 1

Special Populations

Polycystic Liver Disease (PLD)

• Abdominal ultrasound to screen for PLD should be offered to all patients diagnosed with ADPKD (100% consensus) 1
• PLD is arbitrarily defined as the presence of >10 hepatic cysts 3, 6
• Genetic testing should not be used to screen for PLD (100% consensus) 1
• Referral to centers of expertise and counseling of patients with symptomatic PLD is recommended (100% consensus) 1
• Most patients with PLD are and will remain asymptomatic; hence imaging follow-up is not indicated 1
• Treatment may be considered when quality of life is altered or in case of local complications 1, 2
• Routine post-treatment imaging is not indicated in PLD 1, 2

Mucinous Cystic Neoplasms (MCNs)

• A combination of >1 major and >1 minor worrisome feature may be considered suspicious for MCNs (95% consensus) 1
• Surgical resection is the gold standard for suspected MCNs, and complete resection should be aimed for (100% consensus) 1

Common Pitfalls to Avoid

• Avoid unnecessary follow-up imaging for asymptomatic simple cysts, which leads to patient anxiety and healthcare resource waste 2
• Do not order tumor markers to differentiate between hepatic cysts and mucinous cystic neoplasms, as these are unreliable 2, 7
• Do not use CT to diagnose cyst hemorrhage; use ultrasound or MRI instead 1
• Percutaneous aspiration alone (without sclerotherapy) is not generally recommended due to high recurrence rates 4, 5